Chapter 39_ Mgt of Patients with Oral and Esophageal Disorders

1. Management of Patient With Oral and Esophageal Disorders DAISE JEAN L. MEOMEO, PhRN, USRN Clinical Instructor

2. Intro • localized infection at the apex of a tooth root, typically caused by bacterial invasion due to dental caries, trauma, or previous dental procedures • It leads to pus accumulation, causing pain and swelling in the affected area.

3. Periapical Abscess Risk Factors • Poor oral hygiene • Untreated dental caries • Dental trauma • Previous dental procedures (e.g., root canal failure) • Periodontal disease • Immunosuppression (e.g., diabetes, chemotherapy, HIV/AIDS)

4. Periapical Abscess Pathophysiology • Tooth Decay or Trauma → Bacteria invade the pulp • Pulpitis (Inflammation of the Pulp) → Necrosis of pulp tissue • Bacterial Growth & Toxin Release → Triggers immune response • Pus Formation → Accumulation at the apex of the tooth root • Abscess Expansion → Increased pressure causes pain and swelling • Possible Spread to Surrounding Tissues → Can lead to cellulitis, osteomyelitis, or sepsis

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6. Severe, persistent, throbbing toothache Swelling of the face or gums Fever, malaise Sensitivity to hot/cold and pressure Foul taste or bad breath Clinical Diagnostic Evaluations

7. Swollen, red, or tender gums Presence of a fistula (drainage point) Physical Examination:

8. Diagnostic Tests Percussion Test: Pain upon tapping the affected tooth X-rays: Show radiolucency at the tooth apex indicating infection CT Scan: In severe cases, to check for deep tissue involvement

9. Medical Management Antibiotics: (if systemic infection or spreading) • Amoxicillin, Clindamycin, or Metronidazole Pain Management: • NSAIDs (e.g., ibuprofen) • Acetaminophen Drainage of Abscess: • Performed by a dentist through root canal or incision

10. Nursing Management Assess Pain & Swelling • Monitor severity using a pain scale • Assess for signs of spreading infection (e.g., fever, swelling) Administer Medications • Ensure prescribed antibiotics and analgesics are given • Educate on proper medication adherence Provide Oral Hygiene Education • Encourage proper brushing, flossing, and use of antimicrobial mouthwash

11. Nursing Management Dietary Guidance • Soft foods to reduce pressure on the infected tooth • Avoid very hot or cold foods Monitor for Complications • Observe for signs of cellulitis, osteomyelitis, or sepsis

12. Surgical Intervention Root Canal Therapy (RCT): Removal of infected pulp and sealing of the tooth Tooth Extraction: If the tooth is severely damaged and cannot be restored Incision & Drainage: If abscess does not resolve with conservative treatment

13. Prevention Regular dental check-ups Prompt treatment of dental caries Proper oral hygiene (brushing twice daily, flossing) Avoidance of excessive sugary foods

14. Complications Facial cellulitis Spread to jawbone (osteomyelitis) Ludwig’s angina (life-threatening airway obstruction) Brain abscess (rare but serious) Sepsis (bacterial spread to the bloodstream)

15. Prognosis Facial cellulitis Spread to jawbone (osteomyelitis) Ludwig’s angina (life-threatening airway obstruction) Brain abscess (rare but serious) Sepsis (bacterial spread to the bloodstream)

16. NURSING DIAGNOSIS Acute Pain related to periapical infection as evidenced by • Patient verbalization of severe, throbbing toothache • Facial or gingival swelling • Pain intensity rated 7/10 on a numeric pain scale • Sensitivity to hot, cold, and pressure Risk for Infection related to bacterial invasion in the periapical region as evidenced by • Presence of abscess and pus formation • Elevated body temperature (fever) • Redness and swelling in the affected area • Increased white blood cell count (WBC)

17. NURSING DIAGNOSIS Impaired Oral Mucous Membrane Integrity related to abscess formation and tissue inflammation as evidenced by • Presence of an open lesion or pus drainage • Swollen, erythematous gums • Foul odor from the mouth (halitosis) Imbalanced Nutrition: Less than Body Requirements related to pain and difficulty chewing as evidenced by • Reduced food intake • Patient reports avoiding solid foods due to pain • Weight loss over the past few weeks

