Xavier University - Ateneo de Cagayan

College of Nursing

In partial fulfillment of the requirements of Nursing Care Management 117

(NCM 117)

Oral and Esophageal Disorders

Submitted by:

Abragan, Camille Viktoria Ballares, Ma Therese P

Abucay, William Angelo C
Acabo, Gabrielle Jeanz A
Acac, Lance Alistair G
Afdal, Shamsa Hynra P
Aparece, Dara Doreen S
Artajo, Lyka Nicole B
Canda, Brigette Keeshia V
Canoy, Anna Isabella Lili B
Clarito, Kryschelle M
Dagumbal, Jan Levin
del Mar, Almira Louise M

Submitted to:

Mrs. Gemma Panal, RN, MN, LPT

Level III Clinical Instructor

BSN III - NB
December 11, 2020
Disorders of the teeth
a. Dental Plaque and Caries
1. Define the disease condition

Tooth decay is an erosive process that begins with the action of bacteria on
fermentable carbohydrates in the mouth, which produces acids that dissolve
tooth enamel. Tooth enamel is the hardest substance in the human body, but
dental erosion occurs for several reasons. Contributing factors include nutrition,
soft drink consumption, and genetic predisposition.

2. Identify the Causative agent

Dental caries is the most common infectious disease affecting humans. The
principal causative agents are a group of streptococcal species collectively
referred to as the mutans and streptococcus sobrinus are the most important
agents of human caries.

3. Signs and symptoms

Manifestations of dental plaque and caries include toothache (spontaneous pain

or pain the occurs without any apparent cause), tooth sensitivity, mild to sharp
pain when eating or drinking something sweet, hot or cold, visible holes or pits in
the teeth, brown, black or white staining on any surface of a tooth, and pain when
biting down.

4. Medical and Nursing management

Dentists can determine the extent of damage and type of treatment needed using
x-ray studies. Treatment for dental caries include Fillings, Dental Implants, and
Extraction, if necessary. It is the responsibility of the nurse managing the
patient’s care to assess the oral mucosa and decide on subsequent methods of
oral hygiene in consultation with the medical team. Measures to be taught to the
patient for preventing and controlling dental caries include practicing effective
mouth care, reducing the intake of starches and sugars, applying fluoride to the
teeth or drinking fluoridated water, refraining from smoking, controlling diabetes,
and using pit and fissure sealants.
b. Dentoalveolar Abscess or Periapical Abscess
1. Define the disease condition

Dentoalveolar abscess is a pocket of pus found in the tissues around the

root of a tooth caused by a bacterial infection. It can occur at different
parts of the tooth usually for different reasons. A periapical abscess
occurs at the tip of the root and is the most common dental abscess in
children whereas a dentoalveolar abscess occurs in the supporting
structures of the teeth and is the most common dental abscess in adults.
Dental abscess happens when cavities destroy the tooth’s enamel and
dentin which then allows bacteria to reach the dental pulp.

2. Identify the Causative agent

A nonpathologic resident bacterium gains entry when a person’s defenses are

unprotected, this happens when cavities destroy the tooth’s enamel and dentin.
The predominant bacterias associated with dental abscess include Bacteroides,
Fusobacterium, Actinomyces, Peptococcus, Peptostreptococcus, and
Porphyromonas as well as Prevotella oralis, Prevotella melaninogenica, and
Streptococcus viridans. Beta-lactamase producing organisms occur in one third
of dental abscesses.

3. Signs and symptoms

Signs and symptoms of tooth abscess are severe, persistent, throbbing

toothache that can radiate to the jawbone, neck or ear, sensitivity to hot and cold
temperature, sensitivity to the pressure of chewing or biting, fever, swelling in
your face or cheek, tender, swollen lymph nodes under your jaw or in your neck,
sudden rush or foul smelling and foul tasting, salty liquid in your mouth and pain
relief if the abscess ruptures and difficulty breathing or swallowing.

