DISORDERS OF THE MOUTH

1. DISORDERS OF THE MOUTH Common disorders of the mouth and esophagus that interfere with adequate nutrition include poor dental hygiene, infections, & inflammation (stomatitis).

2. DO YOU BRUSH AND FLOSS?

3. POOR DENTAL CARE

4. Disorders of the Mouth • Dental plaque and caries • Etiology/pathophysiology • Erosive process that results from the action of bacteria on carbohydrates in the mouth, which in turn produces acids that dissolve tooth enamel

5. FACTORS THAT CAUSE TOOTH DECAY • The presence of dental plaque; a thin film on the teeth made of mucin and colloidal material found in saliva and often secondarily invaded by bacteria. • The strength of acids and the ability of the saliva to neutralize them. • The length of time the acids are in contact with the teeth. • Susceptibility of the teeth to decay.

6. MEDICAL MANAGEMENT • INTERVENTIONS INCLUDE: 1. Treatment of dental caries by removal of affected areas of the tooth and replacement with some form of dental material. 2. Treatment of periodontal disease centers on removal of plaque from the teeth. 3. If the disease has advanced, then surgical interventions of the gingivae and alveolar bone may be necessary.

7. Dental plaques and tartar

8. ALVEOLAR BONE

9. NURSING INTERVENTIONS 1. Emphasize the importance and the NECESSITY to brush and floss twice a day. The pt. should give a return demonstration for the proper technique for brushing and flossing. 2. Plaque forms continuously and must be removed periodically through regular visits to the dentist. 3. Prevention plays a key role through routine dental care.

10. PREVENTION

11. NURSING INTERVENTIONS, cont. 4. Carbohydrates create an environment in which caries develop and plaques accumulate more easily. Proper nutrition is included in pt. teaching. So the pt. needs to be aware of what food groups he eats for appropriate dental care. 5. The cleansing mechanism of the mouth is impaired when a person is ill. 6. Illnesses, drugs, and irradiation of the mouth all interfered with the normal action of saliva. 7. If the pt. can’t manage oral hygiene, then the nurse or someone who knows how must take on this responsibility.

12. PROGNOSIS • The prevention and elimination of dental caries and plaque is directly related to oral hygiene, dental care, nutrition, and heredity. • All of the above are controllable factors, except heredity. • Factors that can foster good dental health: Regularly brush, floss, and visit the dentist; eat a low-CHO diet; drink fluoridated water.

13. CANDIDIASIS • Etiology/Pathophysiology: 1. This condition is any infection caused by a species of Candida, usually C. albicans. Candida is a fungal organism normally present in the mucous membranes of the mouth, intestine, vagina, and the skin of healthy people. 2. Also known as thrush and moniliasis. 3. More common in the newborn (becomes infected while passing through the birth canal). 4. In older people, it occurs in those who are immunosuppressed, those with DM, leukemia, alcoholism, taking steroids, on chemotherapy, or living with AIDS.

14. THRUSH

15. CLINICAL MANIFESTATIONS • It appears as pearly, bluish white “milk-curd” membranous lesions on the mucous membranes of the mouth, tongue, and larynx. Some of the lesions may be on the mucosa. If you remove the plaque or patch, it will be painful and will bleed.

16. PATCHES OF THRUSH IN THE ESOPHAGUS

17. MEDICAL MANAGEMENT 1. 1-4 mL of nystatin dropped in the infant’s mouth several times/day. 2. For the adult, nystatin or Amphotericin B (oral suspension) or buccal tablets and half-strength hydrogen peroxide/saline mouth rinses may provide some relief 3. Adult vaginal infection: insert vaginal tablets (100,000 units) into the vagina twice a day. 4. Also Ketoconazole is effective.

18. MEDICINES

19. NURSING INTERVENTIONS 1. Use thorough handwashing. 2. Handwashing, care of feeding equipment, and cleanliness of the mother’s nipples are important to prevent spread of the infection. 3. The nurse should clean the infant’s mouth of any foreign material; rinsing the mouth and lubricating the lips. 4. Inspect the mouth by using a flashlight and a tongue blade.

20. NURSING INTERVENTIONS, cont. • 5. For adults, instruct the pt. to use a soft-bristled toothbrush. • 6. Have the adults administer a topical anesthetic (Lidocaine or Benzocaine) one hour before meals. • 7. Give soft or pureed foods and avoid hot, cold, spicy, fried, or citrus foods.

21. PUREED FOODS

22. LEUKOPLAKIA 1. Leukoplakia is a white, firmly attached patch on the mouth or tongue mucosa. This may appear on the lips and buccal mucosa. These nonsloughing lesions cannot be rubbed off by simple mechanical force. 2. They can be benign or malignant. 3. Some can develop into squamous cell carcinomas. A bx. is recommended if the lesions persist for > 2 weeks. They occur most frequently between the 50-70 y.o. They appear more commonly in men.

23. LEUKOPLAKIA

24. Esophageal Varices • “Varicose veins” of the esophagus • Dilated and tortuous veins in the submucosa of the esophagus • Bleeding varices is an emergency • The goals of treatment are to control bleeding, prevent complications, and prevent the reoccurrence of bleeding.

26. Nursing Management • HOB ↑ 30° • VS, including orthostatic hypotension • Monitor lung sounds • NPO • Prepare for NG tube insertion • Administer O2 as ordered • Instruct the client to avoid activities that will initiate vasovagal responses!

