oral care for maxillo-facial oncology patients carolyn...
TRANSCRIPT
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Oral care for maxillo-facial oncology patients
Carolyn Joyce, Staff HygienistCarolyn Joyce, Staff HygienistCardiff Dental Hospital
All Wales Special Interest GroupOctober 9th 2009Llandrindod Wells
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AIM
To describe the role of theDental Hygienist
in thein theMaxillo-facial Oncology Team
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Discuss
� The contribution the Dental Hygienist in the Multi-disciplinary Oncology Team
Theoretical and practical aspects of � Theoretical and practical aspects of training programmes
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Mouth cancer, UK (2004)
� 7,697 people had mouth cancer
� Mortality rate 50%
� 2,718 deaths in 2005
Kills one person every 3 hours in UK� Kills one person every 3 hours in UK
� Rising number of younger people affected
� 25% of young people have no significant risk factors
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Patient’s Care Pathway
Assessment & Diagnosis�
Pre-surgicalPre-surgical�
Immediate pre & post-surgical�
Follow up / On-going care
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JOINT CLINICS
� Joint clinics have arisen from the pressure from the Royal College of Surgeons desperate to avoid a repeat of such incidents that occurred in Bristolsuch incidents that occurred in Bristol
� RCS recommends that individuals are seen by Specialists with an interest in head and neck cancer
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PRE-SURGICAL
� When surgeon and hygienist try to build a relationship with the patient
First point of contact as soon as � First point of contact as soon as relevant, following diagnosis
� Takes place in Joint Head & Neck Clinic
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PRE-SURGICAL
� Early contact vital to reduce treatment complications
Establish ‘life-long’ relationship� Establish ‘life-long’ relationship
� Complete oral assessment
� Establish dental fitness
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PRE-SURGICAL
� Work closely with Restorative Dentist
� Optimise oral condition for surgery
� Provide optimal healing
� Assessment should include radiographs of teeth & jaws (Fayle et al, 1992)
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Pre-Surgical
� First tier role of Dental Hygienist
Oral hygieneLiaise with restorative teamScale and polishScale and polishPreventive advice & treatmentRe-enforce oral hygieneLife-style advice
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IMMEDIATE POST SURGERYIntensive Care Unit
� Feeding regimes: Nil by mouthNG tubesPEG feeds
� Dry mouth: Intubation� Dry mouth: IntubationSide effects of medication
� Build up of detritus and bacteria putting wounds and grafts at risk
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Immediate Post-surgeryIntensive Care Unit
� Oral hygiene vital for wound care
� Reduced manual dexterity post-op
� Nursing staff providing oral care
� Dental Hygienist input is crucial in post-surgical care & staff support with OH
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Aids to Oral Hygiene
� ASPIRATING TOOTH BRUSH
� PROPS
� PROPS
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Objective on Return to Ward
� Re-establish / regain of oral function� Maintain healing environment� Promote swallowing and speech skills� Promote swallowing and speech skills� Liaison with: Dietitian
Speech Language TherapistNursing staff
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Principles
� Establish a pattern of appropriate care right from the onset of the post operative periodoperative period
� Provide Oral Care information as an integral component of general care
(Peterson & Sonis, 1982)
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Oral hygiene advice
� Realistic and simple advice
� Preventive advice� Preventive advice
� Emphasis on the value of maintaining oral comfort during treatment
� Better compliance
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Oral hygiene information
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POST SURGERY FOLLOW UPJoint Head & Neck Clinic
� 60-80% require radiotherapy
� Approx 40% chemothearpy
� Vital to provide a secure dental environment
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ORAL COMPLICATIONS OF RADIOTHERAPY
� MUCOSITIS
� ULCERATION
� CANDIDOSIS
� XEROSTOMIA
� LOSS OF TASTE
� TRISMUS
� OSTEORAINECROSIS AND IRRADIATION
� XEROSTOMIA
� RADIATION CARIES
� DENTAL HYPERSENSITIVITY
� PERIODONTAL DISEASE
AND IRRADIATION ASSOCIATED OSTEOMYELITIS
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During Radiotherapy
� Risk of uncontrolled dental disease
� Regular oral assessment
� Maintain oral hygiene� Maintain oral hygiene
� Fluoride therapy
� Advice on denture wear
� Relieve xerostomia , mucositis etc
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MUCOSITIS