4. Medical and Nursing management

Treatment for tooth abscess is aimed at saving the tooth.

a. Medical Care
- Assess the airway for respiratory distress, oropharyngeal tissue
swelling or inability to handle secretions then secure airway with
endotracheal intubation or tracheostomy
- Properly collect specimen for gram stain and aerobic and anaerobic
cultures
 - Adminites empiric antibiotic therapy if necessary
- Administer analgesia
- Hydrate the patient

b. Surgical Care
- The primary therapy is surgical drainage of any pus collection. A
pulpectomy or incision and drainage is the recommended management of
a localized apical abscess. Incision and drainage or spontaneous rupture
of the abscess quickly accelerates resolution of the infection. Antibiotics is
not recommended for a localized dental abscess.
- Emergent surgery is indicated in the operating room if the airway is
threatened or if the patient's condition is rapidly deteriorating.
c. Malocclusion
1. Definition

Malocclusion is a disorder when the teeth of the upper and lower dental
arcs are misaligned when the jaws are closed. They typically have an
obviously misaligned bite or crooked, crowded, widely spaced, or
protruding teeth. This usually results in dental caries, early loss of primary
tooth and crowding in permanent dentition. (Rapeepattana, et. al, 2019)

2. Causative Agent
Malocclusion is inherited or can be acquired through thumb-sucking,
trauma and some other medical conditions.

3. Signs and Symptoms

a. Abnormal alignment of teeth
b. Abnormal appearance of face
c. Discomfort in chewing
d. Speech difficulties
e. Mouth breathing
f. Inability to bite into food correctly

4. Medical Management
The orthodontist realigns the teeth by gradually forcing it to a new location
with the use of wires or braces. These devices may be unattractive, but
this psychological burden must be overcome if good results are to be
achieved. In the final phase of treatment, a retaining device or a retainer is
worn for several hours each day to further support the tissues as they
adjust to the new alignment of the teeth.

5. Nursing Management
The patient must be instructed by the nurse to practice meticulous oral
hygiene. The retainer must continue to be worn even if the patient will
undergo an orthodontic correction and is admitted to the hospital for some
other problem.
Disorders of the jaw
ii. Temporomandibular Disorders
1. Define the disease condition

A disorder of the temporomandibular joint(s) that causes pain,

usually in front of the ear(s), sometimes in the form of a headache.

2. Identify the Causative agent

Pain in the TMJ can be due to trauma, such as a blow to the face;
inflammatory or degenerative arthritis, or poor dental work or
structural defects that push the mandible back towards the ears
whenever the patient chews or swallows. Grinding or clenching the
teeth due to stress is a frequent culprit. Sometimes muscles around
the TMJ used for chewing can go into spasm, causing head and
neck pain, and difficulty opening the mouth normally.

3. Signs and symptoms

● Pain or tenderness of your jaw

● Pain in one or both of the temporomandibular joints
● Aching pain in and around your ear
● Difficulty chewing or pain while chewing
● Aching facial pain
● Locking of the joint, making it difficult to open or close your mouth