18. NURSING DIAGNOSIS Deficient Knowledge related to lack of awareness about oral hygiene and infection prevention as evidenced by • Patient asking questions about proper oral care • History of poor dental hygiene practices • Frequent untreated dental infections

19. Management of Patient With Oral and Esophageal Disorders DISORDERS OF THE JAW

20. DISORDERS OF THE JAW Common jaw disorders include: • Temporomandibular Joint Disorders (TMD/TMJ Dysfunction) – Affects jaw movement and causes pain. • Malocclusion – Improper alignment of teeth/jaw, leading to functional issues. • Mandibular Fractures – Trauma-related injuries. • Osteomyelitis of the Jaw – Infection of the jawbone. • Bruxism – Grinding or clenching of teeth, leading to jaw pain.

21. Risk Factors • Trauma or injury to the jaw • Arthritis (Rheumatoid or Osteoarthritis) • Genetic predisposition (congenital conditions like micrognathia) • Bruxism (teeth grinding) • Poor dental alignment or missing teeth • Infection (bacterial or viral) • Stress (increased muscle tension in TMJ disorders

22. PATHOPHYSIOLOGY The underlying mechanisms depend on the specific disorder: • TMJ Dysfunction – Inflammation, disc displacement, or muscle dysfunction affect joint movement. • Fractures – Disruption in bone continuity due to direct trauma. • Osteomyelitis – Infection causes bone inflammation, leading to necrosis. • Bruxism – Chronic grinding leads to muscle fatigue, joint wear, and pain.

23. Clinical Diagnostic Evaluations • Physical Examination: Jaw alignment, tenderness, clicking sounds, muscle tightness • X-ray (Panoramic Radiograph): Fractures, osteomyelitis, misalignment • MRI/CT Scan: TMJ disorders, soft tissue involvement, joint degeneration • Blood Tests: Detect infections (osteomyelitis) or systemic conditions (arthritis) • Electromyography (EMG): Assesses jaw muscle activity in cases of bruxism

24. Medical Management • Pain management: NSAIDs, muscle relaxants, corticosteroid injections • Antibiotics: For osteomyelitis and infections • Physical therapy: Jaw exercises, heat therapy, and massage • Orthodontic treatments: Braces, bite splints for malocclusion • Lifestyle modifications: Stress management, dietary adjustments

25. Surgical Intervention Orthognathic Surgery: Corrects severe jaw misalignments TMJ Arthroscopy: Minimally invasive procedure for TMJ disorders Open Reduction and Internal Fixation (ORIF): For jaw fractures Bone grafting: For severe osteomyelitis cases

26. Nursing Management Assessment: Monitor pain, jaw movement, swelling, and function Pain management: Administer prescribed analgesics and muscle relaxants Dietary support: Encourage soft foods to reduce strain on the jaw Patient education: Teach jaw relaxation techniques, proper oral hygiene, and importance of follow-up care Postoperative care (if surgery is done): Wound care, monitoring for infection, pain control

27. Prevention • Use mouthguards to prevent bruxism-related damage • Avoid excessive gum chewing and hard foods • Stress reduction techniques (yoga, meditation) to reduce jaw clenching • Maintain good oral hygiene and regular dental checkups

28. Complications Chronic pain Difficulty eating/speaking Infection (post-surgical or due to osteomyelitis) Nerve damage (leading to numbness or weakness) Joint degeneration

29. Prognosis Mild cases (TMD, bruxism): Often improve with conservative management Fractures: Heal well with proper surgical intervention and rehabilitation Infectious conditions: Good prognosis if treated early with antibiotics Severe cases requiring surgery: Outcome depends on extent of damage and postoperative care

30. Nursing Dx and Intervention 1. Acute Pain Related to: • Inflammation of the temporomandibular joint (TMJ) • Muscle strain due to bruxism • Fracture or trauma • Surgical intervention Evidenced by: • Patient verbalizing pain (e.g., "My jaw hurts when I chew.") • Facial grimacing, guarding behavior • Limited jaw movement due to pain • Pain scale rating

