PALLIATIVE ORAL CARE

A summary of recommendations from            (NICE, NHS Scotland, Palliative Care Wales Guidelines) 

Mouth Care Advice for palliative care residents

 Mouth care is an integral component of both palliative and end of life care. The aim of palliative mouth care management is preventing oral complications,  , maintaining adequate oral function, promote comfort, hydration and overall quality of life.

People in palliative care are often dependent on staff for their mouth care. Unfortunately oral health is often neglected at the end of life as mouth hygiene practices may be forgotten or eliminated, this can contribute to halitosis and can impact on contact with friends and family members avoiding loved one due to bad breath and worsening a person’s isolation.

Evidence shows that 40% of palliative patients suffer from oral conditions for a prolonged period of time and lose their ability to communicate their oral health needs (Chen, Chen, Douglas, Preisser, & Shuman, 2013)

Evidence-informed guidance for health and care professionals

Prevention summary of useful recommendations:

Reference:  NICE: Palliative Care oral, Scottish Palliative Care Guidelines – mouth care, Caring for smiles NHS Scotland Palliative Care Guidelines

Oral health impacts a person's dignity as well as oral function towards the end of life and should be included in the End of Life care plan.  People in palliative care are more vulnerable to oral problems such as thrush no matter how well their mouth is cared for, therefore it is IMPORTANT that the mouth is managed appropriately as part of palliative care. 

Assessment

A systemic approach to assessment and management is necessary.  Always carry out assessments and make decisions in partnership with the person and their carers.

Perform a medical history and exam.  Assess the coping ability and current problems. Nutritional status - whether fluid intake is adequate. Whether the resident can carry out mouth care on their own? 

Ensure the resident and their carer/s are educated about how and when to carry out the patient’s preventive care regime

Establish which health and care professionals have responsibility to ensure this. Record preventive care regimes in the patient’s notes

Frequency of mouth care for palliative/end of life

  • Every 2hrs if in high risk of oral problems

  • Every 1 hr for people who have severe problems such as oral infections, coma severe mucositis, dehydration, immunosuppressed, diabetes or needs oxygen therapy.

Oral care in line with ‘Delivering Better Oral Health’:

  • Brush teeth twice a day using a soft, small-headed toothbrush and fluoride toothpaste. A non-foaming toothpaste is preferred because it is more readily rinsed and residual toothpaste may have a drying effect on the mucosa.

  • Rinse mouth with water after eating.  Use warm water or  sodium chloride solution (1/2 teaspoon of salt in 225ml water as it  helps to remove debris and is soothing and non traumatic   

  •  Dentures  Keep any dentures scrupulously clean . Remove dentures at night , clean with a toothbrush and soap or denture cleaning paste.  (Refer to  Denture Care Guidelines Sept 2018 Oral Health Foundation).  https://www.dentalhealth.org/FAQs/denture-guidelines ) Soak dentures overnight. Note that cleaning dentures with denture cleaning solution is an adjunct to mechanical cleaning 

  • Brush tongue if furry and use antiseptic mouthwash such as Chlorhexidine. 

  • Ensure the intake of adequate fluids

  • Damp gauze (non-fraying type, which has been thoroughly wetted in clean running water) wrapped around a gloved finger may be used if the resident is unconscious or unable to tolerate a toothbrush.

  • Consider highlighting the importance of removing and cleaning away debris, secretions and plaque regularly as part of mouth care, to maintain good oral hygiene and prevent pain and infection.

Refrain from use or use with extreme caution

  • The practice of chewing pineapple and sucking on frozen tonic water should be discouraged in dentate patients due to its acidity. It can over exacerbate the salivary glands and exhaust the saliva causing a dry mouth.

  • Foam swabs should not be used as a method of plaque removal. Swabbing has very little plaque removing ability. There is a risk that sponges may detach from sponge sticks if the adhesive fails. This poses a choking risk to patients. Consider safe alternatives to moisten or clean patients’ mouths. MouthEze sticks are a safer alternative, though a toothbrush should be used ideally as tooth brushing remains the most effective method of plaque control.

  • Glycerine and lemon swabs should be avoided, they often increase the sensation of a dry mouth.

 

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Dry mouth 

The best way to make a person feel better, in addition to toothbrushing is to provide frequent fluids while they are able to drink and when that is no longer possible, ensure that the mouth is kept moist.

Try simple salivary stimulating measures such as unsweetened drinks, sprays, moisten lips 

If symptoms are not relieved consider topical saliva substitutes . It must contain the salivary enzymes lactoferrin and lysozyme which is essential for boosting the natural immune process. 