4. Medical and Nursing management

a. Medical Management:
i. Medications
1. Pain relievers and anti-inflammatories. If over-
the-counter pain medications aren't enough to
relieve TMJ pain, your doctor or dentist may
prescribe stronger pain relievers for a limited time,
such as prescription strength ibuprofen.
2. Tricyclic antidepressants. These medications,
such as amitriptyline, are used mostly for
depression, but in low doses, they're sometimes
used for pain relief, bruxism control and
sleeplessness.
 3. Muscle relaxants. These types of drugs are
sometimes used for a few days or weeks to help
relieve pain caused by TMJ disorders created by
muscle spasms.
ii. Therapies
1. Oral splints or mouth guards (occlusal
appliances). Often, people with jaw pain will
benefit from wearing a soft or firm device inserted
over their teeth, but the reasons why these
devices are beneficial are not well-understood.
2. Physical therapy. Along with exercises to stretch
and strengthen jaw muscles, treatments might
include ultrasound, moist heat and ice.
iii. Surgical or other procedures
1. Arthrocentesis. Arthrocentesis is a minimally
invasive procedure that involves the insertion of
small needles into the joint so that fluid can be
irrigated through the joint to remove debris and
inflammatory byproducts.
2. Injections. In some people, corticosteroid
injections into the joint may be helpful.
Infrequently, injecting botulinum toxin type A
(Botox, others) into the jaw muscles used for
chewing may relieve pain associated with TMJ
disorders.
3. TMJ arthroscopy. In some cases, arthroscopic
surgery can be as effective for treating various
types of TMJ disorders as open-joint surgery. A
small thin tube (cannula) is placed into the joint
space, an arthroscope is then inserted and small
surgical instruments are used for surgery. TMJ
arthroscopy has fewer risks and complications
than open-joint surgery does, but it has some
limitations as well.
4. Modified condylotomy. Modified condylotomy
addresses the TMJ indirectly, with surgery on the
mandible, but not in the joint itself. It may be
helpful for treatment of pain and if locking is
experienced.
 5. Open-joint surgery. If your jaw pain does not
resolve with more-conservative treatments and it
appears to be caused by a structural problem in
the joint, your doctor or dentist may suggest open-
joint surgery (arthrotomy) to repair or replace the
joint. However, open-joint surgery involves more
risks than other procedures do and should be
considered very carefully, after discussing the pros
and cons.

b. Nursing Management:
i. Health teaching. Education can help you understand the
factors and behaviors that may aggravate your pain, so
you can avoid them. Examples include teeth clenching or
grinding, leaning on your chin, or biting fingernails.
Disorders of the esophagus
iii. Dysphagia
1. Define the disease condition

Dysphagia refers to the difficulty in swallowing. Some may

experience complete inability to swallow or may only have trouble
safely swallowing liquids, foods, or saliva. This is the most common
clinical manifestation of esophageal disorder. It is most common in
older adults, babies and individuals who have problems in their
brain or nervous system. Esophageal dysphagia or low dysphagia
is one type of dysphagia which indicates a problem in the
esophagus. This may be due to a certain blockage or irritation.

2. Identify the Causative agent

a. Mechanical Obstruction - this includes congenital defects, cancer

(esophageal cancer), and acquired conditions such as hiatal hernia.
b. Cardiovascular Abnormalities - this is particularly in older people.
Conditions that specifically cause vascular dysphagia are enlarged
heart, aortic aneurysm, and calcification of the descending aorta.
c. Neurologic Diseases - dysphagia may be caused by certain
neurologic diseases such as stroke, multiple sclerosis,
poliomyelitis, and amyotrophic lateral sclerosis.
d. Other causes

3. Signs and symptoms

● Coughing or choking when eating or drinking

● Bringing food back up (sometimes through the nose)
● Sensation that food is stuck in the throat or chest
● Persistent drooling of saliva
● Unable to chew food properly
● “Gurgly” wet sounding voice when eating or drinking
● Recurrent heartburn
● Unexplained weight loss
● Difficulty initiating swallowing
● Recurrent pneumonia

4. Medical and Nursing management

a. Medical Management
i. Botulinum Toxin (Botox) - used when the muscles of the
esophagus have become stiff, it paralyzes the stiff muscle in
which it reduces constriction.
ii. Exercises for swallowing muscles - if you have problems
with your brain, nerves, or muscles, exercises are needed to
train your muscles to work together to help you swallow.
Specific positions of the body and ways how to put food in
the mouth must be learned to be able to swallow better.
iii. Changing diet - eat certain foods and liquids to make
swallowing easier
iv. Dilation - a device is placed down the esophagus to carefully
expand any narrow areas in the esophagus.
v. Endoscopy - a long, thin scope will be utilized to remove an
object or food stuck in the esophagus.
vi. Surgery - some obstructions can only be removed surgically
such as tumor or diverticula. By placing a stent, swallowing
can be improved. Endoscopic dilation can also be
performed.
b. Nursing Management
i. Provide adequate rest periods before meal time.
ii. Encourage intake of a high-calorie diet that involves all food
groups, as indicated.
iii. Position client into 90-degree upright position with the head
flexed forward at a 45 degree angle
iv. Advance slowly, start with small amounts; and if possible
alternate servings of liquids and solids.
v. Increase oral intake and maintain oral hygiene.
iv. Hiatal Hernia

1. Define the disease condition

A hiatal hernia occurs when the upper part of the stomach pushes through
the diaphragm, the muscle that separates the stomach and chest, through
a small opening called the hiatus, separating the abdomen and chest
(diaphragm).

