Part 2

Management of Patients
With Oral and
Esophageal Disorders

2ed Years Student, 2ed Semester

Miss Iman shaweesh
January 2008

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Disorders of the Teeth
DENTAL PLAQUE AND CARIES

 Tooth decay is an erosive process that begins

with the action of bacteria on fermentable
carbohydrates in the mouth, which produces
acids that dissolve tooth enamel. The extent of
damage to the teeth depends on the following:

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 The presence of dental plaque
 The strength of the acids and the ability of
the saliva to neutralize them
 The length of time the acids are in contact
with the teeth
 •The susceptibility of the teeth to decay

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Prevention

 Measures used to prevent and control dental

caries include practicing effective mouth care,
reducing the intake of starches and
 sugars (refined carbohydrates), applying
fluoride to the teeth or
 drinking fluoridated water, refraining from
smoking, controlling diabetes, and using pit and
fissure sealants

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Disorders of the Lips, Mouth, and Gums

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Abnormalities of the Mouth

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Abnormalities of the Gums

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Gerontologic Considerations

 Many medications taken by the elderly cause dry

mouth, which is uncomfortable, impairs
communication, and increases the risk of oral
infection. These medications include the following:
• Diuretics
• Antihypertensive medications
• Anti-inflammatory agents
• Antidepressant medications

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Gerontologic Considerations

 Poor dentition can exacerbate problems of aging,

such as
• Decreased food intake
• Loss of appetite
• Social isolation
• Increased susceptibility to systemic infection
(from periodontal disease)
• Trauma to the oral cavity secondary to thinner,
less vascular oral mucous membranes

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DENTOALVEOLAR ABSCESS
OR PERIAPICAL ABSCESS

 more commonly referred to as an abscessed,

involves the collection of pus in the apical dental
periosteum (fibrous membrane supporting the
tooth structure) and the tissue surrounding the
apex of the tooth (where it is suspended in the
jaw bone). The abscess has two forms: acute
and chronic. Acute periapical abscess is usually
secondary to a suppurative pulpitis (a pus-
producing inflammation of the dental pulp)

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Clinical Manifestations

 The abscess produces a dull, gnawing,

continuous pain, often with a surrounding
cellulitis and edema of the adjacent facial
structures, and mobility of the involved
tooth. The gum opposite the apex of the
tooth is usually swollen on the cheek side.
Swelling and cellulitis of the facial
structures may make it difficult for the
patient to open the mouth.

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Management

 In the early stages of an infection, a dentist or

dental surgeon
 may perform a needle aspiration or drill an
opening into the pulp chamber to relieve tension
and pain and to provide drainage.
 After the inflammatory reaction has subsided,
the tooth may be extracted or root canal therapy
performed. Antibiotics may be prescribed.

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Nursing Management

 The nurse assesses the patient for bleeding after

treatment and instructs the patient to use a warm
saline or warm water mouth rinse to keep the area
clean.
 The patient is also instructed to take antibiotics
and analgesics as prescribed,
 to advance from a liquid diet
to a soft diet as tolerated, and to keep follow-up
appointments.

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Disorders of the Jaw

Temporomandibular disorders are categorized

as follows (National Oral Health Information)

 • Myofascial pain—a discomfort in the muscles

controlling jaw function and in neck and
shoulder muscles
 • Internal derangement of the joint—a dislocated
jaw, a displaced disc, or an injured condyle
 • Degenerative joint disease—rheumatoid
arthritis or osteoarthritis in the jaw joint

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Disorders of the Salivary Glands

 Parotitis (inflammation of the parotid gland) is

the most common inflammatory condition of the
salivary glands, although inflammation can
occur in the other salivary glands as well.
Mumps (epidemic parotitis), a communicable
disease caused by viral infection and most
commonly affecting children, is an inflammation
of a salivary gland, usually the parotid.

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SIALADENITIS

 (inflammation of the salivary glands) may be

caused by dehydration, radiation therapy,
stress, malnutrition, salivary gland calculi
(stones), or improper oral hygiene. The
inflammation is associated with infection by S.
aureus, Streptococcus viridans, or
pneumococcus.

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SALIVARY CALCULUS
(SIALOLITHIASIS)

 Sialolithiasis, or salivary calculi (stones), usually

occurs in the submandibular gland. Salivary
gland ultrasonography or sialography (x-ray
studies filmed after the injection of a radiopaque
substance into the duct) may be required to
demonstrate obstruction of the duct by stenosis.
Salivary calculi are formed mainly from calcium
phosphate.

