Learning Objectives
By the end of this section, you will be able to:
- Discuss pathophysiology, risk factors, and clinical manifestations for oral cavity disorders
- Describe the diagnostics for and laboratory values monitored in the management of oral cavity disorders
- Apply nursing concepts and plan associated nursing care for the patient with oral cavity disorders
- Evaluate the efficacy of nursing care for patients with oral cavity disorders
- Describe the medical therapies that apply to the care of oral cavity disorders
Digestion begins in the upper gastrointestinal tract at the mouth, where individuals chew food—a process called mastication. Mastication results in mechanical digestion when food is broken down into small chunks and swallowed. Masticated food is formed into a bolus as it moves toward the pharynx in the back of the throat and then into the esophagus (Figure 19.4). Dental caries, periapical abscesses, oral cancer, salivary calculus, or temporomandibular joint (TMJ) disorders can prevent a patient from this first step of digestion. This section will look at common oral cavity disorders, as well as how the nurse can effectively care for these patients.
Dental Caries and Plaque
The term plaque refers to a sticky film on the teeth made up of leftover food particles and bacteria. Poor dental hygiene allows plaque to break down or demineralize tooth enamel, causing dental caries or cavities. Dental caries (Figure 19.5) are one of the most common chronic oral cavity diseases, even though they are easily preventable with good oral hygiene (CDC, 2022b). Caries may cause pain, make it difficult to chew foods and drink liquids, and can also affect an individual’s self-esteem when the caries are easily visible.
Pathophysiology
Dental caries are caused by cariogenic bacteria, bacteria that cause tooth decay, in the mouth. These bacteria live in plaque and biofilm on the teeth and convert carbohydrates, such as starches and sugars, into acids (Rathee & Sapara, 2023). This acidic environment causes the calcium on enamel to be slowly dissolved or demineralized, resulting in caries. The caries will continue to expand until appropriately treated. Factors that contribute to an increased chance of dental caries include tobacco use, diabetes, high carbohydrate intake (including high amounts of sugar), advanced age, and dry mouth.
Clinical Manifestations
Initially, dental caries can be asymptomatic. A patient may complain of tooth pain or sensitivity when eating foods that are hot, cold, or sweet. Physical signs ultimately include brown, black, or white discoloration or staining of the tooth. With more advanced disease, a small hole or cavity may appear.
Prevention
Prevention of dental caries starts with brushing teeth two times a day with a fluoride toothpaste and flossing daily. The recommendation is for individuals to see a dentist every 6 months to get a professional teeth cleaning, identify and treat troublesome areas early, and apply a fluoride treatment. Toothbrushes should be replaced every 3 to 4 months. Smoking cessation can also reduce the incidence of dental caries. Other interventions, such as drinking fluorinated water and eating a well-balanced diet, also prevent caries.
In the inpatient setting, it is important for nurses to provide mouth care for patients who are unable to perform self-care. This includes brushing the teeth with a soft-bristled toothbrush or oral sponge and placing water soluble ointment or gel on the lips to prevent drying.
Life-Stage Context
Older Adult Oral Health
Caries and tooth loss can increase with age because of decreased saliva production, receding gums, chronic disease, and vision, cognitive, and physical limitations. Because older adults often have receding gums, cavities are more likely to develop at the root of the tooth. Dry mouth also causes bacteria to build up in the mouth more easily, leading to tooth decay (NIDCR, 2021). Loss of dental benefits upon retirement can contribute to difficulty accessing appropriate dental care (CDC, 2020).
Cancer of the Oral Cavity or Pharynx
Cancer of the oral cavity or pharynx can develop on the tissue of the mouth and gums, on or under the tongue, and at the back of the mouth or throat. It is diagnosed most often in people over the age of 40 years, and accounts for about 3 percent of the yearly diagnosed cancers in the United States (NIDCR, 2023). The 5-year relative survival rate for these types of cancers is 68% in the United States.
Pathophysiology
Oral cancer is caused by DNA mutations in the cells of the mouth, causing a growth of mutated cells to occur. Although the immune system usually detects and eliminates mutated cells in the body, these cells can multiply unnoticed. Although it is unknown what exactly causes the DNA mutations, factors that have been shown to increase the risk of oral cancer include tobacco use, heavy alcohol use, exposure to human papillomavirus, excessive sun exposure to the lips, and a weak immune system.
Clinical Manifestations
Oral cancer is suspected when an oral lesion will not heal and is in place for 2 weeks or longer. The lesion may be an unusual color compared with the surrounding tissues. The cancer may grow or cause bleeding. Generally, the patient is otherwise asymptomatic (Figure 19.6), which delays diagnosis and treatment.
Assessment, Diagnostics, and Laboratory Values
When assessing a patient for oral cancer, signs and symptoms to seek include loose teeth, lip or mouth sores that do not heal, white or red patches inside the mouth, lumps (visible in the mouth or palpated around the jaw or neck), pain in the ears or mouth, hoarseness, and difficulty swallowing, chewing, or moving the jaw. Be sure to accurately document and report findings appropriately.
When a patient is suspected to have oral cancer, the selection of diagnostic testing is dependent on the area of the lesion or tumor. Diagnostic tests that may be used to diagnose oral cancer include endoscopy, biopsy, oral brush biopsy, human papillomavirus testing, x-ray, CT scan, barium swallow study, magnetic resonance imaging (MRI), ultrasound, and positron emission tomography (PET) scan. If metastasis is suspected, other areas of the body may be evaluated.
