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Scottish Palliative Care Guidelines print pdf

Mouth Care

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. Mouth care should be part of daily routine patient care and intervention should be instigated early to prevent more serious problems and treatment complications.

Key principles

  • Assess every patient
  • Plan regular effective mouth care
  • Confidence to refer
  • Identify urgent referrals.

Assessment

All patients are at risk of oral problems and will benefit from planned regular mouth care, particularly patients receiving chemotherapy or radiotherapy who will need careful monitoring both pre- and post-treatment.

  • Drug history is significant as numerous medications can affect the oral environment:
    • opioids, diuretics and anticholinergics increase dry mouth
    • steroids increase the risk of candidosis
    • bisphosphonates increase the risk of osteonecrosis of the jaw. Ill-fitting dentures and surgical intervention including tooth extraction increase this risk, highlighting the need for preventative oral hygiene therapy.
  • Ask patients on a daily basis if they are having problems
  • Ensure privacy
  • Remove dentures before examining the mouth or performing routine mouth care
  • Use a torch to thoroughly examine the mouth
  • Check the lining of the mouth is clean. If not, refer to dry/coated mouth care section of this guideline.
  • Avoid pain by lubricating cracked lips with a water-based product.

Practice Point: Previous applications of water-based lubricants should be gently removed before replacing. Refer to dry/coated mouth care.

  • Look for signs of dryness, coating, ulceration, infection or tooth decay. Assess for pain.
  • Document findings accurately and assess daily or at each visit.
  • Consider dental referral if oral symptoms or if it has been more than 1 year since the patient has been examined by a dentist.

Management

 

Oral Care Table 1 Specific Measures

All patients:

  • Keep mouth and lips clean, moist and intact by removal of plaque and debris. Refer to dry/coated mouth care.
  • Maintain fluid intake with frequent, small drinks.
  • Apply water-based gel to dry lips after oral care.
  • Where possible reduce intake of sugary foods and drinks between meals (refer to ‘Anorexia/Cachexia guideline’). Note: additional oral care requirements as frequency of intake increases.

Dentate patients

  • Natural teeth should be cleaned with fluoride toothpaste (at least 1350ppm) after every meal, but at least twice daily if tolerated.

Practice point: Mechanical brushing of teeth and gums to remove plaque and debris is as important as application of toothpaste or chlorhexidine digluconate 1%w/w dental gel.

  • Patients should be encouraged to spit out excess toothpaste after brushing.
  • The mouth should not be rinsed with water after brushing.
  • Partial dentures should be removed and cleaned separately.
  • A dental hygienist or dentist should provide professional instruction and advice on oral hygiene for those with complex dental work.
  • Silk brushes can be used to perform oral daily care for patients with a painful mouth.

Edentulous patients

  • All dentures should be marked with the patient’s name.
  • A denture fixative may provide relief from extensive movement of dentures.
  • Dentures should be removed overnight and soaked in a suitable cleansing solution
    • Dilute sodium hypochlorite solution for plastic dentures.
    • Chlorhexidine gluconate solution for dentures with metal parts.
    • Rinse dentures thoroughly before replacing in the mouth.
  • Remember to check that the lining of the mouth is clean. If necessary clean the oral mucosa: refer to dry/coated mouth care.
  • Dentures should be checked for cracks, sharp edges and missing teeth daily.

Denture hygiene:

  • Dentures should be brushed at least once daily over a sink of water.
  • Use of a personal toothbrush and running water are adequate for the physical cleaning of dentures.
  • Dentures should be rinsed thoroughly after meals.
  • Dentures should be left out of the mouth overnight and soaked. Refer to ‘Edentulous patients’ advice.

Mouth care if receiving chemotherapy/radiotherapy– key differences

  • See local cancer centre/cancer network policy.
  • Patients may be advised to avoid antipyretic analgesics (paracetamol, aspirin) if at risk of neutropenia (can mask fever due to sepsis).
  • Patients receiving head and neck radiotherapy should avoid oil-based products. Other specialist advice regarding oral care during radiotherapy may also be given by the cancer centre.

Caphosol® is a supersaturated calcium phosphate mouthrinse approved for restricted use for the prevention of oral mucositis in patients undergoing radiotherapy for head and neck cancer, and for patients undergoing chemotherapy. Consultation with a haematologist or oncologist is required before prescription.

Oral Hygiene Care Table 1: Specific measures Version 1 May 2014

 

Dry/coated mouth care

  • Oral care should be provided at least four times daily. Some patients may need more frequent care.
  • Review medication.
  • Gently remove coatings, debris and plaque from soft tissues, lips and mucosa.

Practice point: Failing to gently remove dried secretions, debris and plaque gently can cause pain, ulceration, bleeding and predispose to infection.

  • Use damp gauze to gently soak coated areas.
  • College tweezers, damp gauze or moistened silk toothbrushes can then be used to gently remove coatings and debris.
  • Maintain hydration. Cold, unsweetened drinks (such as sips of water) should be taken frequently through the day.
  • Saliva stimulation should be considered if patient able to comply
    • sugar-free chewing gum.
  • Saliva substitutes or oral gel if other measures insufficient. Refer to section 12.3.5 of British National Formulary (BNF).

