Mouth (Oral) Problems
Oral problems are common in cancer and AIDS, as well as other advanced illnesses. People with hematologic malignancies, e.g., leukemia and those treated for head and neck cancer are especially prone to oral problems. The primary oral complications of cancer are poor oral hygiene, infections, stomatitis, ulcers, dry mouth, and taste alteration (hypogeusia or decreased ability to taste, ageusia or no ability to taste, and dysgeusia or unpleasant taste). Poorly fitting dentures are a common cause of oral problems in illness. Any of these problems may lead to mouth pain, anorexia, malnutrition, and cachexia (also see chapter on gastrointestinal problems). Unfortunately, oral problems in patients with cancer are more often than not overlooked or ignored by medical personnel, hence even simple-to-treat problems cause discomfort and even affect nutritional status for long periods of time. Oral problems in AIDS include candidiasis, oral hairy leukoplakia, herpes simplex, oral warts, recurrent aphthous ulcers, periodontal disease, and lesions due to opportunistic infections and cancer.
Advanced illness and attendant problems, e.g., poor nutrition, compromise the integrity of the mouth and predispose people to infections and other oral problems. Thus increased attention must be paid to oral care throughout the illness and especially as the patient's general condition worsens. The toothbrush should be small and have soft bristles, the toothpaste mild, any mouthwash mild and without alcohol; and the water-pick device operated at a low (power of water jet) setting. Dental flossing should be done carefully to avoid cutting into the person's gums. To avoid spreading infection, areas with lesions or infection should be the last areas flossed.
Frequent small sips of water may are helpful in preventing or lessening the effects of some mouth problems. Bicarbonate of soda gargles help keep the mouth clean and decrease problems of dry mouth and infections, hence are highly recommended.
The fit of dentures changes as disease worsens, hence denture fit must be regularly checked to ensure that they are not causing abrasions or pain.
People who are weak with advanced illness may deny the need for oral care. In the last days of life, oral care may consist only of rinsing the mouth with normal saline or using a foam stick. Oral care should be given every 2-6 hours or at least twice daily. Dentures must be cleaned and removed every night.
Candidiasis (thrush or monilia)
Candidiasis or thrush is the most common fungal infection of cancer and is also common in AIDS - and thus a common cause of mouth pain and/or dryness. In patients with cancer, candidiasis is often overlooked by healthcare providers. Candidiasis is characterized by discomfort and redness in the mouth, and/or removable small white ("cottage cheese") plaques. Candidiasis may progress to or occur independently in the esophagus, causing difficult or painful swallowing, chest pain, and nausea and vomiting. The infection may occur in the vagina (vaginitis); or may become widespread (disseminated candidiasis) and in the latter case, potentially fatal.
Candidiasis is frequently linked with immuno-suppression from illness or treatment, e.g., chemotherapy, steroid and/or antibiotic use. Patients with leukemia, lymphoma, and AIDS are at the greatest risk of developing candidiasis.
Frequent oral care and inspection helps in prevention and early identification of candidiasis. Nystatin (Mycostatin) is commonly used to manage candidiasis, but clotrimazole (several brands) is more effective and has fewer side effects. Amphotericin B (Fungizone) is effective as is oral fluconazole (Diflucan) or itraconazole (Sporanox).
Aspergillosis is a fungal infection of the oral cavity and/or lungs, causing oral lesions, difficulty breathing, cough, bloody and/or purulent sputum, and fever. Aspergillosis is found primarily in bone marrow transplantation and hematologic malignancy. Treatment with long-term steroid therapy and/or antibiotics also carries risk.
Currently, treatment is with itraconazole or amphotericin B; and often amphoteracin B followed by itraconazole. Response to therapy rates are poor, with sequential or combination therapy showing the best response, followed by itraconazole therapy alone, and last, therapy with amphoteracin B alone. Those who recover from pulmonary aspergillosis are at increased risk for pulmonary hemorrhage.
Cryptococcosis is a fungal infection sometimes of the mouth, but often disseminated, including to the central nervous system and lungs. Symptoms include headache and fever; and also nausea and vomiting, changes in mental status, and meningeal signs such as stiff neck.
A common treatment of cryptococcosisis is amphotericin B followed by fluconazole; sometimes followed by suppressive therapy.
