Oral conditions in the community patient: part 1

The World Health Organization (WHO) (2020) defined oral health as ‘a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing’. Patients treated in the community are often vulnerable, and their dependency on others for the provision of care can place them at an increased risk of developing oral health problems.

Poor oral health has been linked to an increase in hospital-acquired infections, poor nutritional uptake, longer hospital admissions and increased care costs (Terezakis et al, 2011). With most oral health conditions being largely preventable, an emphasis needs to be placed on appropriate education, assessment and early intervention to maintain both dignity and wellbeing.

This two-part series outlines common oral health conditions seen in community patients, the impact of oral health on general wellbeing and role of community nursing teams in the provision of oral care.

Importance of oral health

Oral health has a symbiotic relationship with many chronic systemic diseases, including diabetes and cardiovascular disease. Poor oral health can exacerbate existing underlying disease by contributing towards malnutrition and dehydration (Health Education England (HEE), 2016). Improving not only the health of a person's mouth, but also function and ability to eat, drink and communicate can improve overall quality of life. More emphasis needs to be placed on medical professionals' understanding of these links, to increase prioritisation of oral care in line with other areas of general healthcare. The established links between oral health and systemic disease will be covered further in the second part of this series.

Identification of common oral conditions

Xerostomia

Xerostomia (dry mouth) is commonplace in the community, with reports of up to 78% of palliative patients experiencing signs and symptoms of dry mouth (Davies et al, 2005). Polypharmacy, diabetes, radiotherapy and dehydration are all factors that can increase the risk of developing xerostomia. In normal function, saliva acts as a buffer to regulate oral microflora, aid digestion of food and preserve oral tissues (Humfrey et al, 2001). A reduced quantity and quality of saliva can have an adverse effect on enjoyment of simple daily activities, such as eating and talking.

Community nurses often deal with dependent, dysphagic and critically or terminally ill patients, all of whom have been identified as having increased risk of developing xerostomia (British Society for Disability and Oral Health (BSDOH), 2000). Simple recommendations can include encouragement of regular sips of water, application of dry mouth products and usage of sugar-free chewing gum and lozenges. Nurses may also consider careful removal of dried saliva secretions with gauze to provide immediate relief and referral for further assessment by a dentist who may prescribe salivary substitutes or stimulants where appropriate.

Oral candidosis

Oral thrush has been identified to affect between 34% and 70% of palliative patients (Jobbins et al, 1992; Wilberg et al, 2012). It is an opportunistic infection that occurs when there is an overgrowth of commensal Candida fungal species. Oral thrush is seen commonly in palliative patients, those undergoing antibiotic therapy, denture wearers (particularly poorly fitting or maintained dentures), smokers, those with diabetics and immunosuppressed patients. For some patients, Candida infections can be asymptomatic and may only be identified by a health professional or family member providing oral health care.

In the treatment of oral thrush, it is imperative to ensure optimum denture cleanliness and oral hygiene. Simple advice includes the removal of dentures at night and cleaning the denture with a soft toothbrush to remove food debris. Soaking dentures in aseptic solutions can help to remove Candida, which is harboured on the denture (Hasan, 2015). For patients with long-standing Candida infections, it may be necessary to consider reconstruction of dentures, because Candida hyphae can become embedded within the porous acrylic material of dentures.

In severe cases of oral candidosis, or where simple measures have not resolved the fungal infection, community nurses can guide the patients to dental intervention where antifungal medications such as miconazole, fluconazole and nystatin can be prescribed. It is important to have a contemporaneous drug history when considering prescription of antifungals, because drug interactions have been identified between miconazole and fluconazole in patients taking warfarin and statins, due to the metabolism-based drug interaction that occurs (Chen et al, 2007). For patients who have no risk factors for developing oral candidosis, onward referral and further haematological investigation by the GP may be indicated to eliminate underlying disease, such as diabetes.

Oral ulceration

Oral ulceration occurs due to a break in the epithelial layer, exposing the underlying connective tissue. Similar to leg ulceration, the surface of the ulcer is gradually replaced by a fibrin slough, which gives a yellowish appearance. Oral ulceration, unlike leg ulcers, is usually self-limiting, and lesions normally resolve within 10–14 days. Oral ulceration may be recurrent with no triggering factors or underlying systemic conditions and is termed recurrent aphthous stomatitis, or it may be related to several factors, including trauma, immunosuppression, nutritional deficiencies, Behcet's disease, haematological disorders or underlying gastrointestinal diseases, including Crohn's or coeliac disease (Ship, 1996). Basic investigations include haematological tests and diet analysis, and consideration for onward referral is advised if an underlying systemic cause such as inflammatory bowel disease is suspected.