Nursing Care of the Patient with Cancer of the Oral Cavity
Nursing care of the patient with oral cancer focuses on patient support during therapy and treatment, nutrition promotion, pain control, and providing emotional support. Patient teaching is done, with a focus on smoking and alcohol cessation, a healthy diet, and sun safety, and regular exercise should be emphasized. The nursing plan of care should be evaluated and updated as the patient progresses through treatment.
Recognizing Cues and Analyzing Cues
Follow-up is important when discovering lesions or growths in the oral cavity or neck. Asking focused and specific questions, such as when the patient noticed the growth or lesion, if it is painful, and if it has changed at all, will give the nurse cues to further evaluate. Assess the patient for any breathing, chewing, or swallowing difficulties, and report findings to the provider.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priorities of care during treatment are maintaining a patent airway and healthy nutritional status, and providing emotional support, pain relief, and patient education. Frequent airway assessments may be necessary. The patient may require enteral (i.e., through the GI tract) or parenteral (i.e., through an intravenous [IV] access) nutrition during treatment. The nurse should ensure the patient has access to a pen and paper so they can communicate postoperatively. Developing an appropriate care plan based on nursing diagnoses and developing SMART goals will aid the nurse in patient care.
Evaluation of Nursing Care and Outcomes for the Patient with Cancer of the Oral Cavity
To evaluate the effectiveness of nursing actions, review the goal and see if it was achieved by the set deadline. If the goal is not met, goals and interventions will need to be modified. The ideal outcome of care related to oral or oropharangeal cancer is to cure the disease. The nurse maintains an active role in administering and monitoring therapies, including noting the patient’s response. The nurse also evaluates how well symptoms are being managed and collaborates with the provider frequently.
Medical Therapies and Related Care
Medical therapy for the treatment of oral and oropharyngeal cancer depends on the type or nature of the lesion and the preference of the physician and patient. Smaller lesions on the lip may be surgically excised; larger lesions may need radiation therapy. Tongue lesions may be treated with radiation, chemotherapy, surgery, or a combination of therapies. Some cases necessitate removal of part or all of the tongue. For larger neck or mouth dissections, reconstructive surgery may be required using a skin flap from the arm or chest. Depending on the progression of disease and care, the patient may require a temporary or permanent tracheostomy and feeding tube for management. Multiple people make up the interdisciplinary team and can include an oncologist, surgical oncologist, radiation oncologist, plastic surgeon, oncologic dentist, physical therapist, speech language pathologist, psychologist, audiologist, and nutritionist.
Temporomandibular Disorders
The TMJ is a sliding hinge (Figure 19.7) that connects the mandible to the skull. This sliding joint, located on each side of the jaw, allows for the range of motion needed during mastication. Temporomandibular disorder (TMD) is a collection of more than 30 disorders that cause pain and dysfunction of jaw movement. TMD is twice as common in women, especially those between 35 and 44 years old (NIDCR, 2023).
Pathophysiology
The pathophysiology of TMD is unclear. Research suggests it is caused by a combination of psychological stressors, life stressors, genes, jaw trauma, grinding the teeth, and arthritis or other inflammatory conditions.
Clinical Manifestations
The patient may present with pain in the jaw area that may radiate to the face, neck, or ears; limited movement or locking of the jaw; clicking or popping when opening or closing the mouth; and a change in bite alignment.
Assessment and Diagnostics
To assess for TMD, perform a focused assessment of the jaw. Inquire when the symptoms started, what makes them worse or better, and their frequency. Assess the range of movement of the jaw and ask the patient to identify any aggravating factors. Ask if there are any accompanying symptoms, such as headaches or back pain.
Link to Learning
This animation shows a healthy TMJ in motion.
The three main classes of TMD (Figure 19.8) are disorders of the joints, disorders of the muscles, and headaches associated with TMD (NIDCR, 2023).
Generally, diagnosis is based on symptoms, physical assessment, and medical history. An x-ray, CT scan, or MRI may be performed for further evaluation and to rule out other conditions.
Nursing Care of the Patient with Temporomandibular Disorders
Nursing care should focus on pain relief and education about prevention. Prevention education should include self-management strategies, such as stress management to prevent grinding teeth and jaw clenching, that the patient can use in conjunction with other treatments.
Recognizing Cues and Analyzing Cues
A patient who presents with a complaint of jaw pain and also has a history of jaw clenching when experiencing stress, may have TMD. After collecting and recording assessment data, the nurse presents the findings to the provider for further evaluation.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The priority of care would be symptom improvement along with pain management and patient teaching. Teaching should include avoiding eating hard foods, reducing the habit of jaw clenching or gum chewing, application of heat or cold to area, taking NSAIDs, and gently performing stretching exercises of the jaw.
Evaluation of Nursing Care and Outcomes for the Patient with TMD
The nurse will evaluate the care provided to see if symptoms of jaw pain have improved. It is important to note that symptom improvement may happen over time and the patient will have to be educated on the importance of therapy compliance. The primary patient outcome for TMD is improvement of symptoms. The nurse evaluates how often the patient is experiencing pain, including if or how often it is preventing the patient from performing normal tasks, such as eating. It is also important for the nurse to assess if there is improvement to any underlying factors, such as stress management or healthy coping mechanisms the patient has developed.
Medical Therapies and Related Care
TMD is usually a temporary disorder that resolves without aggressive treatment. Physical therapy may be helpful by stretching the soft tissues and muscles supporting the joint to increase range of motion and reduce pain. Medications, such as NSAIDs, muscle relaxants, opioids, or antidepressants, may be prescribed as pain management measures. An intraoral orthotic, or bite guard, may protect the jaw at night from nocturnal teeth grinding (Figure 19.9). Psychological and behavioral therapy can also help the patient with stress management and grinding prevention.