27. Surgical Management • Endoscopic injection (Sclerotherapy) • Endoscopic variceal ligation • Surgical shunt procedures • Splenorenal • Portacaval • Mesocaval • Transjugular intrahepatic portal-systemic

28. DISORDERS OF THE ESOPHAGUS: Gastroesophageal reflux disease (GERD) Etiology/Pathophysiology: 1. GERD is a backward flow of stomach acid up into the esophagus. 2. Sx. are usually burning and pressure behind the sternum. 3. Most cases are attributed to the inappropriate relaxation of the lower esophageal sphincter in response to an unknown stimulus.

29. GERD, cont. • 4. Reflux allows gastric contents to move back into the distal esophagus. • 5. Sx. of GERD develop when the lower esophageal sphincter (LES) is weak or experiences prolonged or frequent transient relaxation, conditions that allow acids and enzymes to flow into the esophagus. • 6. GERD is more common in the post-prandial state; more than 60% suffer delayed gastric emptying. • 7. GERD occurs in all ages.

30. GERD

31. GERD

32. CLINICAL MANIFESTATIONS 1. The sx. vary in severity. 2. The irritation of chronic reflux produces the primary sx., pyrosis, which is heartburn. The pain is described as a substernal or retrosternal burning sensation that tends to radiate upward and may involve the neck , jaw or back. 3.The pain typically occurs 20 minutes to 2 hours after eating. 4. An atypical pain pattern that mimics angina may also occur and needs to be differentiated from true cardiac disease.

33. HEARTBURN

34. CLINICAL MANIFESTATIONS, cont. 5. The second major sx. of GERD is regurgitation. The pt. experiences a feeling of warm fluid moving up the throat. If it reaches the pharynx, a sour taste is perceived. Water brash, a reflux salivary hyersecretion that does not have a bitter taste, occurs less commonly. 6. In severe cases, GERD can produce dysphagia or painful swallowing. 7. Eructation or flatulence are other sx. 8. Nocturnal cough, wheezing, or hoarseness may occur with GERD. 9. It is estimated that > 80% of asthmatics may have reflux.

35. FLATULENCE

36. ASSESSMENT • SUBJECTIVE: 1. Heartburn, substernal or retrosternal burning sensation that may radiate to the back, or jaw (the pain may mimic angina). 2. Regurgitation (not associated with nausea or eructation) in which a sour or bitter taste is perceived in the pharynx. 3. Frequent eructation, flatulence, and dysphagia or trouble swallowing (usually occurs in severe cases) • OBJECTIVE: Sx. may include nocturnal cough, wheezing, and hoarseness

37. DIAGNOSTIC TESTS 1. The gold standard is the 24-hour pH monitoring, which accurately records the number, duration, and severity of reflux episodes and is considered to be 85% sensitive. 2. Mild cases are diagnosed from the sx. 3. The esophageal motility and Bernstein tests can be performed in conjunction with pH monitoring to evaluate LES competence and the response of the esophagus to acid infusion. 4. Barium swallow with fluoroscopy is used to document the presence of a hiatal hernia. 5. Endoscopy is also used to observe for esophagitis, and to rule out any malignancy.

38. MEDICAL MANAGEMENT 1. In its simplest form, only mild sx. are produced. In these cases, avoid problem foods or beverages, stop smoking, or lose weight, if necessary. 2. Use antacids or acid-blocking meds. called H2 receptor inhibitors, such as Tagamet, Zantac, Pepcid, or Axid. 3. More severe and frequent episodes cause asthma attacks, cause severe chest pain, result in bleeding, or promote a narrowing or chronic irritation of the esophagus. In these cases, proton pump inhibitors may be prescribed.

39. 4. Some proton pump inhibitors are: Prilosec, Nexium, Protonix, Aciphex, and Prevacid. • 5. Reglan is used in moderate to severe cases of GERD. It is an example of a class of drugs called promotility agents that increase peristalsis without stimulating secretions . • 6. If nothing else works, a surgical procedure, called a fundoplication is performed to strengthen the sphincter.

40. FUNDOPLICATION

41. 7. If GERD is left untreated, pathologic changes (precancerous) in the esophageal lining can occur; a condition called Barrrett’s esophagus. In Barrett’s esophagus, there is replacement of the normal squamous epithelium of the esophagus with columnar epithelium. Pts. with Barrett’s are at higher risk for adenocarcinoma, so they need to be monitored on a regular basis, (every 1-3 years), by endoscopy and bx.

44. BARRETT’S ESOPHAGUS

45. NURSING INTERVENTIONS 1. Educate the pt. about diet and lifestyle modifications that may alleviate the s/s of GERD. 2. What are the diet recommendations? 3. What are the lifestyle changes?

46. ACHALASIA • Etiology/Pathophysiology: This is also called cardiospasm. It is an abnormal condition in which a muscle cannot relax, particularly the cardiac sphincter of the stomach. The cause is unknown. Factors that can contribute are: nerve degeneration, esophageal dilation, and hypertrophy. These factors disrupt the normal neuromuscular activity of the esophagus. This results in decreased motility of the lower esophagus, absence of peristalsis, and dilation of the lower portion.

47. ACHALASIA, cont. • So little or no food can enter the stomach. Sometimes, the dilated esophagus can hold as much as a liter or more of fluid. • This disease can occur with any age, but is more prevalent in ages 20-50 y.o.

48. ACHALASIA

49. CLINICAL MANIFESTATIONS • The primary sx. is dysphagia. • As the condition progresses, the pt. complains of regurgitation of food, which relieves prolonged distention of the esophagus. • There may be some occurrence of substernal chest pain.

50. ASSESSMENT • The nurse observes for weight loss, poor skin turgor, and weakness.