PERT Program

Tip of the Month: July 2005


PALLIATIVE ORAL CARE


Oral care is essential to maintaining comfort and quality of life for all long-term care residents, and in particular those at the end of life. Meticulous oral care increases the person's comfort, helps maintain the ability to eat and drink, aids in the prevention of infection, and enhances the person's appearance.

Many residents have decreased consciousness and a diminished ability to swallow near the end of life. To ensure that residents do not choke or develop infections (such as pneumonia caused by aspirating microorganisms from the gut, gums, or dental plaque) it is important to position residents in as upright a position as is possible. If an upright position is not possible, turning the resident's head to the side during palliative oral care is the next best solution.

Attempt oral care whenever possible, with a focus on removing dental plaque from natural teeth and dentures, as well as treating dry mouth and mucositis, along with any bacterial, fungal, and viral infections. In the final days or weeks of life, residents may need oral hygiene care every few hours to keep their mouths moist and comfortable.


Dry Mouth

Having a dry mouth can cause a resident discomfort and make him susceptible to other oral health problems. Dry mouth can impair a resident's ability to chew, swallow, and talk, and can decrease general quality of life. Dry mouth can also increase the resident's risk of developing bacterial and viral infections.

Two terms are commonly used to describe dry mouth. Xerostomia is a person's subjective feeling of dryness in the mouth. One cause of xerostomia is salivary gland hypofunction (SGH), which is a reduction in the quality and/or quantity of saliva.

Causes
There are a variety of causes for dry mouth, many of which are commonly experienced by long-term care residents, especially those at the end of life. Causes include
  • Radiation and chemotherapy
  • General decline in physical and cognitive status
  • Medical conditions such as Sjogren's syndrome
  • Side-effects of many medications including antipsychotic, antidepressant, antiparkinsonian, antiemetic, antihypertensive, and opioid medications
Treatments

Treatments for dry mouth include methods for increasing saliva production and preventing unpleasant symptoms.
  • Saliva substitutes (e.g., Biotene®; Salivart®) are the preferred treatment for dry mouth. These products replace or supplement the resident's natural saliva to increase comfort and decrease the risk of bacterial or viral infections. They can be used as often as needed—even every few hours—to relieve symptoms. Available as gels or sprays, saliva substitutes should be applied all over dentures, teeth, tongue, and oral tissues as needed.

  • Saliva stimulants increase the amount of saliva produced, but should be used carefully, as they may cause side effects. Types of saliva stimulants include
    • Pilocarpine (oral formulation, e.g. Salagen®), a prescription medicine used to stimulate saliva production. Common side effects of oral pilocarpine include chills, dizziness, flushing, sweating, and nausea. Because of the side effects, these agents should only be used in consultation with a dental professional or health care provider.
    • SalivaSure™ tablets are available over the counter and can be placed near the saliva ducts and sucked to stimulate saliva production.
    • Chewing gum and sugarless hard candy will also stimulate saliva production.

  • Mouthrinses can relieve the effects of dry mouth, but special care should be taken, as residents are often unable to rinse and spit mouthrinses, and are at risk for choking. Alkaline saline mouthrinses (½ teaspoon salt and ½ teaspoon baking soda in 8oz of water) are commonly used. Antibacterial chlorhexidine gluconate mouthrinse (e.g., Peridex®) may be used, as appropriate, in consultation with a medical or dental professional, for minimizing dental plaque accumulation and oral infections. Considerations for using mouthrinses include
    • DO NOT use mouthrinses that contain alcohol, because these may burn the resident's cheeks, tongue, and other soft tissues, especially if the mouth is dry.
    • DO NOT use hydrogen peroxide mouthrinses as they can destroy the oral mucosa and increase risk for oral infections.
    • DO NOT use "magic mouthrinses" (for example, the often-used combination of Maalox, Benadryl, and a topical anesthetic such as lidocaine to numb the mouth) without first consulting a dental or medical professional.
    • DO NOT use pineapple and other juices as they contain enzymes that destroy the oral mucosa and increase risk for oral infections.
    • If necessary, mouthrinses can be applied using a small spray bottle.

  • Consider using toothpastes specifically made for dry mouth (e.g., Biotene® toothpaste).

  • Remove heavy nasal and oral secretions regularly using mouthswabs and toothbrushes covered with damp gauze. (Some mouthswabs are available premoistened with sodium bicarbonate.) However, DO NOT use lemon and glycerine swabs because these products tend to dry the mouth and mucous membranes.

  • For severe dry mouth, apply KY Jelly® inside the mouth to help with access into the mouth for oral care.

  • Moisten the resident's lips with Vaseline® often.

Mucositis

Mucositis is inflammation and bleeding of the oral soft tissues of the lips, cheeks, gums, and tongue. This condition can cause the resident to be at greater risk for viral and bacterial infections. It is important to treat mucositis, and treatment methods are the same as those used for dry mouth.

Some considerations to keep in mind when treating mucositis include
  • Avoid hydrogen peroxide products because they destroy oral mucosa.
  • Remove heavy nasal and oral secretions frequently.
  • If necessary, remove the resident's dentures to decrease discomfort and facilitate oral care.
  • Consider changing the resident's diet to soft foods.
  • Avoid pineapple and other juices which contain enzymes that destroy oral mucosa and increase the risk of infection and other problems.
  • Avoid mouthrinses containing topical analgesics. If it is necessary to use them for discomfort, consult with a dental professional.

Oral Infections

Residents experiencing dry mouth are at risk for developing oral infections. Two of the most common oral infections experienced by long-term care residents are fungal infections called thrush and denture stomatitis.

Thrush (acute psuedomembranous candidiasis) affects the oral soft tissues and appears as a white or yellow growth that can be wiped off. Thrush is usually treated with topical and/or systemic antifungal medications as prescribed by a medical or dental professional. Liquid antifungals do not remain in the mouth long enough to be effective, so these medications are best administered as lozenges, troches, creams, or gels. (Antifungal medications can also be administered in KY Jelly.)

Denture stomatitis affects the oral soft tissues that are covered by a denture and appears as a red, inflamed area, usually on the palate. The treatment for denture stomatitis is to remove the resident's dentures at night (or as often as possible) and scrub dentures daily in cleanser and water. Denture containers will harbor the fungal organisms and will need to be regularly sterilized or replaced. An alternative treatment is for the resident to suck antifungal lozenges or troches several times daily.

If the infection is severe, antifungal cream or gel can be placed inside a sterilized denture several times daily until the infection has been resolved. Also in cases of severe infection, the resident's dentures will need to be sterilized in a solution of dilute sodium hypochlorite (bleach) or benzalkonium chloride (1:750 dilution) and then scrubbed in cleanser and water. (However, do not use bleach with partial metal dentures as it will corrode the metal.)



This Tip of the Month was adapted from information and photographs that are part of an INFOCONNECT brochure from the Iowa Geriatric Education Center. It was written by Jane Chalmers, BDSc, MS, PhD Associate Professor, College of Dentistry, University of Iowa, Iowa City, IA. Other contributors to the original INFOCONNECT brochure were Dr. Michael Wiseman and Professor Ronald Ettinger.

For further information please contact Jane Chalmers at
Email: jane-chalmers@uiowa.edu
Phone: (319) 335-7203