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Cancer of the Oral Cavity

 Cancers of the oral cavity, which can occur in

any part of the mouth or throat, are curable if
discovered early. These cancers are associated
with the use of alcohol and tobacco.
 Cancer of the oral cavity accounts for less than
2% of all cancer deaths in the United States.
Men are afflicted more often than women.

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Pathophysiology

 Malignancies of the oral cavity are usually

squamous cell cancers. Any area of the
oropharynx can be a site for malignant growths,
but the lips, the lateral aspects of the tongue,
and the floor of the mouth are most commonly
affected.

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Clinical Manifestations

 Many oral cancers produce few or no symptoms

in the early stages. Later, the most frequent
symptom is a painless sore or mass that will not
heal. A typical lesion in oral cancer is a painless
indurated (hardened) ulcer with raised edges.
Tissue from any ulcer of the oral cavity that
does not heal in 2 weeks should be examined
through biopsy.

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Medical Management

 Surgical resection, radiation therapy,

chemotherapy, or a combination of these
therapies may be effective. In cancer of the lip,
small lesions are usually excised liberally; larger
lesions involving more than one third of the lip
may be more appropriately treated by radiation
therapy because of superior cosmetic results.

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 If the cancer has spread to the lymph nodes, the
surgeon may perform a neck dissection. Surgical
treatments leave a less functional tongue;
surgical procedures include hemiglossectomy
(surgical removal of half of the tongue) and total
glossectomy (removal of the tongue).
 Often cancer of the oral cavity has metastasized
through the extensive lymphatic channel in the
neck region

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Neck Dissection

 Malignancies of the head and neck include

those of the oral cavity, oropharynx,
hypopharynx, nasopharynx, nasal
cavity,paranasal sinus, and larynx (Fig)
 These cancers account for fewer than 5% of all
cancers. Depending on the location and stage,
treatment may consist of radiation therapy,
chemotherapy, surg or a combination of these
modalities.

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 A radical neck dissection involves removal of all
cervical lymph nodes from the mandible to the
clavicle and removal of the sternocleidomastoid
muscle, internal jugular vein, and spinal
accessory muscle on one side of the neck.

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 Group Discussion
 Nursing Management
 NURSING PROCESS: THE PATIENT WITH
CONDITIONS OF THE ORAL CAVITY
 Neck Dissection
 NURSING PROCESS: THE PATIENT
UNDERGOING A NECK DISSECTION

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Disorders of the Esophagus

 The esophagus is a mucus-lined, muscular tube that

carries food from the mouth to the stomach. It begins at
the base of the pharynx and ends about 4 cm below the
diaphragm. Its ability to transport food and fluid is
facilitated by two sphincters. The upper esophageal
sphincter, also called the hypopharyngeal sphincter, is
located at thejunction of the pharynx and the
esophagus. The lower esophageal sphincter, also called
the gastroesophageal sphincter, is located at the
junction of the esophagus and the stomach.

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Dysphagia
 (difficulty swallowing) is the most common
symptom of esophageal disease. This
symptom may vary from an uncomfortable
feeling that a bolus of food is caught in the
upper esophagus (before it eventually
passes into the stomach) to acute pain
on swallowing (odynophagia).

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Achalasia
 is absent or ineffective peristalsis of the distal
esophagus accompanied by failure of the
esophageal sphincter to relax in response to
swallowing. Narrowing of the esophagus just
above the stomach results in a gradually
increasing dilation of the esophagus in the
upper chest. Achalasia may progress slowly and
occurs most often in people 40 years of age or
older.

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Clinical Manifestations

 The primary symptom of achalasia is difficulty in

swallowing both liquids and solids. The patient
has a sensation of food sticking in the lower
portion of the esophagus. As the condition
progresses, food is commonly regurgitated,
either spontaneously or intentionally by the
patient to relieve the discomfort produced by
prolonged distention of the esophagus by food
that will not pass into the stomach. The patient
may also complain of chest pain and heartburn
(pyrosis).

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Assessment and Diagnostic Findings

 X-ray studies show esophageal dilation above

the narrowing at the gastroesophageal junction.
Barium swallow, computed tomography

 (CT) of the esophagus, and endoscopy may be

used for diagnosis; however, the diagnosis is
confirmed by manometry, a process in which
the esophageal pressure is measured by a
radiologist or gastroenterologist.

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Management

 The patient should be instructed to eat slowly

and to drink fluids with meals. As a temporary
measure, calcium channel blockers and nitrates
have been used to decrease esophageal
pressure and improve swallowing.
 Achalasia may be treated conservatively by
pneumatic dilation to stretch the narrowed area
of the esophagus (Fig. 35-6). Pneumatic dilation
has a high success rate.