� Mucosal erythema � Sloughing� Ulceration � Considerable discomfort� Considerable discomfort� Dysphagia and oral soreness become maximal 2-4 weeks after radiotherapy begins but usually subside in a further 2-3 weeks post therapy
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MUCOSITIS AND ULCERATION
� Warm saline mouthwash
� Difflam (benzydamine hydrochloride) used prior to meals is effective in alleviating mild to moderate mucositis alleviating mild to moderate mucositis for some patients
� Gelclair
� Mugard new product
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Xerostomia
� Common side effect of radiotherapy even when saliva glands are protected
Can be permanent � Can be permanent
� Has a detrimental effect on oral tissues
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RELIEVE XEROSTOMIA
� Advise high moisture foods� Avoid spicy foods� Fluids with meals� Saliva substitutes - Saliva orthana, Luborant both contain fluoride, Oral Balance saliva Saliva substitutes - Saliva orthana, Luborant both contain fluoride, Oral Balance saliva replacement gel
� Application of flavourless salad oil or dietary fat at night time lubricates the lips and tongue
� Sugar free chewing gum stimulates saliva production eg Orbit
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RELIEVE XEROSTOMIA� Advise high moisture foods� Avoid spicy foods� Fluids with meals� Saliva substitutes - Saliva Orthana, Luborant both contain fluoride, Oral Balance saliva replacement gel, Glandosaneboth contain fluoride, Oral Balance saliva replacement gel, Glandosane
� Application of flavourless salad oil or dietary fat at night time lubricates the lips and tongue
� Sugar free chewing gum stimulates saliva production eg Orbit
� Prevention – Duraphat 2800
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WATER=
Best saliva substitute
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Radiation Caries and Dental Hypersensitivity
� Increase in a softer cariogenic diet
� Soreness of the mouth and loss of taste
� Oral hygiene becomes more difficult� Oral hygiene becomes more difficult
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Osteoradionecrosis
� Complications include:Uncontrolled periodontal diseaseIll fitting denturesImmuno-deficiencyImmuno-deficiencyMalnourishment
� Life-long & long-term
� Poor healing
� Intractable infections
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Osteomyelitis
� Pain
� Trismus
� Exposed bone- sequestration
Pathological fractures� Pathological fractures
� Halitosis
� Life threatening
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Post Surgery Follow-up
� On-going patient education
� Share Skills practical and social
� Develop extended duties:Support groupsSupport groupsCharity workEducational talks
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Summary of role of DH
� Liaison with MaxFax Team
� Attendance at MDT meetings
� Regular ward visits
Pre & Post-operative observation & � Pre & Post-operative observation & treatment
� Education
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Public education
� Life-style factors
� Early detection
� Can improve outcome from 50% to nearer 90% survival ratenearer 90% survival rate
� Late detection results in poor prognosis
� Poor 5 year survival rate
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Education is key to success
� Dental Care Professionals
� Nursing staff
� Dietitians
Speech & Language Therapists� Speech & Language Therapists
� Clinical Nurse Specialists
� Recommend BSDH Guidelines
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Nurse Education
� Ward based teaching
� Formal training programmes
� Hands on tuition on the ward
Role of the nursing team important to � Role of the nursing team important to assist with oral care interventions
� Maintain effective teamwork
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� The DH plays a very important role in the continuing care of the oral cancer patient but also in providing much needed support throughout all aspects of treatment
� The role may extend beyond the clinical setting and could encompass the social and psychological demands which are increasingly put upon clinicians undertaking the treatment of malignancy
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Conclusion
� Dental Hygienist is a key team member
� Oral hygiene and Dental Health
� Well being, wound healing and oral functionfunction
� Teaching
� Extended into supportive roles
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THANKYOUfor
Listening!!
Griffiths & Boyle (2005)Holistic Oral Care
Joyce & Crean (2002)What Does The Dental Hygienist Have To Offer The Oncological Maxillofacial Surgeon. Dental Health 2002; 41: 5-6.
BSDH Guidelines for the Oral
Listening!!BSDH Guidelines for the Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and Bone Marrow Transplantation. J Disabil & Oral Health. 2001; 2: 3-14www.bsdh.org.uk