I.

Overview of the Disease

y Stomatitis is the inflammation of the mouth. It may be of infectious origin or a symptom of systemic disease; it may be caused by mechanical or chemical trauma. y Jagged teeth, cheek biting, and mouth breathing may result in mechanical trauma. y Certain foods and drinks and sensitivity to mouthwashes and dentifrices may produce chemical trauma.

y The inflammatory sloughing of tissue allows

organisms to multiply. Thus, trauma may lead to infection by viruses, bacteria, yeasts, or molds. People who receive chemotherapy for cancer frequently develop severe, very painful stomatitis.
y described an inflammation of the mucous membranes

of the mouth
y condition referred to as mucositis y it is usually a short-term condition, lasting from just a

few days to a few weeks

Aphthous Stomatitis
also known as recurrent aphthous ulcers or

canker sores, is a type of stomatitis that presents with shallow, painful ulcers that are usually located on the lips, cheeks, gums, or roof or floor of the mouth.
this ulcers can range from pinpoint size to

up to 1 in (2.5 cm) or more in diameters.

STOMATITIS

Herpes Stomatitis
can occur anywhere between six months and

five years of age but it is most common in children one to two years old who have not been exposed to the herpes virus before.

Causes:
y Treatments (chemotherapy or radiation therapy) y Poorly fitted and appliances (denture) y Cheek biting y Hot and spicy foods y Disease (herpetic infection) y Poor oral hygiene y Nutritional Deficiencies (Vit. B12 Deficiencies) y Excessive drinking of alcohol y Excessive use of tobacco

Anatomy and Physiology

Mouth (oral Cavity)
y a

mucous membrane, lined cavity. y Lips, protects its anterior opening. y Cheeks, form its lateral walls; Hard palate, forms its anterior roof; Soft palate, forms its posterior roof. y Uvula, is a fleshy fingerlike projection of the soft palate, which extends downwards from its posterior edge.

y Vestibule, space between the lips and cheeks

externally and the teeth and gums internally. Oral Cavity proper, area contained by the teeth.
y Tongue, occupies the floor of the mouth. y Lingual frenulum, a fold of mucus membrane,

secures the tongue to the floor of the mouth and limits its posterior movement.
y Palatine tonsils, paired masses of lymphatic

tissue.
y Lingual tonsils, covers the base of tongue just

beyond.

y The important function of tonsils is, along with

other lymphatic tissues, are part of the bodys defense system. When the tonsils become inflamed and enlarged, they partially block the entrance into the throat, making swallowing difficult and painful. y Oral mucosa is the mucous membrane epithelium of the mouth.

II. Pathophysiology
RISK FACTORS: Treatments (Chemotherapy and radiation therapy) excessive alcohol intake excessive tobacco use hot and spicy foods cheek biting poor oral hygiene ill fitted oral appliances nutritional deficiency Inflammation occurs Kills rapid growing cells (esp. mucus membrane) Ulceration occurs if not detected or treated

Irritation to the Mucous membrane Stomatitis

III. Assessment
A. Nursing History 1. Obtaining a health history allows the nurse to

determine the patients learning needs concerning preventive oral hygiene and to identify symptoms requiring medical evaluation. 2. The history addresses the patients normal brushing and flossing routine; frequency of dental visits; awareness of any lesions or irritated areas in sputum; discomfort caused by certain foods; daily foods intake; use of alcohol and tobacco; and the need to wear dentures.

3. A careful physical assessment follows the health

history. Both the internal and the external structures of the mouth and throat are inspected and palpated. Dentures are partial plates are removed to ensure a thorough inspection of the mouth. In general, the examination can be accomplished by using a bright light source (penlight) and tongue depressors. Gloves are worn to palpate the tongue and abnormalities.

