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Oral problems in palliative care

Mouth / oral problems are common in palliative care

Mouth – an important organ use for expression is often affected in the later stages of malignant terminal conditions It has been reported that 40 % of palliative care patients lose their ability to communicate their oral health needs National Cancer Institute at National Institutes of Health has reported that 80 % of of patients receiving myeloablative chemotherapy will develop oral complications
○ palliative drugs as bisphosphonates and analgesic are associated with oral mucositis and taste disturbance Candidiasis can affect 85 % of palliative care patients ( Jobbins )

Background – problems may happen due to
○ direct effect of the primary disease
○ indirect effect of the primary disease
○ consequence of the treatment of the primary disease
○ direct / indirect effect of a co-existing disease oral cavity tissue exhibit high mitotic turnover -chemotherapy leads to atrophy of tissues radiotherapy leads to sclerosis of the small vessels which vascularise the oral tissues oral mucositis is often seen in patients receiving radiation therapy to the head and neck , chemotherapy for solid tumors or lymphoma as well as those who receive high-dose myeloablative chemotherapy prior to hematopoietics cell transplantation ( up to 90 % patients ) – pathology is complex and has been explained a 5 step process that begins with direct DNA damage from radio or chemotherapy to basal epithelial , submucosal and endothelial cells

oral problems often are under-reported ( patients find difficult to communicate their suffering ) and underestimated
( overlooked and neglected ) it has been shown that 40 % of palliative patients lose their ability to communicate their oral problems oral care usually provided by junior staff with less experience – considered basic nursing activity overall lack of education among staff about the importance of this topic changed eating habits , types of food social impact include – feeling worried , bothered , less satisfying life can lead to depression , lack of proper oral hygiene contributes to halitosis and people around them may stay away from the patient causing social isolation can impact on bonding that occurs with family and friends and professionals functional problems – swallowing difficulty , speaking and eating, food restriction
( weight loss ) , sense of oral dryness and lack of food enjoyment reduced oral intake an weight loss contribute to considerable morbidity

Assessment tailored history taking to ascertain if the person is suffering from the most common complains seen in palliative care patients namely
○ xerostomia
○ oral candidiasis
○ dysphagia
○ mucositis
○ orofoacial pain
○ change in taste
○ ulceration ask about pre-existing dental problems H/O alcohol and tobbacco use Nutrition A grading system could be used such as National Cancer Institute Grading Scale or Patient reported Oral Mucositis Experience Questionnaire

follow a systemic approach it should include
○ general observation
○ intra-oral examination
○ extra -oral examination use a glove , torch and tongue depressor remove any dentures observe the state of lips , mucous membranes , tongue , gums , cheek holes in teeth or broken fillings signs of dehydration , level of oral hygiene , ulceration , vesicles , erythema , white patches ,bleeding and infection is the mouth moist and clean with saliva any mouth ulcers or undiagnosed red or white patches assess nutritional status assess mental state.

Good mouth care is essential in the well being of debilitated patients Regular careful assessment and early interventions are vital and essential aspect of palliative care Advice about regular effective mouth care for all patients
( see links ) Identify and refer if serious oral problem identified to dentist or the palliative care specialist It has been shown in studies that xerostomia , oral candidiasis and dysphagia are the most common oral problems followed by mucositis , orofacial pain , taste change and ulceration

Brushing – twice a day soft toothbrush gentle tongue brushing can help reduce halitosis and prevent tongue coating fluoride containing toothpaste ( some head and neck patients may require toothpaste with a high fluoride content to protect the teeth ) remove the toothpaste by rinsing after brushing use a new toothbrush in case of infection if mouth painful very soft brushes as silk toothbrush or baby toothbrush can be used use water or a fluoride or antiseptic mouthwash foam mouth swabs are an alternative

