STOMATITIS
OVERVIEW OF DISEASE
Stomatitis is a sore or inflammation in the mouth. This can b e in the cheeks, gums, inside of the lips, or on the tongue. There are two main forms of stomatitis: herpes stomatitis and aphthous stomatitis . Both forms usually occur more often in i n children and
teens. Herpes stomatitis is an infection, usually in young children between the ages of six months and 5 years. It’s an infection of the Herpes Simplex 1 (HSV 1) virus , the same virus that causes cold sores on the outside ou tside of the lips in adults. It is related to HSV 2, the virus that causes genital herpes, but it is not the same virus. Aphthous stomatitis is also called canker sores . They are one or a cluster of small pits or ulcers in the cheeks, gums, the inside of the lips, or on the tongue. This is also much more common in young people, most often between 10 and 19 years old. (Krucik, 2013)
16
STOMATITIS
CAUSES
Herpes Stomatitis is caused by infection of the HSV1 virus in young children.
Aphthous stomatitis is caused by a variety of problems with oral h ygiene or damage to mucous membranes.
Some potential causes include:
dry tissues from breathing through the mouth due to clogged nasal passages
Small injuries due to dental work, accidental cheek bite, etc.
sharp tooth surfaces, dental braces, or retainers
celiac disease (allergy to gluten)
food sensitivities to strawberries, citrus fruits, coffee, chocolate, eggs, cheese, or nuts 17
STOMATITIS
allergic response to certain bacteria in the mouth
inflammatory bowel diseases
autoimmune disease that attacks cells in the mouth
HIV/AIDS
weakened immune system
deficiency in Vitamin B12, folic acid, iron, or zinc
certain medications
18
STOMATITIS
CLINICAL MANIFESTATION Symptoms manifestations vary by type of stomatitis.
Allergic 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 It is usually indicated by multiple blisters that occur in the gums, pal ate, cheeks, tongue, or lip border. Eating, drinking, and swallowing may be difficult. Dehydration is a risk. The child can be very irritable. Ulcers may be 34 cm in diameter scattered over mucous membranes; swollen, inflamed gums; enlarged lymph nodes, drooling may occur. A fever is a major marker of the HSV1 infection, which can get as high as 104 degrees Fahrenheit. The fever occurs a few days before the blisters appear. When the blisters pop, ulcers can form in their place. Secondary infections of these ulcers can occur. The entire infection lasts between 7-10 days.
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 mouth 19
STOMATITIS
Necrotizing Necrotic ulceration of mucous membranes with severe pain, increased salivation, and inability to eat; fetid breath; bleeding gums; difficulty talking and swallowing; pseudo membrane on ulcers. Complications include tissue sloughing from necrosis may create craters and other altered tissue topography. Medi-Info, 2015 retrieved from www.medi-info.com
ASSESSMENT AND DIAGNOSTICS Diagnostic Tests
Bacterial and viral culture
Laboratory tests
Biopsy
Patients with acute stomatitis and no symptoms, signs, or risk factors for systemic illness probably require no testing. If stomatitis is recurrent, viral and bacterial cultures, CBC, serum iron, ferritin, vitamin B
12
, folate, zinc, and endomysial antibody are done. Biopsy
at the periphery of normal and abnormal tissue can be done for persistent lesions that do not have an obvious etiology.
Systematically eliminating foods from the diet can be useful, as can changing brands of toothpaste, chewing gum, or mouthwash. (Merck manual 2015).
Assess oral hygiene practices.
Provides information on possible causative factors, and provides guidance for subsequent education. 20
STOMATITIS
Assess nutrition status
Malnutrition can be a contributing cause. Oral fluids needed for moisture to membranes.
Assess for ability to eat and drink.
Inability to chew and swallow may occur second ary to pain of inflamed or ulcerated oral and/or oropharyngeal mucous membranes. Inspection and Palpation
Assess status of oral mucosa; include tongue, lips, mucous membranes, gums, saliva, and teeth.
Home caregivers also need to be informed of the importance of these assessments.
Use adequate source of light.
Remove dental appliances. o
Lesions may be underlying and further irritated by the appliance.
Use a moist, padded tongue blade to gently pull back the cheeks and tongue. o
In order to expose all areas of oral cavity for inspection.
Assess for extensiveness of ulcerations involving the intraoral soft tissues, including palate, tongue, gums, and lips.
Sloughing of mucosal membrane can progress to ulceration.
21
STOMATITIS PATHOPHYSIOLOGY
The pathophysiology depends on the cause, but it involves a process that creates tissue inflammation in the oral mucosa or gums. These inflammatory changes lead to redness, ulceration, and fissures in the mouth.
MEDICAL MANAGEMENT Diagnostic Tests
Bacterial and viral culture
Laboratory tests
Biopsy
Patients with acute stomatitis and no symptoms, signs, or risk factors for systemic illness probably require no testing. If stomatitis is recurrent, viral and bacterial cultures, CBC, serum iron, ferritin, vitamin B
12
, folate, zinc, and endomysial antibody are done. Biopsy
at the periphery of normal and abnormal tissue can be done for persistent lesions that do not have an obvious etiology.
