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Cardiff Masterclass November 2019

Mouth Care

Dr Aoife LowneyConsultant in Palliative Medicine

Why is this Important?

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• most had no policy to promote and protect people’s oral health (52%)

• nearly half were not training staff to support daily oral healthcare (47%)

• 73% of care plans reviewed only partly covered or did not cover oral health

• it could be difficult for residents to access dental care

• Oral symptoms are common in palliative and medically complex patients

• Poor oral hygiene and oral symptoms affect an individual’s quality of life (dysgeusia, poor appetite..)

• Oral health deteriorates when a patient is hospitalised

• A lack of oral care can lead to systemic complications, including:

– Aspiration pneumonia

– Development of infections such as candidiasis

– Reduced oral intake contributing to poor nutrition

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Guidelines

• Multiple national guidelines• Inconsistencies within and between• Inaccurate information

➢ Mouth care guidance and support in cancer and palliative care, 2nd

edition (UK Oral Mucositis in Cancer Group)

➢ NICE Clinical Knowledge Summary: Palliative care – oral

➢ Scottish Palliative Care Guidelines – Mouth Care (Healthcare Improvement Scotland and NHS Scotland)

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Routine Mouth Care

• Teeth cleaned at least 2x per day with SLS – free fluoride toothpaste & a soft toothbrush

• Brush dentures with soapy water over full sink

• Keep dentures out of the mouth overnight in a labelled pot

Additional Helpful Products

• Dental finger shield

• Three sided tooth brush

• Interspace brush

• Combined suction toothbrushes

– (good for patients with dysphagia)

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Mouth Care Assessment

• Mouth care assessment for all patients within 24hrs of admission

• Oral care plan based on assessment

• Actions as indicated

• Reassess weekly

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Mouth Care Assessment

https://mouthcarematters.hee.nhs.uk/links-resources/mouth-care-matters-resources/

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Record Everything!

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Mouth Care Record Example

Common Oral Symptoms

• Xerostomia

• Dried Secretions

• Dysphagia

• Oral Ulceration

• Mucositis

• Fungal Infections

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Xerostomia (Dry Mouth)

Clinical Features Management

➢ Erythematous, fissured tongue

➢ Foamy saliva➢ Cracked lips➢ Dried secretions

Frequent sips of water

Ice chips

Sugar-free Chewing Gum

Artificial saliva

Mouth Moisturising Gels

Lubricate Lips (avoid Vaseline)

SLS-free toothpaste

Avoid Acidic foods

Pilocarpine

Dried Secretions

• Repositioning

• Suctioning is not always helpful as secretions can be too far below the larynx

• Dried secretions should be removed with a soft wetted toothbrush, cloth, or oral cleaning ‘sticks’

• Maintain moistness of oral soft tissues

Clinical Features Management

➢ Airway secretions dry and crust in the mouth

➢ Coughing & congestion

➢ Sounds may be unpleasant and upsetting to family members

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Mouth Care in Dysphagia

Clinical Features Management

➢ Increases risk of aspiration

➢ Reduces oral intake

➢ Can lead to:➢ Malnutrition➢ Dehydration➢ Pneumonia

➢ Excessive drooling

A smear of toothpaste with assisted suction or suction toothbrush can be used when providing oral hygiene.

Oral UlcerationCauses Management

➢ Chemical e.gMedications

➢ Mechanical e.gdentures, cheek biting

➢ Thermal e.g. hot food➢ infection

Topical corticosteroids:

Hydrocortisone lozenges (aphthous ulceration)

Beclomethasonespray/Betamethasone mouthwash (unlicensed indication)

Doxycycline mouthwash for severe recurrent ulcers

Chlorohexidine mouthwashes can prevent secondary bacterial infections

instillagel

Treat HSV

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Mucositis

‘My mouth became ulcerated and I could not swallow my own saliva. Every day of treatment brought some new horrifying change to my body’- Liz

MucositisClinical Features

➢ Reduction in epithelial turnover

➢ Widespread oral inflammation and ulceration

➢ Dysarthria

➢ (GvHD)

Diet of soft, bland, warm food

Frequent saline mouthwash

Ice chips swirled & held in the mouth

SLS-free toothpaste

Caphasol up to 10 times a day

Benzydamine 0.15% oral solution 10ml, 2-3 hourly up to 7 days

Mucosal protectants (E.g. Gelclair, Epsil, Mugard)

Systemic analgesia (swish?)

Bleeding – tranexamic acid

GvHD steroid/calcineurin inh

Management

WHO Oral Toxicity Scale

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Fungal Infections

Clinical Features Management➢ White plaques on

erythematous base

➢ Denture stomatitis

➢ Angular Cheilitis (Staph. Aureus & Candida)

Topical nystatin or miconazole is recommended for first line therapy in immunocompetent patients

See BNF for drug interactions

Oral or IV fluconazole is recommended for first time use in immunocompromised patients and for persistent infection resistant to topical treatment in immunocompetent patients

Clean dentures with Chlorhexidine

Resources

• Mouth Care Matters – Free resources on website:

• http://www.mouthcarematters.hee.nhs.uk/

• Mouth care guidance and support in cancer and palliative care, 2nd edition (UK Oral Mucositis in Cancer Group)

• NICE Clinical Knowledge Summary: Palliative care – oral

• Scottish Palliative Care Guidelines – Mouth Care (Healthcare Improvement Scotland and NHS Scotland)

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