Mouthwash – mouthwash can help with oral hygeine , preventing / treating infection , moistening the oral cavity or providing pain relief saline and salt water rinses are recommended salt water mouthwashes can effectively maintain oral hygeine advice to rinse the mouth after each meal and at night with warm water chlorhexidine – most commonly available mouthwash , has a slow release property and can maintain antimicrobial activity for up to 12 hrs chlorhexidine can stain the teeth brown if used regularly 
( advice to brush teeth before use ) sodium bicarbonate mouthwash 1 % can help reduce the viscosity of oral mucosa and remove oral debris

Dentures- removed twice daily cleaned with brush and rinsed in water remove at night provide information for e.g American Dental 
Association – denture care and maintenance / from
dentists , find more information under links

How often – every 2 hrs if in high risk of oral problems every 1 hr for people with severe problems such as oral infections , come , severe mucositis , dehydration , immunosuppressed , diabetes or needs oxygen therapy.

Xerostomia – subjective report of oral dryness may present as coated tongue , tongue may appear glossy, thick ropey saliva , candidiasis dry mouth can happen due to a variety of reasons which include CVA , diabetes , hypothyroidism , Sjögren’s syndrome , sarcoidosis ,cancer , HIV, hepatitis C , blocked salivary duct , dysphasia , some respiratory ,neurological conditions , psychogenic disorders , decreased mastication , smoking ,mouth breathing , unhumidified O2 review medications for e.g
○ antimuscarinics
○ tricyclic antidpressants
○ opioids
○ anti emetics
more than 400 medication can affect the salivary glands and reduce the flow of saliva address dehydration except in terminal stage patients with xerostomia suffer significantly more with dental caries

sipping water or moistening the oral cavity , spraying salivary gland stimulants as mouthwashes , gels , sprays , lozenges , pastilles and chewing gum saline mouthwashes , saline sprays / nebuliser for e.g
sodium chloride 0.9 % mouthwashes , sprays / nebilisers avoid alcohol containing mouthwashes as they may further desiccate the mouth rubbing petroleum jelly on lips water soluble lubricants ( e.g oral balance gel ) or mucin containing AS saliva orthina saliva replacement ( beware can damage dental health if used for a long time via demineralization of tooth enamel ) for e.g
○ can be used as frequently as needed including before & after meals
○ oral balance gel topically qds
○ some saliva substitutes may be acidic – consider using neutral pH preparations
○ some may have animal components sucking crushed ice , frozen tonic water smoking cessation and ↓↓ caffeine in severe refractory cases specialists may consider using parasympathomimetic saliva stimulants as pilocarpine other therapies which can be useful include acupuncture-like transcutaneous electrical nerve stimulation and acupuncture alone

Oral candidiasis – popularly known as oral thrush can affect up to 70 % to 85 % of palliative care patients creamy white patches multiple white to yellow plaques areas which may bleed and burn often associated with dry mouth other causes may include lack of oral hygiene , anaemia , immunosuppression, nutritional deficiencies , prolonged use of antibiotics , diabetes ,dentures candidiasis can clinically be pseudomembranous , atrophic or hyperplastic type

candida albicans is the most common organism candida associated infections include angular chelitis , medial rhomboid glossitis and denture stomatitis use of topical/ system agents alone or in combination chlorhexidine mouthwash 0.2 % bd nystatin oral suspension 5 mls qds for 7 days nystatin suspension 1 ml as a mouthwash – then swallowed 4 times a day for 7-14 days systemic agents for e.g fluconazole ( capsule or suspension are more likely to be effective ) for e.g 50 mg od x 7 days one off fluconazole 150 mg has also been proven to be effective miconazole oral gel 2 % qds retained near lesions before swallowing , advise to continue using for up to a week after the lesions have healed appropriate denture care ( for e.g leaving denture overnight in dedicated vessels in solutions of water , 0.12 % chlorhexidine solution – ask to seek advice from dentist ) some specialists may recommend prophylactic treatment to prevent candidiasis in high risk pts

