16.10 Mouth care in palliative care

General measures

Mouth care should be offered to all patients with palliative care needs

  • Particular attention is needed for those who cannot manage it themselves
  • Families may be able to contribute to this role
  • Regular teeth brushing with toothpaste (unless neutropenic/low platelets)
  • Regular cleaning of dentures
  • Regular oral care with e.g. chlorhexidine mouthwash
  • Keeping mouth moist – see below
  • Regular inspection of oral mucosa for reversible problems – especially oral thrush, mouth ulcers and bleeding

Dry mouth

Contributory factors:

  • Poor fluid intake and/or poor nutritional state
  • Medication which dries secretions e.g. amitriptyline, hyoscine
  • Hypercalcaemia – potentially reversible
  • Radiotherapy to facial area
  • Mouth breathing
  • Use of non-humidified oxygen

Management

  • Encourage frequent sips of water and offer to suck ice cubes
  • Diet of soft, moist foods with extra gravy, sauces and/or butter (on veg)
  • Artificial saliva - see section 12.3.5 Treatment of dry mouth
  • Pineapple juice/unsweetened fruit chunks – avoid if lesions/ulcers, Please note that some patients develop a sore mouth because of proteolytic enzymes in pineapple natural juices therefore discontinue use of mouth becomes sore
  • Pilocarpine 5mg 3 times daily – If had head and neck radiotherapy. Can cause abdominal pain and diarrhoea, so only rarely indicated.
  • Pink sponges with water if patient unconscious – as required. Families can be shown how to use these to support comfort. Never leave the sponges soaking in water - there have been a small number of choking incidents. See MHRA alert
  • Soft, small children's toothbrushes can be useful.
  • Lip moisturiser. Do not use petroleum based products (e.g. Vaseline) in those on oxygen. Reports of 'sparking' and burns in the literature. Aloe Vera gel can be used

Oral infection

Oral candidiasis

Thrush is common in advanced illness and can cause great distress. If thrush is recurrent, look critically at: oral or inhaled steroids, treatment with antibiotics and oral hygiene care. Check a random blood sugar, especially for those patients on oral steroids.

Pharmacological management:

Miconazole gel
Nystatin oral suspension
Fluconazole
  • Use if nystatin not effective or a systemic antifungal is required
  • 50-100mg once daily for 7 days
  • Reduce dose of fluconazole by 50% if creatinine clearance is less than 50mL/minute
  • Be aware of potential drug interactions as a result of inhibition of various cytochrome P450 enzymes by azole antifungals
  • Higher doses and longer courses may be needed in immunosuppressed patients, and patients with more severe infections
  • See section 5.2 antifungal drugs
  • In resistant cases – seek specialist advice

Mouth ulcers

Herpetic ulceration
Bacterial infection and recurrent aphthous ulcers
Pain

Consider a range of options for symptomatic relief:

  • Regular chlorhexidine mouthwash. Avoid if this stings. (see section 12.3.4 Mouthwashes, gargles, and dentifrices)
  • Topical corticosteroids and local anaesthetic agents such as benzydamine mouthwash
  • Antacid and oxetacaine unlicensed suspension, prescribed by secondary care
  • Sucralfate may be of value, prescribed and dispensed by secondary care
  • Opioids may be required if pain is severe
  • Topical oral salicylates e.g. Bonjela® are available to purchase OTC and may provide symptomatic relief

 

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