Practice point: Avoid Glandosane® in dentate patients (long term use of acidic product may demineralise tooth enamel)

  • Fluoride mouthwash (0.05%) can be used at a different time from brushing
  • Prescription of high-fluoride toothpaste (2800ppm or 5000ppm sodium fluoride) should be considered as dry mouth increases the risk of dental caries. See dental practitioners’ formulary of BNF.
  • Refer to dentist for application of high fluoride varnish (22,600ppm sodium fluoride) for desensitisation as well as caries prevention

Painful mouth care

  • Seek dental opinion.
  • Consider oral mucositis as a possible cause, particularly in patients receiving chemotherapy or radiotherapy. Oral mucositis is a condition characterised by pain and inflammation of the mucous membrane which may present as painful mouth ulceration affecting any or all intra-oral surfaces.
  • Analgesia: soluble paracetamol and/or aspirin used as a mouthwash provides no topical effect. Do not advise patients to use this as a mouthwash. If systemic analgesia required, see Pain Management guideline.
  • Chlorhexidine gluconate 0.2% mouthwash can be considered when pain limits other mouth care methods.10ml used twice daily may be useful to inhibit plaque formation in patients unable to tolerate other mouth care measures. Dilute 1:1 with water if it stings. Alcohol-free preparations are available.

 

Practice point: If patient is unable to rinse and expectorate or there is a aspiration risk, soak gauze in chlorhexidine gluconate 0.2% mouthwash and gently wipe over coated surfaces, teeth and gums.

  • Urgent dental referral is required if mouth ulceration present.

Practice point: Causes include: trauma (from sharp teeth), haematinic deficiency, viral infection (herpes simplex), aphthous ulceration, oral malignancy and mucositis.

  • Gelclair ® is a viscous gel specially formulated to aid in the management of lesions of the oral mucosa. It forms a protective film that, by coating and sticking to the lining of the mouth and throat, offers rapid and effective pain management.

Practice point: The contents of one sachet should be diluted with 40ml of water and used as a mouthwash. This should be repeated three times a day 1 hour before eating or drinking.

Management of oral infections

Fungal infections

The most common types are candidiasis, denture stomatitis and angular cheilitis.

  • Maintain oral hygiene by following advice. Refer to Oral hygiene care.
  • In many cases a systemic antifungal such as fluconazole (capsules or suspension) 50mg daily for 7 days will be indicated (review and extend as necessary).

Practice point: Refer for dental opinion if no improvement in 7 day period.

  • Topical miconazole oral gel should be considered for treating angular cheilitis (soreness, redness and fissures at corners of mouth). Apply 2.5ml topically four times daily retained near lesions before swallowing. Continue use for 48 hours after lesions healed.

Practice point: Always check the BNF thoroughly for drug interactions before prescription of antifungal medication. Of note, fluconazole and miconazole (including topical route) should be avoided in patients prescribed warfarin or statins.

Practice point:  Swab angles, tongue and anterior nares to investigate possible Staphylococcal infection. If present, adjust treatment accordingly.

  • In patients where the above treatment is contraindicated, nystatin oral suspension 100,000 units/ml can be considered. Prescribe 5mls four times daily after food, usually for 7 days. Rinse around mouth and hold in contact with affected areas as long as possible. Continue use for 48 hours after lesions healed.
  • If persistent symptoms refer to dentist.

Viral infections

Herpes simplex is the most common viral infection.

  • Treat infections inside the mouth with oral aciclovir: 200mg five times a day for at least 5 days (or until healing is complete). Soluble preparations are available.
  • Higher doses of antiviral medication should be considered if the patient is immunocompromised - seek advice.
  • Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water-based lubricant, antipyretic medication and analgesia.

Practice point: Viral infections are highly contagious. Strict adherence to infection control measures is essential.

Excessive drooling

  • Problem is impaired swallowing of saliva rather than excessive saliva production – consider physiotherapy assistance around positional change and/or speech and language therapy around swallowing techniques.
  • Neurodegenerative disorders, such as motor neurone disease, Parkinson’s disease, multiple sclerosis.
  • Medication to manage this may exacerbate dry mouth
    • hyoscine, glycopyrronium
  • Seek dental opinion as mouth care regime may need modification.

Taste change

  • Maintenance of nutritional intake is essential.
  • Diet should be adapted to try new foods and drinks which are enjoyable and look good.
  • If minerals are lacking, supplements may be required.
  • See Advice on Diet and Eating for Cancer patients
  • Read Taste changes: how do I eat well with taste changes leaflet available from dietitians.

 

Practice point: If patients are prescribed food supplements and/or having frequent small food intake over the day, there is an added mouth care responsibility.

Resources

Patient/carer advice points

  • Register with a dentist and visit regularly.
  • Smoking and alcohol can contribute to oral problems.

Patient resources

http://www.nhsinform.co.uk/palliativecare/symptomcontrol/mouthcare

References