Risk factors:
Side effects of prescribed drugs Tobacco use Alcohol abuse Exposure to radiation, lead, mercury, acids,

heavy metals Trauma from cheek biting, mouth breathing, or illfitting orthodontia Sensitivity to toothpaste, mouthwash, food dyes, preservatives and spices

B. Physical

Assessment

Parts to be assessed

Technique to be used

Purpose

Lips

Inspection

Examine the lips for moisture, hydration, color, texture, symmetry, and the presence of ulcerations and fissures. The lips should be moist, pink, smooth, and symmetric. The patient is instructed to open the mouth wide; a tongue blade is then inserted to expose the buccal mucosa for an assessment of color and lesions. The gums are inspected for inflammation, bleeding, retraction, and discoloration. The odor of the breath is also rated. The hard palate is examined for color and shape. The dorsum of the tongue is inspected for texture, color and lesions. A thin white coat and large, vallate papillae in a V formation on the distal portion of the dorsum of the tongue are normal findings. The patient is instructed to protrude the tongue and move it laterally. This provides the examiner with an opportunity to estimate the tongues size as well as its symmetry and strength (it assess the 12th cranial nerve hypoglossal).

Gums

Inspection

Tongue

Inspection

yFurther inspection of the ventral surface of the tongue and the floor of the mouth is accomplished by asking the patient to touch the roof of the mouth with the tip of the tongue. yAny lesions of the mucosa or any abnormalities involving the frenulum or superficial veins in the undersurface of the tongue are assessed for location, size, color and pain. yThis is a common area foe oral cancer, which presents as a white or red plaque, an indurate ulcer, or a wary growth.

y A tongue blade is used to depress the tongue for

adequate visualization of the pharynx. It is pressed firmly beyond the midpoint of the tongue; proper placement avoids a gagging response.
y The patient is told to tip the head back, open the

mouth wide, take a deep breath, and say ah, Often this flattens the posterior tongue and briefly allows a full view posterior pharynx.

 These structures are inspected for color, symmetry

and evidence of exudates, ulcerations, or enlargement. Normally the uvula and soft palate rise symmetrically with a deep inspiration or ah, this indicates an intact in vagus nerve-10th CN.
 A complete assessment of the oral cavity is essential

because many disorders, such as cancer, diabetes, and immunosuppressed conditions resulting from medication therapy or AIDS may be manifested by changes in the oral cavity, including stomatitis.

Physical Examination
Signs and symptoms:  Mouth ulcers or sores  Pain in mouth  Sensitivity to spicy foods  Reddened mucus membrane  Dry or swollen tongue  Difficulty swallowing  Inability to eat or drinks

Herpes Stomatitis
 Fever (38.3-40 c), which may precede the       

appearance of blisters and ulcers by one or two days Irritability and restlessness Blisters in mouth, often on the tongue or cheeks or roof of the mouth, which the pop and form ulcers Swollen gums Pain in the mouth Drooling Difficulty swallowing Foul-smelling breath

Aphthous Stomatitis
 Burning or tingling sensation in the mouth prior to

the onset of other symptoms  Skin lesions on the mucous membranes of the mouth, which begins as a red spot or bump, then develop into an open ulcer, which is usually small (one to two mm to one cm in diameter)

Clinical Manifestations:
y Allergy- Shiny erythema with slight edema,

itching, drying, burning

y Thrush-White,

raised, milk- curd patches; bleeding; dryness of the mouth; diminished taste; pain; fever; lymphadenopathy gum retraction from teeth

y Gingivitis-Redness, swelling, bleeding of gums;

y Herpetic-Ulcers 3-4 cm in diameter scattered

over mucous membranes; swollen, inflamed gums; enlarged lymph nodes

y Canker

sores- Small, yellowish, hardened, painful sores with red, raised margins that often appear singly or in groups on the lips or in the corner of the mouth

y Necrotizing-Necrotic

ulceration of mucous membranes with severe pain, increased salivation, and inability to eat; fetid breath; bleeding gums; difficulty talking and swallowing; pseudomembrane on ulcers

C. Diagnostic/Laboratory Test

Blood tests

 May be done to

determine if any infection is present

Cultures
 May

be done to determine if an infectious agent may be the cause of the problem

IV. Medical and Surgical Management

Medical Management
Topical anesthetics for pain Intravenous fluid Viscous lidocaine or topical anesthetics- medicines that numb the mouth Topical or systemic corticosteroids or acyclovir for herpetic lesions