31. Nursing Dx and Intervention 1. Acute Pain Nursing Interventions: • Assess pain level regularly using a pain scale • Administer prescribed analgesics (NSAIDs, muscle relaxants) • Apply warm compresses to relax muscles or cold packs for swelling • Encourage soft diet to reduce strain on the jaw

32. Nursing Dx and Intervention

33. Nursing Dx and Intervention

34. Nursing Dx and Intervention Nursing Interventions: • Provide a soft or liquid diet as recommended • Teach slow eating techniques to prevent choking • Monitor for signs of aspiration (especially in post-surgical patients)

35. ORIF PRE-OP Preoperative Interventions (Pre-op) 1. Patient Assessment: • Medical History: Assess for any history of medical conditions such as diabetes, hypertension, or infections that could affect healing. • Physical Examination: Assess the jaw’s mobility, tenderness, alignment, and any existing neurological deficits (numbness, weakness). • Pain Level: Evaluate pain severity to determine appropriate analgesic management.

36. ORIF PRE-OP Preoperative Interventions (Pre-op) 2. Diagnostic Testing and Preparation: • Imaging: Ensure all necessary imaging (X-rays, CT scans) is done to assess fracture site and plan surgical approach. • Laboratory Tests: Complete blood count (CBC), clotting profile, and other tests to assess patient’s overall health and ability to undergo surgery. • Preoperative Medications: Administer any ordered pre-op medications (e.g., sedatives, antibiotics) and ensure patient is NPO (nothing by mouth) as ordered.

37. ORIF PRE-OP Preoperative Interventions (Pre-op) 3. Education and Psychological Support: • Explain the Procedure: Educate the patient about the ORIF procedure, expected outcomes, and postoperative care. • Prepare for Postoperative Care: Explain what to expect post-op, including pain management, the need for soft foods, and possible limitations. • Anxiety Management: Address any concerns the patient has about surgery, anesthesia, and recovery.

38. ORIF PRE-OP Preoperative Interventions (Pre-op) 4. Infection Prevention: • Antibiotics: Administer prophylactic antibiotics to prevent infection at the surgical site. • Oral Hygiene: Encourage good oral hygiene before surgery to reduce the risk of postoperative infection.

39. ORIF INTRA-OP INTRAoperative Interventions (Intra-op) 1. Monitoring and Support: • Vital Signs: Continuous monitoring of vital signs (heart rate, blood pressure, oxygen saturation) during the procedure. • Anesthesia: Ensure proper administration of anesthesia, including local anesthesia at the fracture site or general anesthesia, depending on the case.

40. ORIF INTRA-OP INTRAoperative Interventions (Intra-op) 2. Surgical Assistance: • Sterile Technique: Assist in maintaining a sterile field and proper aseptic technique throughout the surgery. • Positioning: Position the patient comfortably for optimal access to the jaw, ensuring that the airway is open and protected. • Fracture Reduction and Fixation: Ensure the jaw is properly realigned, and internal fixation devices (plates, screws) are securely placed.

41. ORIF INTRA-OP INTRAoperative Interventions (Intra-op) 3. Blood Loss and Fluid Management: • Fluid Balance: Monitor and manage fluid intake and output to avoid dehydration or excessive fluid loss. • Blood Loss: Be prepared to manage any potential blood loss during the procedure and administer blood products if necessary.

42. Postoperative Interventions (Post-op) 1. Immediate Postoperative Care: Airway Management: Ensure the patient’s airway is clear and unobstructed, especially if there is swelling in the jaw area. Provide supplemental oxygen if needed. Pain Management: Administer prescribed pain medications (opioids, NSAIDs) and monitor effectiveness. Consider a PCA (patient-controlled analgesia) pump for controlled pain relief. Vital Signs: Monitor blood pressure, pulse, and temperature regularly to detect signs of complications (e.g., infection, hemorrhage). ORIF POST-OP