Because oral ulcers are largely self-resolving, treatment is usually based on symptom management. Topical treatment includes the use of over-the-counter mouthwashes, such as benzydamine hydrochloride mouthwash. In cases where trauma from teeth or dentures is suspected, patients will require dentist intervention to remove the traumatic factor. For patients with recurrent oral ulceration, consideration of an exclusion diet may be adopted under the guidance of a health professional, with elimination of foods such as cinnamon, crisps, benzoates and tomatoes. Oral ulcers that are still present after 3 weeks without resolution should be treated as suspicious and should be reviewed urgently, through a 2-week pathway by a medical or dental practitioner, due to risk of this being oral cancer.

Oral cancer

Oral cancer is a malignancy that can affect multiple areas of the oral cavity, including the lips, tongue and mouth. Unlike many other malignancies, oral cancer can be described as a ‘self-induced disease’ (WHO, 1984). Major risk factors for developing cancer include the use of tobacco, excess alcohol use and, more recently, the increasing prevalence of the human papilloma virus (HPV), particularly subtypes 6 and 16 (Warnakulasuriya, 2009). Signs and symptoms include the presence of a non-healing ulcer, white and/or red patches within the mouth, unexplained intra- and/or extra-oral swellings, tooth mobility (which is not related to gum disease), reduced tongue movement, altered speech or dysphagia and new disturbances in taste or sensation (HEE, 2016).

Although oral concerns are unlikely to be the reason for the nursing visit, it is important that oral symptoms associated with concerning clinical features are addressed promptly. It is essential that, if a single ulcer has persisted for more than 3 weeks with an unknown cause, an urgent referral be made to a local oral surgery or oral and maxillofacial department to exclude malignancy. Highlighting concerns to GPs and dentists and even completing an onward referral from the nursing team itself to secondary care can help identify oral malignancy earlier and improve the long-term prognosis of the patient. Preventative advice, including reduction and ideally elimination of tobacco and alcohol, can reduce the risk of developing oral malignancy, in addition to improving the overall general health of the patient.

Mucositis

Mucositis is a side effect of chemotherapy and radiotherapy, with symptoms usually commencing 1–2 weeks after initial treatment. Maintenance of good oral hygiene, use of warm saltwater rinses and ensuring hydration of the oral cavity through ice chips, sugar-free chewing gum and regular sips of water can aid symptomatic relief of mucositis. Application of topical anaesthetics, saliva stimulants and substitutes can also aid comfort. Benzydamine hydrochloride is an anti-inflammatory and local anaesthetic agent that has demonstrated efficiency in reducing the intensity and duration of mucositis (Epstein et al, 1989). Adherence to a soft, bland diet and avoiding foods that can cause mucosal irritation and trauma to the soft tissues can also be beneficial (Table 1). Patients may require nutritional supplementation to ensure adequate nutrition. However, these should be prescribed with caution, because these high-calorie drinks may have a detrimental effect on the patient's natural dentition, and, as such, appropriate dietary support and oral hygiene measures should be used to avoid complications such as dental decay at a later stage. Liaison with the patient's oncologist can provide further information and support regarding appropriate products to alleviate symptoms.

Gingivitis

Gingivitis (inflammation of gums) is a reversible inflammatory condition of the gums, which is normally preventable with good oral hygiene. Gingivitis can be localised (affecting a small area of the mouth) or generalised (affecting a large area of the mouth). Early intervention is essential to prevent gingivitis from advancing into periodontitis, which can lead to tooth mobility, dental pain, infection and subsequent tooth loss. Mechanical plaque debridement using a toothbrush is essential, with adjuncts including dental floss and interdental brushes used to clean in between teeth. Short-term adjuncts of topical antibacterial agents, including chlorhexidine gluconate, can also be used, but should not serve as a replacement to toothbrushing. It is important to reduce the bacterial load within the oral cavity, particularly in vulnerable patient groups, to avoid general health complications, such as bacterial infective endocarditis. Nursing teams can support patients by recognising this condition, assisting in the provision of oral care (including support to the patient's main care providers) and providing appropriate signposting to dental services for tailored preventative advice and cleaning.