2. Identify the Causative agent

A hiatal hernia occurs when weakened muscle tissue allows your stomach
to bulge up through your diaphragm. It's not always clear why this
happens. But a hiatal hernia might be caused by age related changes in
the diaphragm, injury to the area, being born with a unusually large hiatus,
and persistent and intense pressure on the surrounding muscles, such as
while coughing, vomiting, straining during a bowel movement, exercising
or lifting heavy objects.

3. Signs and symptoms

Symptoms include heartburn, regurgitation of food or liquids into the

mouth, backflow of stomach acid into the esophagus (acid reflux), difficulty
swallowing, chest or abdominal pain, shortness of breath, and vomiting of
blood or passing of black stools, which may indicate gastrointestinal
bleeding.

4. Medical and Nursing management

a. Medical Management
i. Antacids that neutralize stomach acid - Antacids, such as
Mylanta, Rolaids and Tums, may provide quick relief.
Overuse of some antacids can cause side effects, such as
diarrhea or sometimes kidney problems.
ii. Medications to reduce acid production - Known as H-2-
receptor blockers — include cimetidine (Tagamet),
famotidine (Pepcid) and nizatidine (Axid).
iii. Medications that block acid production and heal the
esophagus - These medications — known as proton pump
inhibitors — are stronger acid blockers than H-2-receptor
 blockers and allow time for damaged esophageal tissue to
heal. Over-the-counter proton pump inhibitors include
lansoprazole (Prevacid 24HR) and omeprazole (Prilosec,
Zegerid).
iv. Surgery - Surgery is generally used for people who aren't
helped by medications to relieve heartburn and acid reflux,
or have complications such as severe inflammation or
narrowing of the esophagus. This may involve pulling your
stomach down into your abdomen and making the opening
in your diaphragm smaller, reconstructing an esophageal
sphincter or removing the hernia sac.
b. Nursing Management
i. Instruct client to avoid lying down after a meal or eating late
in the day
ii. Elevate the head of client’s bed 6 inches (about 15
centimeters)
iii. Encourage client to eat several smaller meals throughout the
day rather than a few large meals
iv. Advise client to avoid foods that trigger heartburn, such as
fatty or fried foods, tomato sauce, alcohol, chocolate, mint,
garlic, onion, and caffeine
Diverticulum

1. Define the disease condition

A diverticulum is an outpouching of the mucosa and submucosa that protrudes through

a weak portion of the stomach muscle. Diverticula may occur in one of the three areas
of the esophagus—the pharyngoesophageal or upper area of the esophagus, the
midesophageal area, or the epiphrenic or lower area of the esophagus—or they may
occur along the border intramurally.

2. Identify the Causative agent.

Diverticulitis results from normal colonic flora released into the peritoneal cavity through
a colonic perforation. Therefore, this is a polymicrobial infection. The most common
organisms include anaerobes, such as Bacteroides fragilis, and gram negatives, such
as Escherichia coli.

3. Signs and symptoms.

Symptoms include difficulty swallowing, fullness in the neck, belching, regurgitation of

undigested food, and gurgling noises after eating. When the patient assumes a
recumbent position, undigested food is regurgitated, and coughing may be caused by
irritation of the trachea. Halitosis and a sour taste in the mouth are also common
because of the decomposition of food retained in the diverticulum.

