Sights, smells, memories, tastes, touch, integrate into every day enjoyment and the quality of life.

The mouth is often neglected in the terminally ill and inpatients with life threatening illness (1,2). The oral consequences of medication, especially during chemotherapy and radiotherapy are significant and protocols have been established to minimize the effects. Some of the consequences are permanent and this has implications in palliative care.

In the case of the terminally ill patient the underlying terminal disease impacts on the oral cavity. Usually when one thinks of care of the dying patient it is of someone dying of cancer and more recently of AIDS. However many other chronic illnesses: motor neuron disease, multiple sclerosis, rheumatoid arthritis, Huntingtons Chorea, stroke, Parkinson’s disease, dementia, and the frail, all have their special nursing needs in the last months and weeks of life.

The focus of this paper will be on the general oral conditions most likely to emerge during this period, the likely reasons for them and some suggestions of have maximize the quality of life by maximizing oral comfort. (Table 1). Historically, and rather arbitrarily, dentistry has little to do with the management of the dying patient. Dental undergraduate training, with its focus on restorative dentistry, ill equips dentists to manage patients in palliative care. Usually it is those dentists working in a Hospital environment that become involve.

Yet from an evolutionary and sensory point of view the mouth is given a large cortical representation in the sensory and motor cortex. Paradoxically cortical representation of body – the evolutionary values- is almost inversely proportional to the value placed by Western culture places on parts of the body. As social primates grooming – both in speech and hands-on is given primacy.

When it comes to maximizing quality of life it is often necessary to rethink our society’s values and rely on the kudos our evolutionary legacy gives to caring in general and grooming in particular. The perioral structures of the face including the lips and cheeks communicate. The intraoral structures; the tongue, palate and teeth serve a large number of functions. This collections of anatomical parts is a composite organ that evolved for defense, fight, incision, mastication, signaling, with facial expression and speech, gestures for contact and grooming, for love and affection (3).

Quality of life depends on keeping these functions intact.

From a patients perspective, after pain and nausea control, the ability communicate easily, to taste and enjoy food, and to be nice to be near is of paramount importance.

Unfortunately the side effects of many medications, especially chemotherapeutic and anticolinergic agents used in palliative care, compromise this enjoyment by effecting salivary flow, mucosal stability, and alteration in the oral microflora.(4)

The Mouth as an Ecosystem.

The mouth supports an extensive range of commensal bacteria now thought to be an important part in the maintenance of oral health. This microflora is supported by the mucosa and saliva. Any alteration in this environment can be used as an opportunity by the commensals to become the dominant species. The most troublesome is Candida sp. The maintenance of salivary flow and the nutritional status of the mucosa can correct the imbalance and restore oral comfort.

To feel confident about managing the oral care of the dying patient there are two integrated models to consider: the medical model and the behavioral model.
The Medical model:

It is useful to look at the anatomy, physiology, oral ecology, and pharmacology. Understanding the mouth from these perspectives it becomes relatively straight forward to sort out oral pathology and its rational management . Most of the remedies are common sense and oral comfort can be maximized.

The most common problems and their most likely etiology (Table 2):

The Mucosa:

The oral cavity including the lips to the vermilion border requires moisture for its integrity. The mucosa has a high turnover rate being replaced every 10 to 12 days. Chemotherapy and Radiotherapy interfere with this. As a consequence the mucosa can become atrophic and easily injured.

Ulceration

The presence of cytotoxic drugs and underlying neutropenia contribute to mouth ulcers With a break in the mucosal integrity secondary bacterial contamination is established. Prevention of ulcers in the compromised mucosa is often difficult but management involves protection of the broken mucosal surface .The ulcer can be protected with mucosal adhesives (Orobase -Bristol Myers Squibb). If minor ulceration is persistent, then topical corticosteroids *(hydrocortisone hemisuccinate, 2.5mg four times a day if slowly dissolved in the mouth can facilitate healing. If these remedies fail then recalcitrant cases may need stronger topical steroids or systemic steroids. Often there is a readily identifiable source of trauma (a sharp tooth or an over extended denture). In addition to removing the source of trauma an antimicrobial preparation containing chlorhexidine is of value (see below)*. In heavily infected ulcers a mouthwash made with one 250 mg capsule of tetracycline hydrochloride dissolved in warm water, three times daily for three days. Thalidomide has been reported as being effective in the treatment of chronic painful oropharyngeal ulceration and it have a greater place in management (5).

Candidosis:

The most troublesome species is Candida albicans. A compromised mucosa, reduced salivary flow, and general debilitation make the mouth vulnerable to opportunistic organism. Toxins produced by this organism irritate the mucosa (Denture Stomatistis). It is usually associated with plastic full and partial dentures worn 24 hours a day. The organisms colonize the acrylic resin and assaults the mucosa with their toxic metabolites. The condition usually responds quickly to mouth rest, antifungals, and denture sterilization (Table 2). Angular chelitis is often associated with oral candidosis but it is important to note that this may be a dual infection with Staphylococcus aureus.

