Oral care is frequently overlooked by caregivers when caring for dying patients. Terminally ill patients have many oral complications as a result of their disease process, treatments, and medications. These conditions can include oral cavity pain, oral mucositis, candida, and most commonly xerostomia. If left untreated, these conditions can lead to other complications; including anorexia and difficulty swallowing, breathing, and communicating.
Oral pain should be treated both topically and systemically. Topical applications can either be single agents such as viscous lidocaine, benzydamine, and sucralfate or compounds such as milk of magnesia and diphenhydramine (Epstein & Schubert, 2004).
Xerostomia, or dry mouth, is most commonly treated by increased fluid intake with frequent sips of water and humidification. Salivary flow can be stimulated by oral activity such as chewing. Different tastes like sour and bitter also contribute to increased flow. Patients can utilize sugar-free gums, lozenges, candies, or mints containing xylitol for symptomatic relief of dry mouth. There are several products available over the counter for the relief of xerostomia. One of the most well-known products is Biotene. The product line includes gels, rinses, and gums. When xerostomia is present, products containing alcohol should be avoided.
Mucositis can be treated by both palliative and preventive methods. When mucositis is present, patients find relief with oral rinses. These rinses include 2% lidocaine, baking soda and saline or BAX. BAX is a compound of lidocaine, diphenhydramine, sorbitol, and Mylanta. Chlorhexidine gluconate rinses are also beneficial. Mucilages, which are unmedicated jellylike substances, can be used to provide comfort. They are normally fruit flavored and a frequently kept in the refrigerator to add symptom relief. Other behavior modifications can be helpful to reduce the incidence and severity of mucositis. These include avoiding hard, spicy, or hot foods that trigger pain, frequent rinses with saline solutions, and sucking on ice chips or popsicles. In addition to palliative therapies, prevention is important. Dental evaluations and elimination of potential problems such as grossly decayed teeth and periodontal disease will help with patient comfort. The practice of daily oral maintenance with alcohol-free antimicrobial mouth rinses, brushing/swabbing, and oral antifungal medications will help to decrease the bacterial load in the mouth and reduce the chance that ulcerative mucositis will become secondarily infected and/or cause systemic infections (www.NIH.gov).
Candida is an opportunistic disease caused by Candida albicans and is frequently seen in end of life patients. Candidiasis is normally painful and the treatment is twofold. Prevention can be aided through the use of PerioBalance gum, acidophilus supplement rinse, xylitol-based products or Chlorhexadine gluconate oral rinses. Management of the condition is achieved primarily with antifungal medications. Systemic administration can either be 200mg ketoconazole daily with food or 100mg fluconazole. Duration of treatment depends on the signs and recurrences of the disease. Topical treatment entails the use of nystatin or clotrimazole tablets dissolved orally. Patients with xerostomia may find that topical treatment is difficult due to their dryness and ability to dissolve the tablets orally.
Control of oral conditions and discomfort for the hospice patient can help with their comfort, dignity, and quality of life. If left untreated, oral conditions can lead to difficulty swallowing, eating, communicating, and breathing.
Lynda Bean, RDH, BSDH