ORAL CARE Professor Rod MacLeod

Senior Staff Specialist, Hammond Care and

Conjoint Professor of the University of Sydney

Anne Morgan Practice Advisor. HNZ

Genesis Lecture, July 2012

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Introduction

Mouth care is a frequently neglected but crucial aspect of

palliative care in all settings, It maintains self esteem,

comfort, and the person’s ability to communicate, socialise

and enjoy food and drinks

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Why worry about oral care?

• Patients at the end of life are vulnerable to oral problems

(Gillam & Gillam 2006)

• The impact of oral discomfort impacts on many aspects of

the lives of patients/residents

• People at EOL are frequently exposed to compromising

factors

• Research has ranked xerostomia in patients with

advanced disease as the third most distressing symptom

(Sweeney and Bagg, 2000, Davies et al, 2001, Rydholm and Strang 2002, Wiseman 2000 …)

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Risk factors for oral problems

• Debility

• Dry mouth

• Chemotherapy

• Poor oral intake

• Local irradiation

• Dehydration

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Even patients don’t rank it

Because oral care is often still seen by

health professionals as of minor

importance, despite the high incidence of

oral discomfort such as dryness (89%) and

infection, patients/residents do not perceive

these symptoms as clinically important and

often fail to report the problem.

Reported in a study from a community and hospice setting in Canada,

Oneschuk et al, 2000

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Physical effects

• Patient comfort

• Loss of enjoyment of food

• Loss of appetite and inability to maintain

nutrition

• Swallowing difficulties

• Poor protection from infection

• Communication difficulties

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Psychological Effects

• Frustration

• Swallowing difficulties

• Loss of taste means lack of enjoyment

• Prolonged periods of eating ‘mush’

• Unbearable at times

• Frustration gives way to annoyance and

anger

• Being misunderstood because of slurred

speech

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Social effects

• Difficulties in communication

leading to embarrassment

• Social impact of not being able

to enjoy and share meals with

family and friends

• Limits social outings and participation at

special occasions

• Avoid close physical contact

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Individualised care regimen

Timely oral care assessment and an

individualised regime are required to

establish the frequency and type of care

required in order to limit the occurrence of

oral complications (McQuire, 2003)

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Key questions for mouth care

• Is infection present?

• Is the mouth dry?

• Is the mouth dirty?

• Is the mouth painful?

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Oral health assessment

Body text

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Oral assessment guide

• Voice

• Swallow

• Lips texture (?dry, cracked. Bleeding)

• Tongue (?unusual coating, blisters, dry)

• Saliva

• Mucous membranes (?coating, ulcers)

• Gingiva (?oedema, redness, bleeding)

• Teeth/dentures (?debris, plaque)

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Major and minor salivary glands

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Functions of saliva

• cleansing and lubrication

• buffering

• remineralisation

• antimicrobial

• taste

• digestion

• mucosal integrity

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Aetiology of dry mouth

Functional

• dehydration

• psychological

• medication

• diabetes mellitus

• liver cirrhosis

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Aetiology of dry mouth

Structural

• developmental

• radiation therapy

• Sjögren syndrome

• infections

• graft-versus-host disease

• sarcoidosis 17

Replicating saliva

• Glycerine and thymol

Hygroscopic → dryness

• Carboxymethylcellulose

+ buffers, calcium and fluoride

• Saliva orthana

Animal mucin (~ religious

groups/vegetarians)

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Stimulating saliva

• Candies or mints

Sorbitol, xylitol-containing gum

• Chewing gum

• Pharmacological agents

• Lifestyle adaptation

• Diet drinks (low pH)

• Reduce caffeine and alcohol

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Dry mouth alternatives

• Semifrozen tonic water and gin

• Semifrozen fruit juice or pieces

• Frequent sips of cold water or water

sprays

• Petroleum jelly on the lips

• Frozen nystatin popsicles

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Drugs

Pilocarpine • Used for over 100 years

• No tablet available in NZ

• Use drops (significant dose variation)

• Solution is initially made up as

0.5mg/1ml, prescribing 500ml and

labelled to take 5ml four times daily po

(with increasing doses)

• Too high a dose leads to sweating,

nausea and loose bowels, less

commonly urgency and vivid dreaming

• Take care with asthma

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Infected mouth

Candidiasis

• 29-50% healthy adults are carriers

• Up to 89% of people with advanced

cancer

• Nystatin – may not be the best option

• Fluconazole (perhaps ketoconazole)

• Remember to clean dentures properly

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Care plan summary

• Report findings of assessment

• Offer oral care at least four times a day:

after each meal and at bedtime

• Use soft toothbrushes and mild

toothpaste or jumbo plain swabs

• Drug therapy as necessary

• Refer for dental treatment

• Repeat oral assessment daily

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Solution choices for oral care

• Lemon and Glycerin swabs – NO !!!

• Increase oral dryness due to dehydrating effects of glycerin and over-stimulation of saliva

• Exhaustion of salivary glands from effects of lemon

• No evidence of cleansing properties

• Citric acid damages tooth enamel

• Accelerates decalcification

• Increases likelihood of painful tooth sensitivity

Oral Care for People with Advanced Cancer; an evidence based protocol

Stuart Milligan, Maria McGill, Petrina Sweeney, Carol Malarkey

International Journal of Palliative Nursing 2001, Vol 7, No 9

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Chlorhexidine

• Do not use more than once every 12 hours

• Antibacterial, antifungal, antiplaque

• Can be unpalatable – may lead to taste alteration

• Astringency can lead to increased oral pain

• Incompatible with nystatin- two compete for the same binding sites

• Relatively expensive

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Sodium Bicarbonate

• Mucolytic properties

• Neutralises oral environment especially when there is infection

• Concentrations in excess of 1% can irritate mucosa

• Unpleasant taste can mean non-compliance

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Mouthwashes

• Pleasant tasting

• Deodorant effect

• Expensive

• Efficacy unknown

• Not always well tolerated if patient nauseated or anorexic

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Water or Normal Saline

• Widely used, well accepted, effective mouthwash

• Use warm or cool – not icy cold

Normal Saline

• Convenient and inexpensive

• Mild antiseptic

• Non-irritant (1 tsp to 500mls)

• Not so well tolerated by patients with altered taste or nausea

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The dying person

• Moisten mouth regularly

• Show family how to do this

• Gently with plain jumbo swabs

• Use fluids familiar to the person

• Lip balms useful

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Changing practice

• Create and implement a protocol

• Implement staff education and regular updates

• Audit oral care practices

• Provide information leaflets for patient’s and families

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In conclusion

Oral problems, especially dryness are a significant problem for people at the end of life and impact on people’s feelings and affect their quality of life. Oral care must therefore be raised to a clinical priority in hospice, hospital and community settings to improve standards of holistic palliative care.

Oral discomfort in palliative care: results of an exploratory study of the experiences of terminally ill patients

Rohr Y., Adams J., Young L. International Journal of Palliative Care3 2011

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