The best way to make a person feel better, in addition to toothbrushing is to provide frequent fluids while they are able to drink and when that is no longer possible, ensure that the mouth is kept moist.
Try simple salivary stimulating measures such as unsweetened drinks, sprays, moisten lips
If symptoms are not relieved consider topical saliva substitutes . It must contain the salivary enzymes lactoferrin and lysozyme which is essential for boosting the natural immune process.
Avoid glycerin as it dehydrates the mucosa and lemon juice exhausts saliva secretion and acidic foods eg. pineapple or acidic artificial saliva products on people with teeth.
Carers should be mindful that dry mouth may make it more difficult for certain oral medications to dissolve intra-orally or be swallowed by patients. This may require address, for example if medication gets stuck to the soft tissues cheeks and other soft tissue in the mouth.
Lubricate lips Apply water-based saliva replacement gels or aqueous cream to lips
Hydration and nutrition status should be assessed as part of mouth care. Hydrate with water /ice chips to reduce mouth dryness and make patients more comfortable to help manage bacterial growth.
Consider highlighting the importance of removing and cleaning away debris, secretions and plaque regularly as part of mouth care, to maintain good oral hygiene and prevent pain and infection.
Halitosis- Good oral hygiene -clean tongue, good care of dentures Fluid intake, Exclude garlic & onions, Smoking cessation , consider saliva supplements if pt has a dry mouth, Treat underlying cause -
mouthwash containing antimicrobial agent.
Oral Candida infection. Manage local and systemic risk factors for oral candida infection in conjunction with anticandidal treatment.
Manage local and systemic risk factors in conjunction with anticandidal treatment. The choice of drug treatment may be directed by local policy or based on advice from local microbiologist. For NICE Guidelines treatment and when to refer to NICE Guidelines [March 2021] here
Mouth Ulcers and mucositis Depending on the severity of pain and underlying cause such as iron, folate or Vit B12 deficiency. Treatment choice should be guided by the severity of pain. Refer to Nice Guidelines [March 2021] here
Assess daily for changes.
End of life care
All aspects of mouth care that will provide comfort and improve quality of life should be included in the patient’s care plan [for example, pain relief, management of dry mouth, removing dry secretions, frequency of mouth rinsing].
The focus is on oral hygiene, alleviation of symptoms and ensuring the patient is appropriately hydrated, it is recommended that the management of dry mouth is included in the patient’s care plan.
For the conscious pt
Consider changing or stopping meds that cause dry mouth. The mouth can be moistened every 30 minutes with water from a spray or dropper or ice chips placed in the mouth.
For the unconscious pt
Moisten the mouth at least every 1 hr with water from a spray, dropper or ice chips.
To prevent crack lips use Vaseline or KY- Jelly if on oxygen
Clean dentures and teeth.
Families and friends should also be made aware of the mouth care regime at the end of life to ensure they can support the patient and have greater involvement in their last days of life.
Oral pain
Treat underlying cause of pain if possible, if not treat pain symptomatically.
Use of topical non- opioid analgesics such as Benzydamine spray/mouthwash, Lidocaine 5% ointment or 10% spray
For severe pain seek advice if pain is difficult to manage.
Mouthwash
Water is a way to reduce mouth dryness and make patient more comfortable - manage bacterial growth
Chlorhexidine - has a slow release property that maintains antimicrobial activity for up to 12 hrs
Sodium bicarbonate mouthwash 1% - is reported to reduce the viscosity of oral mucus therefore enhancing the removal of oral debris. Use recommended concentration because it may cause mucosal irritation. *There are no controlled studies to support its use over other mouthwash rinses.
Other aspects of mouth care: training, dental access, and products, tools and support for patients
Health and care professionals involved in the day-to-day care of patients should be trained and have access to training to deliver appropriate mouth care for palliative patients. There is currently very limited training available for staff and health and care professionals may not prioritise mouth care as part of palliative care. Training should contribute to improved mouth care and consistent advice.
When to refer to a specialist
1. If in doubt about the diagnosis, management or any oral problems
2. Mouth problems are causing a decreased intake of food - concerns about malnutrition
3. Severe herpes simplex infection
4. Severe mucositis - can be extremely painful
5. Suspect Neutropenic ulcer
6. Aphthous ulcers are bleeding
7. Severe persistent candida infection
8. Disturbed taste [prolonged]
9. Pain that is difficult to manage
10. Communication problems [Speech and language therapist]
For more information on palliative mouthcare management see links below
[1] NICE [March 2021] NICE Clinical Knowledge Summary: Palliative care – oral [Online] Available at: //cks.nice.org.uk/palliative-care-oral
[2] NHS Scotland [revised Dec 2020]. Scottish Palliative Care Guidelines – Mouth Care. [Online] here NHS Scotland Caring for Smiles 'Oral Care at the End of Life' PDF here
[3] Public Health England, Oral health toolkit for adults in care homes [Nov 2020] Section 5 - How to support residents with mouth care part 2 [27/11/20] Palliative and end of life care presentation here