Dental caries

A recent survey reported that over 50% of care home residents in the West Midlands to have dental decay requiring dental treatment (Tomson et al, 2015). Although dental decay can be asymptomatic, it can progress to sensitivity and acute dental pain if the dental pulp (nerve inside the tooth) becomes infected. Infected teeth generally require either definitive endodontic treatment (cleaning and removal of the nerve inside the tooth) or extraction. They can lead to life-threatening cervicofacial infections, which can result in emergency hospital admission.

Although it is imperative to ensure that patients have adequate nutritional intake, it is also important that nursing staff aid the education of patients to limit the number of ‘sugar attacks’ to a maximum of four per day to also protect and maintain oral health. This is particularly important for patients who have xerostomia and, thus, lack the saliva required to protect teeth from developing dental caries. For patients who are at increased risk of dental decay (including palliative patients, patients with active dental caries and those who have undergone head and neck radiotherapy), high-fluoride toothpaste (5000 ppm) can be prescribed by their dentist.

Tooth surface loss

Tooth surface loss (TSL) describes the loss of the tooth structure due to wearing of the tooth over time. Although some degree of tooth wear occurs from the natural ageing process, pathological tooth loss can be caused by three main categories: erosion, attrition and abrasion (HEE, 2016). TSL often arises as a combination of these conditions and can vary in symptomatology from sensitivity to pain if dental treatment is not sought.

Erosion is caused by frequent or prolonged exposure to acid, either from extrinsic sources (e.g. food and drinks, including citrus fruits and carbonated drinks) or intrinsic causes (e.g. acid reflux). Susceptible patients include those with gastro-oesophageal reflex disorders (GORDs) and patients who have medical conditions that increase vomiting. Nursing teams can support susceptible patients by reinforcing dietary advice and liaising with GPs if intrinsic causes of tooth erosion are suspected.

Abrasion is the wearing away of the tooth surface by a mechanical force and is often caused by overzealous tooth brushing. Patients who receive assistance to brush their teeth are at risk of abrasion, because it is particularly challenging to gauge the appropriate pressure when assisting with mouth care for another person. Electric toothbrushes often incorporate pressure sensors to help regulate pressure and can be used as an alternative to conventional toothbrushing with a manual toothbrush.

Attrition is the wearing down of a tooth due to prolonged tooth-to-tooth contact (such as grinding or clenching). Bruxism, or grinding, can often occur subconsciously at night-time, and can occur from increased stress and anxiety. Chronic bruxism can result in shortening of the crowns of the teeth, which can become challenging if patients require dental treatment at a later date, such as provision of dentures. Patients may also have accompanying myofascial pain due to overuse of the muscles of mastication. If attrition is suspected, patients can be signposted to a dentist, where a mouth guard can be constructed to protect the teeth from further wear.

Role of community nurses in supporting oral health

Table 2 summarises common oral health conditions and their symptoms, and provides clinical photographs to illustrate these. It is important that a holistic approach to patient care is used within nursing teams. This should include an evaluation of clinical problems, which may impact on a person's general health. Following an initial patient assessment, these clinical problems should be revisited throughout the patient's care. Although general issues, such as weight loss, nutrition, pressure risk and hydration, are automatically assessed, the assessment of oral health risk factors is less likely to be undertaken.

Although nursing staff are not expected to diagnose oral conditions, it is important that the team has appropriate education, awareness and ability to recognise when oral health is deteriorating. This role also involves the provision of preventive and management advice where appropriate, in addition to signposting and referral to other services, as required. It is essential that community nurses are continued to be supported in formal oral health training within their respective trusts to ensure optimum holistic patient care.

This summary highlights some of the common oral conditions, but it is by no means a comprehensive overview. Introduction of simple preventative measures including simple dietary, smoking and alcohol advice and early intervention measures can help support the wider healthcare team in maintaining oral health.

Conclusion

Maintenance of adequate oral health is essential for patient comfort and psychological and physical wellbeing. Prevalence of oral disease increases in vulnerable patient group, and, therefore, community nurses have an important role in early identification, support and maintenance of oral health.

KEY POINTS

• Maintenance of good oral health is fundamental for general and dental wellbeing
• A multidisciplinary approach to oral care is required for optimum holistic patient care
• Nurses should be familiar with simple oral health advice and identification of common oral conditions

CPD REFLECTIVE QUESTIONS

• If a patient complained of dry oral mouth symptoms, what simple advice could you give to manage their symptoms?
• What factors may increase the risk of a patient developing oral ulcers?
• What suggestions could you make to a patient's diet to reduce mucositis symptoms?