Pharmacological management
y Acetaminophen-for fever over 101 F (38.3 C)

and to address pain

y Antibiotics (antiviral) acyclovir, penciclovir, y Topical or oral tetracycline

Generic/ Brand name

Classification

Mechanism of Action

Nursing Responsibilities

Acetaminophen

Analgesic and antipyretic medications

Antipyretic: reduces fever by acting directly on the hypothalamic regulating center to cause vasodilation and sweating which helps dissipates the heat.

Take the drug only for complaints indicated, it is not an anti inflammatory agent. Discontinue drug if hypersensitivity occur.

Generic/ Brand name

Classification

Mechanism of Action

Nursing Responsibilities

Acyclovir

Anti viral medications

Anti viral activity; Oral acyclovir is inhibits viral DNA not a cure for your replication. disease but should make you feel better and this drug may cause burning, itching, rash, notify to the health care provider if this are pronounce.

Generic/ Brand name

Classification

Mechanism of Action

Nursing Responsibilities

Oral Tetracycline

Antibiotics and tetracycline

Bacteriostatic: Inhibits protein synthesis of susceptible bacteria. Preventing cell replication.

Administer oral medication on an empty stomach, 1 hour before or 2-3 hours after meals.

V. Nursing Management

1.Promoting mouth care

The nurse instructs the patient in the importance and techniques of preventive mouth care. If a patient cannot tolerate brushing or flossing, an irritating solution of 1 type of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution.

 The nurse reinforces the need to perform oral care

and provides such care to patients who cannot provide it for themselves.
 If a bacterial or fungal infection is present, the

nurse administers the medication at home

 The nurse must monitor the patients physical and

psychological response to treatment

Advise the patients to avoid dry, bulky and irritating foods and fluids, as well as alcohol and tobacco Encourage the patient to increase fluid intake

2.Ensuring adequate food and fluid intake

 The patients weight age and level of activity are

recorded to determine whether nutritional intake is adequate

 A daily calories count may be necessary to

determine the exact quantity of food and fluid ingested

The frequency and pattern of eating are recorded to determine whether any psychosocial or physiological factors are affecting ingestion The goal is to help the patient attain maintain desirable body weight and level of energy, as well as to promote the healing of tissue

3. Minimizing pain and comfort  providing information about pain control methods

Strategies to reduce pain and discomfort include avoiding foods that are spicy, hot or hard  A soft or liquid diet may be preferred  The patient is instructed about mouth care. Using a soft tooth brush may prevent secondary trauma

It may be necessary to provide the patient

with an analgesics such as viscous lidocaine or opiods as prescribed Topical medication such as sucralfate and aluminum magnesium liquid antacids may provide reliefs The nurse can reduce the patients fear of pain

4. Preventing Infection
 Laboratory results should be evaluated

frequently and the patients temperature checked every 4 to 8 hours or an elevation that may indicate infection
 Visitors who might transmits microorganisms are

prohibited if the patients immunologic system is depressed

 Sensitive skin tissues are protected from trauma

to maintain skin integrity and prevent infection

 Aseptic technique is necessary when changing

dressings
 Signs of wound infection (redness, swelling,

drainage, tenderness) are reported to the physician

Nutritional Concepts

 Some physician may be recommended a variety

of dietary measures to treat stomatitis.

 Cottage  Cheese  Buttermilk  Yogurt

 Obtain history of radiation or chemotherapy

regimen.  Check for oral burning, pain, or change in tolerance to temperature.  Do oral exam noting evidence of lesions within the mouth and tongue.

Health Teachings about:

 avoid commercial mouth washes, citrus fruit

juices, spicy foods, extremes in food temperature, crusty or rough foods  use straw to facilitate fluids bypassing inflammed lesions (if indicated)  use soft tooth brush or toothettes for oral care  check for proper fit of dentures