Pseudomembranous candidosis can become established when the organisms invade the mucosa. In addition to the local measures mentioned it is often necessary to treat the condition aggressively with systemic antifunguals.(Table 2). Back to The Mouth as an Ecosystem

Saliva:

Saliva is essential to the mucosal health and to the enjoyment of food. There are three major sets of glands: the parotid, submandibular and sublingual. There are also numerous accessory glands. Saliva produced is of varying consistencies. They are innovated by the autonomic nervous system both parasympathetic and sympathetic systems. Parasympathetic stimulation produces a serous secretion. Stimulation of the sympathetic system produces a protein rich secretion.

Its absence (Xerostomia).

Chemotherapy, radiotherapy and many medications with a xerostomic effect either blockade the parasympathetic system or elicit an anticholinergic effect. Some therapies permanently destroy salivary gland tissue. The distressing symptom of diminished salivary flow can be minimized by a variety of means but it is important to identify the cause so that an appropriate therapy can be started including saliva substitutes*. (Table 3)

Its excess:

This is often a problem in motor neuron disease and specific anticholinergics can be used, Hyoscine, for example.

Taste:

Inadequate saliva minimizes the dissolution of tastants from food so the taste buds are not activate.

The Dentition:

It is not often that an acute pulpitis or an acute periodontal abscess develops. Most symptoms can be controlled by the use of anti-inflammatories, analgesics, and antibiotics. Definitive dental treatment is often difficult to deliver but in some situations sedative dressing can be placed in the home or at the bed side.

Halitosis:

Bad breath several identifiable causes: the lungs, the stomach, the oropharynx, the nose and sinus cavities and the oral cavity. The most common problem source of malodor is from anaerobic bacteria from the dorsum of the tongue. Chlorhexidine mouthwash has been show to be an effective treatment (6,7). Another source is food impaction between the teeth.

Loose Dentures:

Many older patients wear full dentures. Often they are ill-fitting and many years old. Loose dentures are the most common complaint in a Hospice situation (8,9). Their success is largely a function of good fit and the oral gymnastic ability of the patient. When there is loss of integrity of these abilities troublesome dentures feature as a major source of oral distress. The fit of the denture can be improved quickly by applying tissue conditioning materials (Shofu Tissue Conditioner and CoComfort Tissue Conditioner). These materials stick to the acrylic resin and are good for a month or more. When used thickly on the lower denture they provide a significant cushioning effect thereby reducing the trauma to the mandibular ridge mucosa. If salivary flow is inadequate to achieve an atmospheric seal denture adhesives (Fixodent, Polygrip) greatly help retention oft he maxillary prosthesis.

Behavioral consideration:

The teeth are our primary biological weapon. Fear and anxiety provoke clenching and tooth sharpening (especially while asleep and commonly referred to as bruxism). The sequel – sore muscles, sore teeth, temporomandibular joint pain. The forces involved in clenching and grinding are ten time or more than those used when eating. Mucosa covered by dentures is readily traumatized dentures are worn all the time. While it may be difficult to convince a patient to leave their prostheses out at night or when sleeping the benefits can be or significant value.

The behavioral model

When searching the index to medical literature (and this data-base includes nursing and dentistry) using the text words “oral care” the majority of articles are about the nursing management of patients undergoing radiotherapy and chemotherapy. There is a papacy of material concerning the oral care of the terminally ill patient. When repeating the same search using the text words “oral hygiene” an overwhelming number of articles come from dental literature. When using the text words “oral grooming” non emerge.

Unfortunately the words that are used to describe mouth care suggest an action: “cleaning teeth and mouth”, something that is resisted by care-givers in general. However, when this is turned about and grooming is suggested it harnesses the desire to caress and care for a loved one. Grooming suggests massage, gentle pressure, an involvement with the receiver, and most of all pleasure. It also heightens interest of the caregiver to the mouth and minor changes will be noted by someone who has an intimate knowledge of the area and is monitoring changes over time. It is often the groomer that alerts the other professional staff to change requiring professional advise.

Removing plaque and oral debris can be a difficult task especially when the saliva becomes sticky. Mouth care can be facilitated by using a mucolytic mouthwash used frequently during the day and night. Table salt and bicarbonate of soda in equal amounts (one teaspoon to a glass of hot water) is simple an effective.

Chlorhexidine gluconate (0.2%) (Savacol – Colgate, or Chlorhexidine Mouthwash – Delta West, Upjohn) are effective antiplaque agents. They are chemical toothbrushes. These are rather bitter to taste but can be diluted 50/50 and are still effective. They can also be used as a lavaged and swabbed about the teeth and gums.

Broxodent 2000 electric tooth brushes are effective in providing massage and cleaning. Their vibration frequency (20 – 50 cycles per second) relax spastic muscles and provide a pleasurable sensation. (10)

Table 1

Commonly encountered oral problems in terminally ill patients

Dry mouth:

Mucositis

Oral Ulceration – drug induced during neutropenic episodes

anemia

-traumatic

-viral

Fungal contamination

Fungal infections

Denture problem Back to introduction

Table 2

Antifungal preparations:

Nystatin liquid drops, lozenges, Miconazole gel.

