People in palliative care often rely on staff for mouth care, but oral health is frequently overlooked at the end of life. Poor mouth care can lead to bad breath, discomfort, infection, and social isolation, as family and friends may avoid close contact. Around 40% of palliative patients experience ongoing oral problems and may lose the ability to communicate their needs. Oral care should therefore be part of every end-of-life care plan to maintain comfort, dignity, and quality of life.

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Assessment should include medical history, oral examination, nutrition, hydration, coping ability, and whether the person can manage their own mouth care. Patients and carers should be educated on mouth care routines, and responsibilities should be clearly documented. Mouth care should usually be provided every 2 hours, or every hour for patients at high risk of oral complications.

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Good oral care includes brushing teeth twice daily with a soft toothbrush and fluoride toothpaste, rinsing the mouth after meals, cleaning dentures thoroughly, brushing the tongue if coated, and maintaining hydration. Damp gauze may be used if a patient cannot tolerate a toothbrush. Removing plaque, secretions, and debris regularly helps prevent infection and pain.

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Some practices should be avoided.

Foam swabs are ineffective for plaque removal and may present a choking risk. Glycerine and lemon swabs can worsen dry mouth, while acidic foods such as pineapple may irritate the mouth and reduce saliva production.

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Dry mouth management focuses on keeping the mouth moist with fluids, sprays, ice chips, saliva substitutes, and lip lubrication. Hydration and nutrition should be monitored closely. Good oral hygiene and antimicrobial mouthwash may help manage halitosis. Oral infections such as candida, ulcers, and mucositis should be treated promptly according to guidelines.

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In end-of-life care, the priority is comfort through hydration, pain relief, symptom control, and regular mouth cleansing. Conscious patients may need mouth moistening every 30 minutes, while unconscious patients require mouth care at least hourly. Families should be informed about the mouth care plan so they can support the patient.

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Health professionals should receive appropriate training in palliative mouth care. Referral to specialists is recommended for severe infections, persistent ulcers, uncontrolled pain, malnutrition concerns, communication difficulties, or when diagnosis and management are uncertain.

 

 

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Evidence-informed guidance for health and care professionals

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Reference:  NICE Guidance Palliative care – oral,  Palliative Care oral, Scottish Palliative Care Guidelines – mouth care, Caring for smiles NHS Scotland Palliative Care Guidelines, Public Health England, Oral health toolkit for adults in care homes.  For up-to-date links and resources click here

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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. 

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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? 

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

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

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Frequency of mouth care 

• 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.

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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.

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Refrain from use or use with extreme caution

• 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.

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• 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.

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

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​​​​​For more information on palliative mouthcare management see links below

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[1] NICE (July 2023) NICE Clinical Knowledge Summary: Palliative care – oral [Online] Available at:  https://cks.nice.org.uk/palliative-care-oral 

[2] NHS Scotland (revised April 2020). Scottish Palliative Care Guidelines – Mouth Care. [Online] here   NHS Scotland Caring for Smiles 'Oral Care at the End of Life' PDF here

[3] Public Health England, Oral health toolkit for adults in care homes [Nov 2020]  Section 5 - How to support residents with mouth care part 2 [27/11/20] Palliative and end of life care presentation  here 

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

[5] End of Life Mouth Care Management webinar (PDF) here

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