43. Postoperative Interventions (Post-op) 1. Immediate Postoperative Care: • Airway Management: Ensure the patient’s airway is clear and unobstructed, especially if there is swelling in the jaw area. Provide supplemental oxygen if needed. • Pain Management: Administer prescribed pain medications (opioids, NSAIDs) and monitor effectiveness. Consider a PCA (patient-controlled analgesia) pump for controlled pain relief. • Vital Signs: Monitor blood pressure, pulse, and temperature regularly to detect signs of complications (e.g., infection, hemorrhage). 2. Positioning and Mobility: • Head Elevation: Keep the head elevated to reduce swelling, typically at a 30-45 degree angle. • Jaw Protection: Use a soft bandage or support to immobilize the jaw to prevent dislocation or unnecessary movement. • Mobilization: Encourage early ambulation as tolerated to prevent complications like deep vein thrombosis (DVT).

44. Postoperative Interventions (Post-op) 3. Infection Prevention: • Wound Care: Inspect the surgical site for any signs of infection (redness, swelling, discharge). Maintain dressing integrity and change as needed. • Antibiotics: Continue the prescribed course of antibiotics to prevent infection. • Oral Hygiene: Provide guidance on gentle oral hygiene (using mouthwash or a soft toothbrush) while avoiding disturbing the surgical site. 4. Nutritional Support: • Dietary Modifications: Begin a soft or liquid diet immediately post-op, depending on the surgeon’s recommendations. • Hydration: Ensure adequate fluid intake to maintain hydration and support healing. • Monitor Intake and Output: Keep track of the patient’s oral intake and urinary output to ensure adequate nutrition and hydration.

45. Postoperative Interventions (Post-op) 5. Monitoring for Complications: • Swelling: Monitor for excessive swelling and apply ice packs as needed to reduce it. • Bleeding: Watch for any signs of postoperative bleeding, especially from the surgical site or in the mouth. • Neurological Signs: Assess for numbness, tingling, or weakness in the face, which may indicate nerve damage. • Wound Dehiscence: Watch for any signs of wound separation or infection. 6. Education for Discharge: • Oral Care: Provide instructions on maintaining oral hygiene without disturbing the wound site. Consider the use of a saline rinse or other gentle mouthwash. • Post-op Exercises: Instruct on jaw exercises (once cleared by the surgeon) to promote healing and mobility. • Follow-Up Care: Ensure the patient has a follow-up appointment with the surgeon for wound check and removal of sutures if necessary. • PT

46. Management of Patient With Oral and Esophageal Disorders DISORDERS OF THE SALIVARY GLAND

47. DISORDERS OF THE SALIVARY GLAND

48. Disorders of the Salivary Gland Risk Factors: • Age: Older adults may be more prone to salivary gland dysfunction due to dehydration or age-related changes. • Dehydration: Insufficient fluid intake can reduce saliva production. • Medications: Anticholinergic drugs, antihistamines, and certain antidepressants may decrease salivation. • Autoimmune diseases: Conditions like Sjögren's syndrome can affect the salivary glands. • Smoking: Tobacco use can lead to dry mouth (xerostomia) and increased risk of infection. • Infections: Bacterial or viral infections (such as mumps) can cause swelling and pain in the salivary glands. • Chronic illnesses: Diabetes, HIV/AIDS, and other systemic diseases can affect gland function.

49. Pathophysiology Sialolithiasis: Formation of stones within the salivary ducts can obstruct saliva flow, leading to swelling and pain. Sialadenitis: Inflammation of the salivary glands, often due to infection (bacterial or viral), can cause pain, swelling, and reduced salivation. Sjögren’s syndrome: An autoimmune disorder where the body’s immune system attacks the salivary glands, leading to dry mouth (xerostomia) and difficulty swallowing. Tumors: Benign and malignant tumors can develop in the salivary glands, leading to swelling, pain, and potential dysfunction.

50. Clinical Diagnostic Evaluations: Physical examination: Inspection of the mouth, face, and neck for swelling or tenderness. Imaging: Ultrasound, CT scans, and MRI can help identify blockages, tumors, or structural abnormalities. Sialography: An imaging technique using contrast dye to assess the ducts of the salivary glands. Biopsy: In cases of suspected cancer or persistent lumps, a tissue biopsy may be performed to examine for malignancy. Salivary flow tests: Measuring the quantity and quality of saliva to assess gland function.