Mucositis – A general term used to describe the inflammatory response of mucosal epithelial cells to the cytotoxic effects chemotherapy and radiotherapy Oral mucositis ( OM ) is the inflammation of the mucosal membrane which causes ulceration leading to pain , dysphagia and impairment in ability to talk may present as inflammation and bleeding of the oral soft tissues of lips , cheeks , gums and tongue pain can be a significant issue leading to nutritional problems Specialists team could employ WHO grading of mucositis to assess severity

once mucositis has started a multi-disciplinary approach may be beneficial -input from medical staff, dentists , oral hygienists , specialist nursing staff , pharmacists or radiographers aim to keep the oral mucosa clean and moist manage any infections as per findings consider dietitian input to advise about swallowing problems , malnutrition , weight loss, food adjustments , consistency , method of intake ( PEG / RIG , nasogastric feeding, fortification ) supplements manage pain with topical and systemic agents ( for e.g opiates ) topical agents as
○ oxetacaine ( antacid and antacid suspension ) topically 1- mls qds , lidocaine gel , spray
○ benzydamine HCl 0.15 % ( Difflam ) 15 ml 2-3 hrly which can be
 diluted 1 : 1 with water if it stings ( non-steroidal antiinflammatory 
mild local anaesthetic agent )
○ soluble paracetamol / aspirin gargle
○ Orabase ( carmellose paste ) 30 g adheres to mucous membranes
○ gelclair sachets – forms a protective film, Episil , Mugard
○ caphosol mouthrinse ( expensive )

Ulcers – where possible try and identify the cause consider swab if ulcer persists seek specialist advice

chlorhexidine mouthwash 0.2 % bd bonjela can be used 1st line ( choline salicylate -gel formation of an aspirin derivative ) hydrocortisone oral mucoadhesive buccal tablets 2.5 mq qds – allow to dissolve slowly in contact with water beclometasone spray or betamethasone soluble tablets can be also used ( risk candidiasis and systemic SEs -restrict use in cases of severe ulceration or difficult to reach sites ) antibiotic as metronidazole for foul smelling ulcers acyclovir 200 mg x 5/ day for viral ulcers

References

  1. European Oral Care in Cancer Group Oral Care Guidance and Support First Edition *EOCC-Guidelines-online-version-v8.pdf (wsbhospices.co.uk)
  2. Palliative care- oral CKS NHS Palliative care – oral | Health topics A to Z | CKS | NICE
  3. Venkatasalu, Munikumar Ramasamy et al. “Oral health problems among palliative and terminally ill patients: an integrated systematic review.” BMC oral health vol. 20,1 79. 18 Mar. 2020, doi:10.1186/s12903-020-01075-w
  4. Saini, Rajiv et al. “Dental expression and role in palliative treatment.” Indian journal of palliative care vol. 15,1 (2009): 26-9. doi:10.4103/0973-1075.53508
  5. Dental Nursing Oral discomfort in palliative care : results of an exploratory study Oral discomfort in palliative care: results of an exploratory study – DentalNursing (dental-nursing.co.uk)
  6. Sheikh Abrar and Pavan Manohar Patil. Palliative Oral Healthcare for Patients with Terminal Stages of Malignancy. Biomed J Sci & Tech Res 31(1)-2020. BJSTR.
    MS.ID.005046 *Palliative Oral Healthcare for Patients with Terminal Stages of Malignancy (biomedres.us)
  7. Scottish Palliative Care Guidelines Scottish Palliative Care Guidelines – Mouth Care
  8. Mouth Care Advice for palliative care residents Palliative Mouth Care | Knowledge Oral Health Care (kohc.co.uk)
  9. Topical treatment options for painful mouth Ashtons Hospital Pharmacy Services Topical treatment options for painful mouth – Ashtons Hospice Pharmacy Services (ashtonshospitalpharmacy.com)
  10. Bell A, Kasi A. Oral Mucositis. [Updated 2021 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565848/

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