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Achalasia may be treated surgically by
esophagomyotomy

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DIFFUSE SPASM

 spasm is a motor disorder of the esophagus.

The cause is unknown, but stressful situations
can produce contractions of the esophagus. It is
more common in women and usually manifests
in middle age.
 characterized by difficulty or pain on swallowing
(dysphagia, odynophagia) and by chest pain
similar to that of coronary artery spasm.

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Assessment and Diagnostic Findings

 Esophageal manometry, which measures the

motility of the esophagus and the pressure
within the esophagus, indicate that
simultaneous contractions of the esophagus
occur irregularly. Diagnostic x-ray studies after
ingestion of barium show separate areas of
spasm.

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Management

 Conservative therapy includes administration of

sedatives and long-acting nitrates to relieve
pain. Calcium channel blockers have also been
used to manage diffuse spasm. Small, frequent
feedings and a soft diet are usually
recommended to decrease the esophageal
pressure and irritation that lead to spasm.

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HIATAL HERNIA

 The esophagus enters the abdomen through an

opening in the diaphragm and empties at its lower
end into the upper part of the stomach. Normally,
the opening in the diaphragm encircles the
esophagus tightly, and the stomach lies
completely within the abdomen. In a condition
known as hiatus (or hiatal) hernia, the opening in
the diaphragm through which the esophagus
passes becomes enlarged, and part of the upper
stomach tends to move up into the lower portion
of the thorax.

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There are two types of hiatal hernias: sliding
and paraesophageal
 Sliding, or type I, hiatal hernia occurs when the
upper stomach and the gastroesophageal junction
(GEJ) are displaced upward and slide in and out
of the thorax (Fig. 35-8A). About 90% of patients
with esophageal hiatal hernia have a sliding
hernia.
 A paraesophageal hernia occurs when all or part
of the stomach pushes through the diaphragm
beside the esophagus

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Clinical Manifestations

 may have heartburn, regurgitation, and

dysphagia, but at least 50% of patients are
asymptomatic. Sliding hiatal hernia is often
implicated in reflux. The patient with a
paraesophageal hernia usually feels a sense of
fullness after eating or may be asymptomatic.

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Assessment and Diagnostic Findings

 Diagnosis is confirmed by
x-ray studies,
barium swallow,
and fluoroscopy.

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Management

 Management for an axial hernia includes

frequent, small feedings that can pass easily
through the esophagus. The patient is
advisednot to recline for 1 hour after eating, to
prevent reflux or movement of the hernia, and to
elevate the head of the bed on 4- to 8-inch (10-
to 20-cm) blocks to prevent the hernia from
sliding upward. Surgery is indicated in about
15% of patients.

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Management

 Medical and surgical management of a

paraesophageal hernia is similar to that for
gastroesophageal reflux; however,
paraesophageal hernias may require
emergency surgery to correct torsion
(twisting) of the stomach or other body
organ that leads to restriction of blood flow
to that area.

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DIVERTICULUM

 A diverticulum is an outpouching of mucosa and

submucosa that protrudes through a weak
portion of the musculature. Diverticula may
occur in one of the three areas of the
esophagus—the pharyngoesophageal or upper
area of the esophagus, the midesophageal
area, or the epiphrenic or lower area of the
esophagus— or they may occur along the
border of the esophagus intramurally.

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 The most common type of diverticulum, which is
found three times more frequently in men than
in women, is Zenker’s diverticulum (also known
as pharyngoesophageal pulsion diverticulum or
a pharyngeal pouch). It occurs posteriorly
through the cricopharyngeal muscle in the
midline of the neck. It is usually seen in people
older than 60 years of age.

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Clinical Manifestations

 include difficulty swallowing, fullness in the

neck, belching, regurgitation of undigested food, and
gurglingnoises after eating.
 The diverticulum, or pouch, becomes filled with food or
liquid. When the patient assumes a recumbent position,
undigested food is regurgitated, and coughing may be
caused by irritation of the trachea.

 Halitosis and a sour taste in the mouth are also common

because of the decomposition of food retained in the
diverticulum.

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Assessment and Diagnostic Findings

 A barium swallow may be performed to

determine the exact nature and location of a
diverticulum.
 Manometric studies are often performed for
patients with epiphrenic diverticula to rule out a
motor disorder.
 Esophagoscopy usually is contraindicated
because of the danger of perforation of the
diverticulum,

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Management

 Because pharyngoesophageal pulsion

diverticulum is progressive,the only means of
cure is surgical removal of the diverticulum.
During surgery, care is taken to avoid trauma to
the common carotid artery and internal jugular
veins.
 Food and fluids are withheld until x-ray studies
show no leakage at the surgical site. The diet
begins with liquids and progresses as tolerated.