Avoid glycerin  as it dehydrates the mucosa and lemon juice exhausts saliva secretion and  acidic foods eg. pineapple  or acidic artificial saliva products on people with teeth.

Carers should be mindful that dry mouth may make it more difficult for certain oral medications to dissolve intra-orally or be swallowed by patients. This may require address, for example if medication gets stuck to the soft tissues cheeks and other soft tissue in the mouth.

  • Lubricate lips  Apply water-based saliva replacement gels or aqueous cream to lips

Hydration and nutrition status should be assessed as part of mouth care. Hydrate with water /ice chips to reduce mouth dryness and make patients more comfortable to help manage bacterial growth.

 

Consider highlighting the importance of removing and cleaning away debris, secretions and plaque regularly as part of mouth care, to maintain good oral hygiene and prevent pain and infection.

 

Halitosis- Good oral hygiene -clean tongue, good care of dentures Fluid intake, Exclude garlic & onions, Smoking cessation , consider saliva supplements if pt has a dry mouth, Treat underlying cause -

mouthwash containing antimicrobial agent.

Oral Candida infection.  Manage local and systemic risk factors for oral candida infection in conjunction with anticandidal treatment.

Manage local and systemic risk factors in conjunction with anticandidal treatment. The choice of drug treatment may be directed by local policy or based on advice from local microbiologist.  For NICE Guidelines treatment and when to refer www.cks.nice.org.uk/palliative-care-oral

Mouth Ulcers and mucositis   Depending on the severity of pain and underlying cause such as iron, folate or Vit B12 deficiency.  Treatment choice should be guided by the severity of pain.  Refer to Nice Guidelines Palliative Care Oral www.cks.nice.org.uk

Assess daily for changes.

 

 

End of life care

 All aspects of mouth care that will provide comfort and improve quality of life should be included in the patient’s care plan (for example, pain relief, management of dry mouth, removing dry secretions, frequency of mouth rinsing).

The focus is on oral hygiene, alleviation of symptoms and ensuring the patient is appropriately hydrated, it is recommended that the management of dry mouth is included in the patient’s care plan.

  • Keep the mouth hydrated

For the conscious pt

Consider changing or stopping meds that cause dry mouth.

For the unconscious pt

Moisten the mouth at least every 1 hr with water from a spray, dropper or ice chips. 

  • To prevent crack lips use Vaseline or KY- Jelly if on oxygen

  • Clean dentures and teeth.

  • Families and friends should also be made aware of the mouth care regime at the end of life to ensure they can support the patient and have greater involvement in their last days of life.

Oral pain

Treat underlying cause of pain if possible, if not treat pain symptomatically.

Use of topical non- opioid analgesics such as  Benzydamine spray/mouthwash, Lidocaine 5% ointment or 10% spray

For severe pain seek advice if pain is difficult to manage.

Mouthwash

  • Water is a way to reduce mouth dryness and make patient more comfortable - manage bacterial growth

  • Chlorhexidine - has a slow release property that maintains antimicrobial activity for up to 12 hrs

  • Sodium bicarbonate mouthwash 1% - is reported to reduce the viscosity of oral mucus therefore enhancing the removal of oral debris.  Use recommended concentration because it may cause mucosal irritation.  *There are no controlled studies to support its use over other mouthwash rinses.

Other aspects of mouth care: training, dental access, and products, tools and support for patients

Health and care professionals involved in the day-to-day care of patients should be trained and have access to training to deliver appropriate mouth care for palliative patients. There is currently very limited training available for staff and health and care professionals may not prioritise mouth care as part of palliative care. Training should contribute to improved mouth care and consistent advice.

 

When to refer to a specialist

1. If in doubt about the diagnosis, management or any oral problems

2. Mouth problems are causing a decreased intake of food - concerns about malnutrition

3. Severe herpes simplex infection

4. Severe mucositis - can be extremely painful

5. Suspect Neutropenic ulcer

6. Aphthous ulcers are bleeding

7. Severe persistent candida infection

8. Disturbed taste (prolonged)

9. Pain that is difficult to manage

10. Communication problems (Speech and language therapist)

[1] NICE (2016) NICE Clinical Knowledge Summary: Palliative care – oral [Online] Available at:  https://cks.nice.org.uk/palliative-care-oral 

[2] NHS Scotland (2017). Scottish Palliative Care Guidelines – Mouth Care. [Online] Available at: (Accessed May 2017)

[3] Public Health England (2017). Delivering better oral health: an evidence-based toolkit for prevention. Third edition. [Online] Available PDF HERE  

[4] Summary Palliative  Oral Care summary sheet (PDF)  download here