Stomatitis

Overview of the Anatomy

Food enters to the digestive tract through the mouth, or oral cavity, a mucous membrane lined cavity. The lips protect its anterior opening, the cheeks from its lateral walls, the hard palate forms its anterior roof and the soft palate forms its posterior roof. The uvula is a fleshy fingerlike protection of the soft palate , which extends downward form its posterior edge. The space between the lips and cheeks externally and the teeth and gums internally is the vestibule. The area contained by the teeth is the oral cavity proper. The muscular tongue occupies the floor of the mouth. The tongue has several bony attachment tow of these are to the hyoid bone and the styloid processes of the skull. The lingual frenulum, a fold of mucous membrane, secures the tongue to the floor of the mouth and limits its posterior movements. At the posterior end of the oral cavity are paired masses of lymphatic tissue, the palatine tonsils. The lingual tonsil covers the base of the tongue just beyond. The tonsils, along with other lymphatic tissues are part of the bodys defense system. When the tonsils become inflamed and enlarged they partially block the entrance into the throat ( pharynx), making swallowing difficult and painful. As the food enters the mouth, it is mixed with saliva and masticated. The cheeks and closed lips the food between the teeth during chewing. The nimble tongue continually mixes food with saliva during chewing and initiates swelling. Thus, the breakdown of food begins before the food has even left the mouth. Papillae containing taste buds , or taste receptors found on the tongue surface. And so besides its food manipulating function, the tongue allows us to enjoy and appreciate as it is eaten

Overview of the Disease

Stomatitis, inflammation of the oral mucosa, is a common disorder of the mouth. It may be caused by viral ( herpes simplex) or fungal ( candida albicans) infections, mechanical trauma ( cheek biting ) and irritants such as tobacco or chemotherapeutic agents. Stomatitis is commonly seen in people who are immunocompromised ( clients with HIV disease), people with cancer, frail older adults and the end of life. Statistical facts Up to 75% of people undergoing chemotherapy to treat cancer experience oral mucositis a type of stomatitis Oral mucositis tends to affect younger clients, women and people receiving fluorocil more frequently than others. Clients who also use alcohol and tobacco have a greater risk of developing oral mucositis. 100% of clients undergoing radiation therapy of the head and neck develop oral mucosistis. Nearly 90% of clients treated with stem cell transplant develop oral mucositis.

Risk Factors Age >65yrs old Impaired immune status ( HIV disease, cancer, diabetes) Chronic renal failure or heart failure Chemotherapy radiation therapy, stem cell therapy Oxygen therapy, mouth breathing Medications ( antibiotics, phenytoin, anticholinergics, corticosteroids) Poor oral hygiene, ill-fitting dentures Tobacco and alcohol use

Assessment
Lips are dry with swelling Inspections and lesions Lesions may be cause by poor fitted dentures Dry lips may due to practicing mouth breathing Sometimes indicate vitamin deficiency Maybe due to sensitivity in chemicals Can be caused by vitamin b12 deficiency

Swollen red gums Swelling bucal mucosa Smooth , red, shiny tongue

Inspection Inspection Inspection and palpation

Pathophysiology
The oral mucosa which lines the oral cavity, is relatively thin, fragile layer of stratified squamous epithelial cells. The blood supply to the oral mucosa is rich as epithelial cells. Slough, stem cells in the sub mucosa develop into epithelial cells to replace those that are lost. The health and integrity of the oral mucosa are therefore dependent on the ability of stem cells to continuously reduce. The pathophysiology of oral mucositis has only recently been fully understood. Radiotherapy and chemotherapy has damage the DNA of epithelial cells, resulting in necrosis and death of some cells. This stimulates the release of inflammatory mediators that further damage tissues, causing additional epithelial cells to die. As a result the oral mucosa thins. Tumors necrosis factor alpha ( INF-a) is released, which activates additional inflammatory cytokines. Tissues below the mucosa are damaged as well. In the ulcerative stage of oral mucositis, irregular ulcers that extend form the epithelium onto the sub mucosa develops. As nerve endings begins 2 to 3 weeks, the oral mucosa does not fully recover, and remains vulnerable to damage or inflammation. Stomatitis can lead to malnutrition, fluid and electrolyte imbalance and other complications such as sepsis and bacterial endocarditis.

Interventions
Encourage all clients to regularly perform mouth care, including teeth brushing and flossing. Provide frequent mouth care with non-dying agents for clients who are unable to provide self-care. Encourage clients with ill-fitting dentures or other dental prostheses (such as partial plates) to see a qualified dentist or denturist. Suggest clients taking an extended course of antibiotic therapy or who have impaired immune function consume 8 oz. of yogurt containing live bacterial cultures or 8 oz. of buttermilk daily unless contraindicated. Discuss dietary modifications, such as limiting consumption of highly spiced of acidic foods & avoiding very hot beverage. Clients undergoing chemotherapy should avoid use of alcohol & tobacco because these substances further damage oral mucosa, increasing the risk for oral mucositis.

Medical Surgical Management

Using a topical anesthetise, such as 2% viscous lidocaine, diphenhydra-mine (Benadryl) solution or benzocaine spray or gel promote comfort & the ability to consume oral food & fluids. Orabase, a protective paste, may be applied to oral ulcers to promote comfort. Triamcinolone acetonide may be mixed in orabase to reduce inflammation & promote healing. Sodium bicarbonate mouthwashes may provide relief & promote cleansing

For fungal infections:

Nystatin oral suspension; clients swish & swallow the solution. Clotrimazole lozenges also treat oral fungal infections. Fluconazole or ketoconazole.

Herpetic Lesions:
Acyclovir ointment provides comfort & lubricantion while limiting the spread of the virus.

Acyclovir capsules reduce the severity of symptoms & the duration of lessions.

Bacterial infections:
Oral penicillin is the treatment of choice if the client is not allergic & the cultured bacteria are sensitive. Palifernin, has been approved to reduce the incidence & duration of oral mucositis in clients undergoing high-dose chemotherapy with or without radiation therapy in preparation for bone marrow or stem cell transplant.

Nursing Management & Diagnosis

Impaired Oral Mucous Membrane Stomatitis & oral mucositis disrupt the integrity of the oral mucous membrane. Regardless of cause, the pain & symptoms must be relieved to promote comfort as well as food & fluid intake. Assess & document oral mucous membranes & the character of any lesions every 4 to 8hrs. (Baseline & on going assessment data provide the basis for evaluation) Assist with through mouth care after meals, at bedtime, & every 2 to 4hrs. while awake. If unable to tolerate a toothbrush, offer sponge or gauze toothettes. Avoid using alcohol-based mouthwashes or lemon-glycerin swabs. Provide saline or sodium bicarbonate rinse or a combined saline/sodium bicarbonate rinse after every meal & between meals. (Mouth care promotes hygiene, comfort & healing. Alcohol-based mouthwashes & lemon glycerine swabs may dry & irritate mucous membranes, causing pain & further tissue damage, whereas saline or bicarbonate rinses promote comfort & healing. Asses knowledge & teach about condition, mouth care, & treatments. Instruct to avoid alcohol, tobacco, & spicy or irritation to foods. (knowledge promotes client participation in the plan of care & compliance. Alcohol, tobacco, & hot , spicy, or rough foods may injure the flamed mucous membranes.

Prevention and Prognosis

Managing any underlying health conditions and on going treatments such as chemotherapy The recommended diet and oral hygiene regime, including foods and substances ( alcohol, tobacco products ) to avoid. Nutritional supplements to help meet nutritional requirements

Prescribed medications, its route, side effect, frequency of administration and signs and symptoms to report.