Clinical Journal of Oncology Nursing • Volume 16, Number 2 • Supportive Care 1

Oral Care for Hospice Patients With Severe Trismus

Hannah Wrigley, BN, RN, and Elizabeth Johnston Taylor, PhD, RN

Oral care is a hallmark of attentive, high-quality nursing care. Oral care improves a patient’s sense of well-being, communication, nutritional status, and lowers the risk for pneumonia. However, for patients with severe trismus, oral care may seem impossible. Trismus is the inability to open the mouth more than 35 mm and often results from medical therapies for head and neck cancers. This article details a simple approach to oral care that was successfully implemented with fi ve hospice patients with severe trismus.

Hannah Wrigley, BN, RN, is a staff nurse and Elizabeth Johnston Taylor, PhD, RN, is the research director, both at Mary Potter Hospice in Wellington, Aotearoa, New Zealand. Taylor is also an associate professor in the School of Nursing at Loma Linda University in California. The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. No fi nancial relationships relevant to the content of this article have been disclosed by the authors or editorial staff. Taylor can be reached at beth.taylor@marypotter.org.nz, with copy to editor at CJONEditor@ons.org.

Digital Object Identifi er: 10.1188/12.CJON.xx-xx

A married, 41-year-old male of mixed Maori and New Zealand European eth-nicity, M.C. had been em-ployed as a painter. Nine months prior to his admis-

sion to an urban hospice service, he had been diagnosed with tonsilar carcinoma that grew at the right base of his tongue and tonsil. After diagnosis, M.C. had a percutaneous endoscopic gastronomy tube inserted and began receiving ra-diation and chemotherapy with curative intent.

One month prior to his admission to the hospice program, the cancer reoc-curred locally. M.C. refused the offer of a neck dissection, but continued to receive chemotherapy. Because most of his care was received in the home, he did require some support in the hospice inpatient unit (IPU). At that time (two months pri-or to his death), M.C. could not talk and had diffi culty swallowing. He received medication via a dermal patch to dry oral secretions. Although the jaw and neck pain were managed by several analge-sics, breakthrough pain did occur. M.C. also received antibiotics for pneumonia. While in the IPU, M.C. had not received

any oral care for several weeks because of the pain and diffi culty with severe tris-mus, and family and healthcare providers could not identify a way to offer this most basic hygiene.

Trismus, the inability to open the mouth more than 35 mm, often results from therapies for head and neck cancers (Bensadoun et al., 2010). Findings note that 25%–50% of all patients undergoing primary treatment for a head and neck cancer suffer from trismus (Bensadoun et al., 2010; Louise Kent et al., 2008; We-ber, Dommerich, Pau, & Kramp, 2010). Although several mechanical, medical, and surgical treatments have been de-veloped to ameliorate the symptom of trismus (Chen, Wong, Ou, & Lee, 2010; Hartl, Cohen, Julieron, Marandas, Janot, & Bourhis, 2008; Mardini, Chang, Tsai, Coskunfirat, & Wei, 2006; Shulman, Shipman, & Willis, 2008; Stubblefi eld, Manfi eld, & Riedel, 2010), no description exists in the literature about how to pro-vide oral care for patients who continue to experience trismus.

Oral care not only contributes to feelings of well-being (e.g., diminishes halitosis, improves taste), it also plays a signifi cant role in eating, nutritional

status, and verbal and nonverbal com-munication (Stout, Goulding, & Powell, 2009; Sumi, Ozawa, Miura, Michiwaki, & Umemura, 2010). In addition, oral care signifi cantly reduces the risk for pneumonia and other respiratory infec-tions in institutionalized older adults and ventilated patients (Arpin, 2009; El-Solh, 2011; Goss, Coty, & Myers, 2011).

Administering the Procedure

This article describes an approach to oral care that was successfully imple-mented with M.C. and four subsequent patients with severe trismus (see Figure 1). The patients could not open their mouths more than 5–10 mm and were unable to use a foam swab or toothbrush for several weeks because of their severe trismus. The procedure for this oral care is as follows. First, ensure that the patient is as comfortable as possible (e.g., pain medication delivered 30 minutes prior to oral care). Describe the procedure to the patient and have supplies ready, including mouth rinse at lukewarm temperature (saline, boiled or sterile water, or nonal-coholic mouth rinse work best) (Stricker & Sullivan, 2003). Next, assist the patient with sitting up in bed or chair, place a ba-sin or bowl beneath his or her head, and drape a towel around the patient’s neck and upper body. Give the patient the distal end of a size 12 or 14 suction catheter to insert into his or her mouth. Draw up the mouth rinse in 50 cc syringe, and slowly push it into the catheter. The patient is to let the mouth rinse and accompanying debris then drip into the basin.

The rinsing procedure is continued; allow the patient to move the end of the catheter around the inside of his or her mouth as needed, until the patient reports satisfaction with the oral care or is unable to tolerate the procedure any longer. Sometimes, the rinse emerges from the nares; allowing patients to blow

Supportive Care Valerie Burger, RN, MA, MS, OCN®—Associate Editor Supportive Care

2 April 2012 • Volume 16, Number 2 • Clinical Journal of Oncology Nursing

their nose into a tissue cleans this pas-sageway as well. Typically, one oral care session uses around 150 cc of rinse be-fore the mouth feels clean to the patient. Depending on an institution’s infection control policies, the syringe and catheter can be cleaned and kept at the bedside for repeated use, aiming for four rinsing procedures per day.

Although the procedure may be em-barrassing, patients who have needed this oral care have been exceedingly ap-preciative when it was introduced. After M.C. was given this oral care, his wife continued to administer the procedure at home. Although one will never know, it is valid to consider how the lack of oral care may have contributed to his developing pneumonia. This procedure will enable quality oral care to continue for patients despite severe trismus at the end of life.

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1. Ensure the patient is as comfortable as possible.

2. Describe the procedure to the patient.3. Have supplies ready, including a 12 or

14 suction catheter, a 50 cc syringe, and mouth rinse at lukewarm temperature.

4. Assist the patient with sitting up; his or her head should be bent over the bowl.

5. Drape a towel over the patient’s neck and upper body.

6. Insert the distal end of the catheter into the patient’s mouth.

7. Draw up mouth rinse into the syringe and slowly push it into the catheter.

8. Let the mouth rinse and debris drip into the basin.

Figure 1. Oral Care Procedure for Patients With Severe Trismus

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