Systematically eliminating foods from the diet can be useful, as can changing brands of toothpaste, chewing gum, or mouthwash ( Merck manual, 2015).
If signs of mild stomatitis occur (sensation of dryness and burning; mild erythema and edema along the mucocutaneous junction):
Increase frequency of oral hygiene by rinsing with one of the suggested solutions between brushings and once during the night. 22
STOMATITIS
Discontinue flossing if it causes pain.
Provide systemic or topical analgesics as ordered. o
Increased sensitivity to pain is a result of thinning of oral mucosal lining.
Instruct patient that topical analgesics can be administered as "swished and swallow" or "swish and spit" 15 to 20 minutes before meals, or painted on each lesion immediately before mealtime. Topical analgesics include the following: 1. Dyclone 1% 2. Viscous lidocaine (10 ml per dose up to 120 ml in 24 hours)
These provide a "numbing" feeling.
o
Xylocaine (viscous 2%)
o
Benadryl elixir (12.5 mg per 5 ml) and an antacid mixed in equal proportions. o
Instruct patient to hold solution for several minutes before expectorating, and not to use solution if mucosa is severely ulcerated or if drug sensitivity exists.
o
Caution client to chew or swallow after each dose
As numbness of throat may be experienced.
o
Explain use of topical protective agent
To coat the lesions and promote healing as prescribed 23
STOMATITIS Zilactin or Zilactin-B
Has benzocaine for pain and is painted on lesion and allowed to dry to form a protective seal. Substrate of an antacid and Kaolin preparations.
This substance is prepared by allowing antacid to settle. The pasty residue is swabbed onto the inflamed areas and, after 15 to 20 minutes, rinsed with saline or water. The residue remains as a protectant on the lesion.
Refer patient to dietitian for instructions on maintenance of a well-balanced diet. (NANDA, 2013)
24
STOMATITIS NURSING DIAGNOSIS
Altered Oral Mucous Membrane related to dehydration, trauma: chemical (e.g., acidic foods, drugs, noxious agents, alcohol); mechan ical (e.g., ill-fitting dentures, braces, tubes [endotracheal or nasogastric]), surgery in oral cavity, nothing by mouth for more than 24 hours, ineffective oral hygiene, mouth breathing, malnutrition, lack of or decreased salivation.
Altered nutrition: less than body requirements related to inability to ingest adequate nutrients because of oral pain, gingival disease, ill-fitting dentures.
Body image disturbance related to difficulty with eating or h alitosis. Noncompliance related to lack of finances and lack of motivation.
NURSING MANAGEMENT
Implement meticulous mouth care regimen after each meal and every 4 hours while awake.
To prevent buildup of oral plaque and bacteria. Patients with oral catheters and oxygen may require additional care. For eating problems:
Encourage diet high in protein and vitamins o
Serve foods and fluids lukewarm or cold o
To promote healing and new tissue growth.
As this may feel soothing to the oral mucosa.
Serve frequent small meals or snacks spaced throughout the day o
To maintain fluid balance and nutrition.
25
STOMATITIS
Encourage soft foods (mashed potatoes, puddings, cu stards, creamy cereals) o
Encourage use of a straw o
To avoid tissue trauma and pain.
To make swallowing easier.
Encourage peach, pear, or apricot nectars and fruit drinks instead of citrus juices o
As these are not irritating and are easier to swallow.
Brush with a nonirritating dentrifice such as baking soda.
Remove and brush dentures thoroughly during and after meals and as needed. To reduce risk of infection and improve appetite.
Rinse the mouth thoroughly during and after brushing. Removing food particles decreases risk of infection related to trapped decaying food.
Avoid alcohol-containing mouthwashes. As these may dry oral mucous membranes, increasing risk fo r disruption of mucous membrane.
Use recommended mouth rinses:
Hydrogen peroxide and saline or water (1:2 or 1:4). Peroxide solutions should be mixed immediately before use and held in mouth for 1 to 1.5 minutes. Follow with a rinse of water or saline. o
To maintain oxydizing property
Baking soda and water (1 tsp in 500 ml).
Salt (.5 tsp), baking soda (1 tsp), and water (100 ml).
26
STOMATITIS
Keep lips moist.
To prevent drying and cracking.
Use a lip product or a water-soluble lubricant (K-Y jelly, Aquaphor Cream)
To minimize risk of aspirating non-water-soluble agent.
Include food items with each meal that require chewing.
As this stimulates gingival tissue and promotes circulation.
Minimize trauma to mucous membranes. Avoid use of tobacco and alcohol.
As these are irritating and drying to the mucosa.
Avoid extremely hot or cold foods. Avoid acidic or highly spiced foods.
Have loose-fitting dentures adjusted.
Rubbing and irritation from ill-fitting dentures promotes disruption of the oral mucous membrane. (NANDA, 2013)
27