Systemic antifungals: Ketoconazole and Fluconazole.

Topical pain relief:

Difflam (Benzydamine, 3M) lozenges or mouthwash (not recommended for children) Xylocane topical preparations used with care to avoid profound general mucosal anesthesia with the risk of cheek and tongue biting. Back to The Medical Model , Candidosis

Table 3

If the glandular tissue is intact:

Stimulation by chewing gum or sucking sweets. The preferred gum is “V6” (Stafford-Miller) or Freedent (Wrigleys).

Pilocarpine in controlled dose can be used as a salivary stimulant.(11)

Adjuncts: water.

If the glandular tissue is absent or damaged:

Salivary replacements, either methyl cellulose based(Luborant) or mucin based

(Saliva Orthana). They are not suitable when eating. Back to Xerostomia

Table Summary

Corticosteroid mouth-wash

The corticosteroid mouth-wash. Betnesol (Glaxo Wellcome) [Betamethasone sodium phosphate]. 0.5mg tabs. Soluble. Four tablets in 10 ml of water. Swish about mouth for two minutes. Spit out. Do not swallow.

PILOCARPINE

Pilocarpine – parasympathetic stimulant. See “The Problem of the Persistent Dry Mouth” M.M. Ferguson, E.E. MacFadyen, and P. Hayes. In New Zealand Pharmacy, October 1991. pp14-17.

The solution is conveniently made with a vial of pilocarpine eye-drops (0.5%-6%),diluting the drops to an appropriate concentration containing citrate/phosphate buffer (pH 5.0):

Pilocarpine 20-300mg

Benzoic acid solution BP 2.0ml

(equivalent to 5% benzoic acid solution)

Citric acid 102mg

Di-Sodium hydrogen phosphate 369mg

Sorbitol 25mg

Concentrated peppermint water 2.5ml

Water to 100ml

Normally the patient is started with a low dose (about 2.5mg). This is gradually increased until a therapeutic response is obtained. Side effects of sweating, diarrhea, and nausea. The aim is to find a comfortable therapeutic zone.

Denture sterilization

All plastic dentures area best sterilised with an overnight soak in a mild solution of hypochlorite. The most convenient is household bleach. About a teaspoon in a bowl of water.

Tissue conditioners

Tissue conditioners: Viscolgel (de Tray)

Tissue Conditioner (Shofu)

CoComfort (GC America Inc.) Back to Loose Dentures

Artificial saliva

Saliva replacement solution can be made up by a pharmacy. 10% gylcerine, 3% methylcellulose, 0.5% Sodium fluoride. Water to make up to vol. required. Three to four drops onto the tongue as needed. Back to Xerostomia

References

1. Kirkham S. Sore mouth in context. European Journal of Palliative Care, Supplement 1, 1995, 2:3.
2. Krishnasamy M. Oral problems in advanced cancer. European Journal of Cancer Care 1995, 4 (4): 173-177 Back to introduction
3. Every RG. The Teeth as weapons. Lancet 1965: 27 685-688 Back to introduction
4. Bonaventura A. Complications of Cytotoxic Therapy, Part 1, Australian Prescriber, 1995, 18 No 3, 65-67 Back to introduction
5. Ryan J, Colman J, Pedersen J, Benson E. Thalidomide to treat esophageal ulcer in AIDS. New England Journal of Medicine 1992, 304, 208-209 Back to Ulceration
6. De Boever EH, and Loesche WJ. Assessing the contribution of anaerobic microflora of the tongue to oral malodor. Journal of the American Dental Association, 1995, 126: 1384-1393.
7. Rosenberg M, Clinical assessment of bad breath; Current Concepts. Journal of the American Dental Association, 1996,127: 475-482. Back to Halitosis
8. Sweeny MP, Bagg J. Oral Care for Hospice Patients With Advance Cancer. Dental Update, 1995, December 22 no 2: 424-427.
9. Boakes M. Vibrotactile stimulation. British Journal of Occupational Therapy, 1990 53: 220-224. Back to Loose Dentures
10. Walls AWG and Murray ID. Dental care of patients in a hospice. Palliative Medicine. 1993, 7: 313-321.
11. Ferguson MM, MacFadyen EE, and Hayes P, The problem of persistent dry mouth. New Zealand Pharmacy October 14-17 Back to Table 3
12. Pankhurst CL, Smith EC, Dunne SM, Jackson SHD, and Proctor G, Diagnosis and Management of the Dry Mouth: Part 1. Dental Update 1996 23 no2: 56- 62.
13. Regnard C and Fitton S. Mouth care: a flow diagram. Palliative medicine, 1989,3: 67-69.

Acknowledgments

Dr David Hay, Oral Health Service at Auckland Hospital, Auckland.
Dr Peter Dennison.

Should you want a copy of this material in A4 format please contact Kevin Scally by email kevin@8.co.nz or at :

Kevin B. Scally
Dental Surgeon
Canterbury Health Limited
PO Box 1740
Christchurch
New Zealand.