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PERFORATION

 The esophagus is not an uncommon site of

injury. Perforation may result from stab or bullet
wounds of the neck or chest, trauma from motor
vehicle crash, caustic injury from a chemical
burn (described later), or inadvertent puncture
by a surgical instrument during examination or
dilation.

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Clinical Manifestations

 The patient has persistent pain followed by

dysphagia. Infection,
 fever, leukocytosis, and severe hypotension
may be noted. In
 some instances, signs of pneumothorax are
observed.

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Assessment and Diagnostic Findings

 Diagnostic x-ray studies and fluoroscopy

are used to identify the site of the injury.

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Management

 Because of the high risk of infection, broad-

spectrum antibiotic therapy is initiated. A
nasogastric tube is inserted to provide suction and
to reduce the amount of gastric juice that can
reflux into the esophagus and mediastinum.
Nothing is given by mouth; nutritional needs are
met by parenteral nutrition. Parenteral nutrition is
preferred to gastrostomy because the latter might
cause reflux into the esophagus. Surgery may be
necessary to close the wound, and postoperative
nutritional support then becomes a primary
concern.

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CHEMICAL BURNS

 Chemical burns of the esophagus may be caused

by undissolved medications in the esophagus.
This occurs more frequently in the elderly than it
does among the general adult population. A
chemical burn may also occur after swallowing of
a battery, which may release caustic alkaline.
Chemical burns of the esophagus occur most
often when a patient, either intentionally or
unintentionally, swallows a strong acid or base

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RX
 Esophagoscopy and barium swallow- to
determine the extent and severity of damage.

 The patient is NPO, and IV fluids adm

 A NGT may be inserted by the physician.

 Vomiting and gastric lavage are avoided to

prevent further exposure of the esophagus to
the caustic agent.

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RX
 The use of corticosteroids to reduce
inflammation and minimize subsequent scarring
and stricture formation is of questionable value.

 The value of the prophylactic use of antibiotics

for these patients has also been questioned

 For strictures that do not respond to dilation,

surgical management is necessary.

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GASTROESOPHAGEAL REFLUX
DISEASE

 Some degree of gastroesophageal reflux

(back-flow of gastric or duodenal contents into
the esophagus) is normal in both adults and
children. Excessive reflux may occur because of
an incompetent lower esophageal sphincter,
pyloric stenosis, or a motility disorder. The
incidence of reflux seems to increase with
aging.

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Clinical Manifestations
(GERD)

 pyrosis (burning sensation in the esophagus),

 dyspepsia (indigestion), regurgitation,
 dysphagia or odynophagia (difficulty swallowing,
pain on swallowing), hypersalivation, and
esophagitis. The symptoms may mimic those of
a heart attack.

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Assessment and Diagnostic Findings
(GERD)

 Diagnostic testing may include an endoscopy or

barium swallow to evaluate damage to the
esophageal mucosa.
 Ambulatory 12- to 36-hour esophageal pH
monitoring is used to evaluate the degree
of acid reflux.
 Bilirubin monitoring (Bilitec) is used to measure
bile reflux patterns.

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Management (GERD)

 Management begins with teaching the patient to

avoid situations that decrease lower esophageal
sphincter pressure or cause esophageal
irritation.
 The patient is instructed to eat a low-fat diet;
 to avoid caffeine, tobacco, beer, milk, foods
containing peppermint or spearmint, and
carbonated beverages; to avoid eating or
drinking

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Management (GERD)

 2 hours before bedtime; to maintain normal

body weight; to avoid tight-fitting clothes; to
elevate the head of the bed on 6- to 8-inch (15-
to 20-cm) blocks; and to elevate the upper body
on pillows.

 If reflux persists, the patient may be given

medications such as antacids or histamine
receptor blockers. Proton pump inhibitors
(medications that decrease the release of
gastric acid,

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Management (GERD)

 Surgical management involves a fundoplication

(wrapping of a portion of the gastric fundus
around the sphincter area of the esophagus).
Fundoplication may be performed by
laparoscopy.