Viral infections in patients with cancer are primarily from herpes simplex virus (HSV). Symptoms of HSV infection include removable painful yellowish membranes in the oral cavity and blister-like vesicles on or adjacent to the lips.
Managing HSV Infection
Intravenous acyclovir is currently the most effective treatment. Topical acyclovir is sometimes used for external lesions.
Oral bacterial infections are especially common during and after chemotherapy and in people who are immuno-suppressed. They are characterized by pain, fever, abscesses, and small oral hemorrhages.
Managing Bacterial Infections
Treatment consists of broad-spectrum antibiotic therapy followed by pathogen-specific therapy if necessary. Dental care is essential in managing and preventing bacterial infection.
Stomatitis is inflammation of the inside of the mouth, including the tongue, gums, soft palate, and (inside) cheeks. Oral mucosa is reddened, ulcers may develop and they may be infected with candida, and bleeding may occur. Stomatitis is usually caused by radiation to the head or chemotherapy, and may also be related to or exacerbated by infection, poor dental hygiene, denture problems, vitamin deficiency, or blood disorders.
Frequent thorough oral care helps reduce or minimize problems of stomatitis. Spicy, salty, and other irritating foods are avoided. Pain is treated with analgesic rinses and/or morphine or other analgesics. Popsicles may help numb the mouth. Other measures include lubricating cream as needed for dry lips, cleansing rinses 2-3 times daily (sodium chloride solution, bicarbonate of soda, dilute hydrogen peroxide), analgesic rinses (xylocaine viscous 2%, equal parts of diphenhydramine hydrochloride (Benadryl) elixir 12.5 mg/5 ml and Maalox every two hours.
Recurrent aphthous ulcers ("canker sores") are a common oral problem in persons with leukemia and AIDS. Aphthous ulcers are painful and appear either as clusters of small blisters, or when blisters are gone, as a small ulcer with a flat white center surrounded by yellowish margins and inflammation. They are caused by changes in the blood (neutropenia), infection, trauma, drug toxicity, or unknown factors.
Managing Aphthous Ulcers
Treatment is the same as for stomatitis.
Xerostomia is characterized a feeling of dryness in the mouth (the mouth may or may not actually be dry), thirst, discomfort, and difficulty swallowing. Because saliva protects the inside of the mouth and is part of the digestive process, actual dryness may result in secondary problems such as infection, difficulty in eating and digestion, and accelerated tooth decay. The most common causes of dry mouth are medications (especially opioids and metoclopramide) and oral fungal infections (primarily candidiasis). Other causes include decreased saliva caused by radiation, erosion of oral tissue from disease, treatment, infection, and other factors; dehydration caused by anorexia, vomiting, diarrhea, and/or difficulty swallowing; and mouth breathing and oxygen therapy. Often there is a combination of factors at work.
Whenever possible, specific causes are addressed. As with other problems of the mouth, good oral care is necessary. Comfort measures include bicarbonate of soda gargles, sugarless gum, hard candy, popsicles or other means of increasing moisture or stimulating saliva. Commercial saliva substitutes are available, or home made preparations can also be used. Glycerin, cologel, and normal saline (mixed 1:1:8) works as well as most commercial saliva substitutes. No saliva substitute performs all the functions of saliva (protection, digestion), but substitutes do improve comfort. Medications that help reduce xerostomia include pilocarpine, dehydroergotamine, and 2% citric acid solution.
Common taste changes include hypogeusia (decreased taste overall), ageusia (absence of taste), and dysgeusia (distorted - especially bitter - taste). Dealing with taste changes is complicated by many people not reporting or even realizing they exist. Food may simply be less palatable. However, carefully considering which foods are unpalatable or have less or no taste may show that, indeed, taste has changed. Common causes of taste changes include cancer treatment and medications; and protein, vitamin, or zinc deficiencies. In some cases, taste changes are not permanent.
Managing Taste Changes
Decreased taste can be partially overcome by taking hot, strong-smelling foods, and by simply taking nutritious foods, e.g., supplements, whether or not they taste. Distorted taste is addressed by modifying some foods and eliminating others. If foods seem too sweet, then decreased sugar added may help. If meats taste unpleasant, they should be eliminated and another source of protein added. Alternative means of feeding, such as nasogastric feeding or hyperalimentation are seldom appropriate. Good oral care is part of the care for any oral problem.
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