I. Overview of the DiseaseStomatitis 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.

Jagged teeth, cheek biting, and mouth breathing may result in mechanical trauma.

Certain foods and drinks and sensitivity to mouthwashes and dentifrices may produce chemical trauma.

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.

described an inflammation of the mucous membranes of the mouth

condition referred to as mucositis

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:

Treatments (chemotherapy or radiation therapy)Poorly fitted and appliances (denture)Cheek bitingHot and spicy foodsDisease (herpetic infection)Poor oral hygieneNutritional Deficiencies (Vit. B12 Deficiencies)Excessive drinking of alcoholExcessive use of tobacco

Anatomy and PhysiologyMouth (oral Cavity)

a mucous membrane, lined cavity.

Lips, protects its anterior opening.

Cheeks, form its lateral walls; Hard palate, forms its anterior roof; Soft palate, forms its posterior roof.

Uvula, is a fleshy fingerlike projection of the soft palate, which extends downwards from its posterior edge.

Vestibule, space between the lips and cheeks externally and the teeth and gums internally. Oral Cavity proper, area contained by the teeth.

Tongue, occupies the floor of the mouth.

Lingual frenulum, a fold of mucus membrane, secures the tongue to the floor of the mouth and limits its posterior movement.

Palatine tonsils, paired masses of lymphatic tissue.

Lingual tonsils, covers the base of tongue just beyond.

The important function of tonsils is, along with other lymphatic tissues, are part of the body’s defense system. When the tonsils become inflamed and enlarged, they partially block the entrance into the throat, making swallowing difficult and painful.

Oral mucosa is the mucous membrane epithelium of the mouth.

II. PathophysiologyRISK FACTORS:

Treatments (Chemotherapy and radiation therapy) excessive alcohol intake excessive tobacco use

hot and spicy foodscheek biting

poor oral hygiene ill fitted oral appliances nutritional deficiency

Kills rapid growing cells (esp. mucus membrane)

Irritation to the Mucous membrane

Inflammation occurs

Ulceration occurs if notdetected or treated

Stomatitis

III. AssessmentA. Nursing History

1. Obtaining a health history allows the nurse to determine the patient’s learning needs concerning preventive oral hygiene and to identify symptoms requiring medical evaluation.

2. The history addresses the patient’s 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 drugsTobacco useAlcohol abuseExposure to radiation, lead, mercury, acids,

heavy metalsTrauma from cheek biting, mouth breathing, or

ill- fitting orthodontiaSensitivity 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.

Gums Inspection 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.

Tongue Inspection 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 tongue’s size as well as it’s symmetry and strength (it assess the 12th cranial nerve – hypoglossal).

Further 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.

Any 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.

This is a common area foe oral cancer, which presents as a white or red plaque, an indurate ulcer, or a wary growth.

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.

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 ExaminationSigns 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:

Allergy- Shiny erythema with slight edema, itching, drying, burning

Thrush-White, raised, milk- curd patches; bleeding; dryness of the mouth; diminished taste; pain; fever; lymphadenopathy

Gingivitis-Redness, swelling, bleeding of gums; gum retraction from teeth

Herpetic-Ulcers 3-4 cm in diameter scattered over mucous membranes; swollen, inflamed gums; enlarged lymph nodes

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

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

CulturesMay be done to

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

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

Acetaminophen-for fever over 101 F (38.3 C) and to address pain

Antibiotics (antiviral) – acyclovir, penciclovir,

Topical or oral tetracycline

Generic/ Brand name

Classification Mechanism of Action

Nursing Responsibiliti

es

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 Responsibilitie

s

Acyclovir Anti viral medications

Anti viral activity; inhibits viral DNA replication.

Oral acyclovir is not a cure for your 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 Responsibilitie

s

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.CottageCheeseButtermilkYogurt

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 carecheck for proper fit of dentures