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CANCER OF THE ESOPHAGUS

 USA carcinoma of the esophagus occurs more

than three times as often in men as in women. It
is seen more frequently in African Americans
than in Caucasians and usually occurs in the
fifth decade of life. Cancer of the esophagus
has a much higher incidence in other parts of
the world, including China and northern Iran

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 cancer of the esophagus has been associated
with ingestion of alcohol and with the use of
tobacco. There seems to be an association
between GERD and adenocarcinoma of the
esophagus. People with Barrett’s esophagus
(which is caused by chronic irritation of mucous
membranes due to reflux of gastric and
duodenal contents) have a higher incidence

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Pathophysiology

 Esophageal cancer is usually of the squamous

cell epidermoid type; however, the incidence of
adenocarcinoma of the esophagus is increasing
in the United States.
 Tumor cells may spread beneath the
esophageal mucosa or directly into, through,
and beyond the muscle layers into the
lymphatics.

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Clinical Manifestations

 Symptoms include dysphagia, initially with solid

foods and eventually with liquids; a sensation of
a mass in the throat; painful swallowing;
substernal pain or fullness; and, later,
regurgitation of undigested food with foul breath
and hiccups.

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 As the tumor progresses and the obstruction
becomes more complete, even liquids cannot
pass into the stomach. Regurgitation of food
and saliva occurs, hemorrhage may take place,
and progressive loss of weight
 Later symptoms include substernal pain,
persistent hiccup, respiratory difficulty, and foul
breath. The delay between the onset of early
symptoms and the time when the patient seeks
medical advice is often 12 to 18 months.

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Assessment and Diagnostic Findings

 new endoscopic techniques are being studied

for screening and diagnosis of esophageal
cancer, currently diagnosis is confirmed most
often by EGD with biopsy and brushings.

 Endoscopic ultrasound or mediastinoscopy

is used to determine whether the cancer has
spread to the nodes and other mediastinal
structures.

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Medical Management

 If esophageal cancer is found at an early stage,

treatment goals may be directed toward cure;
however, it is often found in late stages, making
relief of symptoms the only reasonable goal of
therapy.

 Treatment may include surgery, radiation,

chemotherapy, or a combination of these
modalities,

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 Standard surgical management includes a total
resection of the esophagus (esophagectomy) with
removal of the tumor plus a wide tumor-free margin of
the esophagus and the lymph nodes in the area.

 When tumors occur in the cervical or upper thoracic

area, esophageal continuity may be maintained by free
jejunal graft transfer, in which the tumor is removed and
the area is replaced with a portion of the jejunum (Fig).

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 A segment of the colon may be used, or the
stomach can be elevated into the chest and the proximal
section of the esophagus anastomosed to the stomach.

 Tumors of the lower thoracic esophagus are more

amenable to surgery than are tumors located higher in
the esophagus, and gastrointestinal tract integrity is
maintained by anastomosing the lower esophagus to the
stomach.

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 Surgical resection of the esophagus has a relatively high
mortality rate because of infection, pulmonary
complications, or leakage through the anastomosis.

 Postoperatively, the patient will have a nasogastric tube

in place that should not be manipulated. The patient is
given nothing by mouth until x-ray studies confirm that
the anastomosis is secure and not leaking.

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Nursing Management

 Intervention is directed toward improving the

patient’s nutritional and physical condition in
preparation for surgery, radiation therapy, or
chemotherapy.

 A program to promote weigh gain based on a

high-calorie and high-protein diet, in liquid or
soft form, is provided if adequate food can be
taken by mouth.

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Nursing Management

 informed about the nature of the postoperative

equipment that will be used, including that required for
closed chest drainage, nasogastric suction, parenteral
fluid therapy, and gastric intubation.

 After recovering from the effects of anesthesia,

the patient is placed in a low Fowler’s position,
and later in a Fowler’s position, to assist in
preventing re- flux of gastric secretions.

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Nursing Management

 The patient is observed carefully for-

regurgitation and dyspnea. A common
postoperative complication is aspiration
pneumonia.

 If jejunal grafting has been performed, the nurse

checks for graft viability hourly for at least the
first 12 hours. To make the graft visible,

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Nursing Management
 Moist gauze covers the external portion of the
graft. The gauze is removed briefly to assess
the graft for color and to assess for the
presence of a pulse by means of Doppler
ultrasonography.
 The nasogastric tube is removed 5 to 7 days
after surgery, and a barium swallow is
performed to assess for any anastomotic leak
before the patient is allowed to eat.

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Nursing Management
 Once feeding begins, the nurse encourages the
patient to swallow small sips of water and, later,
small amounts of pureed food.
 After each meal, the patient remains upright for
at least 2 hours to allow the food to move
through the gastrointestinal tract.
 If radiation is part of the therapy, the patient’s
appetite is further depressed and esophagitis
may occur.

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