4. Medical and Nursing management.

Diverticulum is progressive, the only means of cure is surgical removal of the

diverticulum. During surgery, care is taken to avoid trauma to the common carotid artery
and internal jugular veins. In addition, a myotomy of the cricopharyngeal muscle is
performed to relieve spasticity of the stomach muscles. Postoperatively, the surgical
incision is observed for leakage from the esophagus and a developing fistula. Food and
fluids are withheld until x-ray studies show no leakage at the surgical site. The diet
begins with liquids and is progressed as tolerated. Intramural diverticula usually regress
after the esophageal stricture is dilated.

Provide measures to rest the colon during an acute exacerbation, which results when
food or bacteria in the diverticula cause inflammation. Administer nothing by mouth.
Administer IV fluids. Institute nasogastric suctioning. Keep the client on bed rest
Help restore the client’s normal bowel elimination pattern by administering one or more
of the following: Bulk laxatives, Stimulant laxatives, Stool softeners, Saline laxatives,
and at least 8 oz of water with any agent. Help prevent constipation. Encourage daily
exercise such as walking, which increases bowel peristalsis. Teach the client about
nursing care. Inform the client that all nursing interventions for diverticulitis are aimed at
moving the stool through the colon as easily and with as little irritation as possible.
Administer medications, which may include antibiotics, opioid analgesics, and
antispasmodics. Provide return to normal bowel elimination patterns as symptoms
subside. Slowly increase oral intake until the client is drinking six to eight glasses of
water daily. Offer a low-fiber diet until signs of infection decrease; then gradually
increase fiber until the client is eating a high-fiber diet. If a high-fiber diet alone prevents
constipation, encourage medication with caution, especially in elderly clients
v. Perforation
1. Define the disease condition

Esophageal perforation refers to a presence of hole in the esophagus. The

esophagus is a muscular tube-like organ where food and liquid pass from the
mouth to the stomach. This disease is uncommon, but it is a serious medical
condition. It may be in the neck, chest, or abdomen. A history of preexisting
upper gastrointestinal pathology such as gastroesophageal reflux disease,
hiatal hernia, carcinoma, strictures, radiation therapy, Barrett esophagus,
varices, achalasia, and infection raises the chances of an individual to
develop a perforation.

2. Identify the Causative agent

There are several causes in this disease condition, one of which is an

injury to the esophagus due to an accident. Another is when a medical
instrument is inserted for diagnostic or treatment procedures which can
potentially perforate the esophagus. Prolonged vomiting and forceful
retching are also one of the factors since gastric acid passes through the
esophageal lining leading to irritation and perforation. Ingestion of bones
or other foreign objects and throat tumors are the less common causes of
the disease.

3. Signs and symptoms

Signs and symptoms of esophageal perforation include air bubbles under

the skin, difficulty swallowing or dysphagia, fever and chills, low blood
pressure and tachycardia, pain at the perforation site (in the neck, chest,
or abdomen), rapid or labored breathing, and vomiting which may include
blood.

4. Medical and Nursing management

The physician’s main priority is to treat the perforation as quickly as

possible to prevent any signs of infection. A patient should receive
treatment within 24 hours of diagnosis. The fluid that leaks out of the hole
of the esophagus can be trapped in the tissue between the lungs. Which
will lead to breathing difficulties and lung infections. A permanent
narrowing of the esophagus can develop if the disease is not treated
immediately. To prevent complications, early treatment includes draining
any traces of fluid inside the chest. The doctor may also prescribe
antibiotics to prevent infection. The patient will observe NPO until the
treatment is completed. Surgical management includes closing the
perforation site. The surgeon will have to remove any scar or infected
tissues around the area and sew the hole until it is completely closed.
Large perforations may require partial esophagectomy or removal of a
portion of the esophagus and connecting the remaining section to the
stomach. After the surgery, it is the nurse’s responsibility to always check
the client’s airway, breathing, and circulation. The nurse should assess the
surgical site to see if there are any signs of infection. The nurse should
also monitor the client’s vital signs every 4 hours or as indicated by the
physician, as well as the intake and output, and IV line.
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