Assessment

When performing an oral assessment, ask about a history of recent infections, nutritional changes, oral hygiene habits, oral trauma, or stress. A drug history should also be collected, including over-the-counter (OTC) drugs and nutritional and herbal supplements. Document the course of the current outbreak, and determine if stomatitis has occurred frequently. Ask the patient if the lesions interfere with swallowing, eating, or communicating.

The symptoms of stomatitis range in severity from a dry, painful mouth to open ulcerations, predisposing the patient to infection. These ulcerations can alter nutritional status because of difficulty with eating or swallowing. When they are severe, stomatitis and edema have the potential to obstruct the airway.

In oral candidiasis, a type of yeast infection, white plaque-like lesions appear on the tongue, palate, pharynx (throat), and buccal mucosa (inside the cheeks) (Fig. 56-1). When these patches are wiped away, the underlying surface is red and sore. Patients may report pain, but others describe the lesions as dry or hot. The older adult patient who has systemic illness or is taking antibiotics or chemotherapy is particularly susceptible to oral candidiasis.

FIG. 56-1 Oral candidiasis.

While examining the mouth, wear nonsterile gloves. Use adequate lighting, using a penlight and tongue blade. Assess the mouth for lesions, coating, and cracking. Document characteristics of the lesions including their location, size, shape, odor, color, and drainage.

If lesions are seen along the pharynx and the patient reports dysphagia (pain on swallowing), suspect that the lesions might extend down the esophagus. Additional swallowing studies may be prescribed by the health care provider to establish a firm diagnosis.

The physical assessment should also include palpating the cervical and submandibular lymph nodes for swelling. Advanced practice nurses and other health care providers usually perform this part of the examination.

Interventions

Interventions for stomatitis are targeted toward health promotion through careful oral hygiene and food selection. When providing mouth care for the patient, the nurse may delegate oral care to unlicensed assistive personnel (UAP). Because the accountability for the delegated task is the nurse’s, remind UAP to use a soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity. Toothpaste should be free of sodium lauryl sulfate (SLS), if possible, because this ingredient has been associated with various types of stomatitis. Teach the patient to rinse the mouth every 2 to 3 hours with a sodium bicarbonate solution or warm saline solution (may be mixed with hydrogen peroxide). He or she should avoid most commercial mouthwashes because they have high alcohol content, causing a burning sensation in irritated or ulcerated areas. Health food stores sell more natural mouthwashes that are not alcohol-based. Teach the patient to check the labels for alcohol content. Frequent, gentle mouth care promotes débridement of ulcerated lesions and can prevent superinfections. Chart 56-2 lists measures for special oral care.

Drug therapy used for stomatitis includes antimicrobials, immune modulators, and symptomatic topical agents. Complementary and alternative therapies may also be tried.

Antimicrobials, including antibiotics, antivirals, and antifungals, may be necessary for control of infection. Tetracycline syrup (swish/swallow) 250 mg/10 mL four times daily for 10 days may be prescribed, especially for recurrent aphthous ulcers (RAUs). The patient rinses for 2 minutes and swallows the syrup, thus obtaining both topical and systemic therapy. Minocycline swish/swallow and chlorhexidine mouthwashes may also be used.

A regimen of IV acyclovir (Zovirax) is prescribed for immunocompromised patients who contract herpes simplex stomatitis. Acyclovir is typically administered to those with normal kidney function at a dose of 5 mg/kg, infused at a constant rate over a 1-hour period every 8 hours for 7 days. Patients with healthy immune systems may be given acyclovir in oral or topical form.

For fungal infections like yeast, nystatin (Mycostatin) oral suspension 600,000 units four times daily for 7 to 10 days is the drug most often used. The patient swishes and swallows the topical preparation. Ice pop troches (lozenges) of the antifungal preparation allow the drug to slowly dissolve, and the cold provides an analgesic effect. Topical triamcinolone in benzocaine (Kenalog in Orabase) and oral dexamethasone elixir used as a swish/expectorate preparation are commonly used for stomatitis, especially RAU.

Immune modulating agents that may be prescribed include:

The exact mechanism for how these drugs work is not clear. However, they may inhibit release of mediators that contribute to the inflammation seen in patients with RAU.

Other drugs can be used to control pain, such as OTC benzocaine anesthetics (e.g., Orabase, Anbesol) and camphor phenol (Campho-Phenique). Fifteen mL of 2% viscous lidocaine every 3 hours (maximum of 8 doses per day) can be used as a gargle or mouthwash. Teach patients to use this drug with extreme caution because its anesthetizing effect may cause burns from hot liquids in the mouth. Patients may also become more susceptible to choking when using viscous lidocaine.

Dietary changes may also help decrease pain. Cool or cold liquids can be very soothing. Teach patients to avoid hard, spicy, salty, and acidic foods or fluids that can further irritate the ulcers. Include foods high in protein and vitamin C to promote healing, including scrambled eggs, bananas, custards, puddings, and ice cream, unless the patient has lactose intolerance.

Squamous Cell Carcinoma

More than 90% of oral cancers are squamous cell carcinomas that begin on the surface of the epithelium. Over a period of many years, premalignant (or dysplastic) changes begin. Cells begin to vary in size and shape. Alterations in the thickness of the lining of the epithelium develop, resulting in atrophy. These tumors usually grow slowly, and the lesions may be large before the onset of symptoms unless ulceration is present. Mucosal erythroplasia is the earliest sign of oral carcinoma. Oral lesions that appear as red, raised, eroded areas are suspicious for cancer. A lesion that does not heal within 2 weeks or a lump or thickening in the cheek is a symptom that warrants further assessment (Oral Cancer Foundation, 2010).

Squamous cell cancer can be found on the lips, tongue, buccal mucosa, and oropharynx. The major risk factors in its development are increasing age, tobacco use, and alcohol use. Most oral cancers occur in people older than 40 years. Tobacco use in any form (e.g., smoking or chewing tobacco) can increase the risk for cancer. A person who frequently consumes alcohol and uses tobacco in any form is at the highest risk. Genetic changes in patients with oral cancer have been found, especially the mutation of the TP53 gene (McCance et al., 2010).

An increased rate of oral cancer is found in people with occupations such as textile workers, plumbers, and coal and metal workers. Additional factors, such as sun exposure, poor nutritional habits, poor oral hygiene, and infection with the human papilloma virus (HPV16) may also contribute to oral cancer (Oral Cancer Foundation, 2010). People with periodontal (gum) disease in which mandibular (jaw) bone loss has occurred are especially at risk for cancer of the mouth.

Mouth cancers account for about 3% of all cancers in men and 2% of all cancers in women in the United States. Over 37,000 new cases are diagnosed each year, with almost 8000 deaths (Oral Cancer Foundation, 2010). Most cancers occur in middle-aged and older people, although in recent years, younger adults have been affected, probably as a result of sun exposure.