Management of oral problem

in Palliative care setting

Prepared by
Jenisha Adhikari
BSN
 Introduction
 Oral complications from radiation to the
head and neck or chemotherapy for any
malignancy can compromise patients’
health and quality of life, and affect their
ability to complete planned cancer
treatment.
 For some patients, the complications can
be so debilitating that they may tolerate
only lower doses of therapy, postpone
scheduled treatments, or discontinue
treatment entirely.
 Oral complications can also lead to
serious systemic infections
 Oral complications of cancer treatment arise in
various forms and degrees of severity, depending
on the individual and the cancer treatment.
 Chemotherapy often impairs the function of bone
marrow, suppressing the formation of white blood
cells, red blood cells, and platelets
(myelosuppression).
 Some cancer treatments are described as
stomatotoxic because they have toxic effects on
the oral tissues.
Oral complications
common to both
chemotherapy and
radiation
 Oral mucositits
It is a common complication
of chemotherapy. It begins
5-10 days after the
initiation of chemotherapy
and lasts 7-14 days.
Chemotherapy-
induced oral
mucositis causes the
mucosal lining of the
mouth to atrophy and break
down forming ulcers
 Xerostomia/salivary gland dysfunction

• Dryness of the mouth due to thickened,

reduced, or absent salivary flow; increases
the risk of infection and compromises
speaking, chewing, and swallowing.
Medications other than chemotherapy can
also cause salivary gland dysfunction.
Persistent dry mouth increases the risk for
dental caries.
 Functional disabilities
• Impaired ability to eat, taste, swallow, and
speak because of mucositis, dry mouth,
trismus, and infection.
 Taste alterations
• Changes in taste perception of foods,
ranging from unpleasant to tasteless.
 Nutritional compromise
• poor nutrition from eating difficulties
caused by mucositis, dry mouth,
dysphagia, and loss of taste.
 Abnormal dental development

• Altered tooth development, craniofacial

growth, or skeletal development in
children secondary to radiotherapy and/or
high doses of chemotherapy before age 9
 Neurotoxicity
• Persistent, deep aching and burning pain
that mimics a toothache, but for which no
dental or mucosal source can be found.
This complication is a side effect of certain
classes of drugs, such as the vinca
alkaloids.
Bleeding •  Oral bleeding from the
decreased platelets and
clotting factors
associated with the
effects of therapy on
bone marrow. 
Radiation
caries
Lifelong risk of
rampant dental
decay that may
begin within 3
months of
completing radiation
treatment if changes
in either the quality
or quantity of saliva
persist
Trismus
tissue
fibrosis
 Loss of elasticity of
masticatory muscles
that restricts normal
ability to open the
mouth.
Jaw lock

Reduced opening of
jaw
Restricted
mandibular movement
Osteonecros
is
Blood vessel
compromise and
necrosis of bone
exposed to high-
dose radiation
therapy; results in
decreased ability to
heal if traumatized.
Nursing Management for Oral Problems

 Plan and implement a meticulous mouth

care regimen after each meal regularly and
every 4 hours while awake.
 Increase the frequency of oral hygiene by
rinsing with one of the suggested solutions
between brushings and once during the
night especially if signs of mild stomatitis 
 Discontinue flossing if it causes pain.
 Explain that topical analgesics can be
administered as 15 to 20 minutes before
meals, or painted on each lesion
immediately before mealtime. Instruct
patient to hold solution for several
minutes before expectoration.
 Explain the use of topical protective agents

 Zilactin or Zilactin-B
This medicated gel contains benzocaine for pain and is painted on the
lesion and allowed to dry to form a protective seal and promote healing of
mouth sores.

 Gelclair
This is a bioadherent oral gel that covers the oral cavity and forms a
protective barrier to relieve pain.

 Palifermin
This agent decreases the incidence and duration of severe oral mucositis
in patients with hematological cancers undergoing high-
dose chemotherapy followed by bone marrow transplantation.
 Give local antimicrobial agents as ordered.

 Use tap water or normal saline to provide oral care; do not use
commercial mouthwashes containing alcohol or hydrogen
peroxide

 If patient does not have a bleeding disorder and is capable to

swallow, encourage to brush teeth with a soft pediatric-sized
toothbrush using a fluoride-containing toothpaste after every
meal and to floss teeth daily.

 Maintain the use of lubricating ointment on the lips.

 For eating problems:
• Encourage a diet high in protein and vitamins.
• Serve foods and fluids lukewarm or cold.
• Serve frequent small meals or snacks spaced
throughout the day.
• Encourage soft foods (e.g., mashed potatoes,
puddings, custards, creamy cereals).
• Encourage the use of straw.
• Encourage peach, pear, or apricot nectars and
fruit drinks instead of citrus juices.
 Use foam sticks to moisten the oral mucous
membranes, clean out debris, and swab out the mouth
of the edentulous patient. Do not use to clean the teeth
or else the platelet count is very low, and the patient
is prone to bleeding gums

 Have loose-fitting dentures adjusted.

 Make sure that if patient has denture on, he/she has it

cleaned daily and if possible take them off before
sleeping
 Educate patient on how to inspect the oral
cavity and monitor for signs and
symptoms of infection, complications, and
healing.
 Educate patient on how to implement a
personal plan of oral hygiene including a
schedule of care.