Current learning in palliative care

Helping patients with symptoms other than pain
4: Oral problems
Introductory level
Aim of this worksheet
To learn to assess and manage oral problems Coleman Education
Centre
How to use this worksheet
St. Oswald’s Hospice
You can work through this worksheet by yourself, or with a tutor. Read the case study below, then work on the questions overleaf. The work page is on the right side, the information page is on the left. Work any way you want: you can try answering from your own knowledge (in which case fold over the information page), you can use the information page (this is not cheating- you learn as you find the information), or you can use other sources of This version written and edited by:
Lynne Gibson
It should take you about 15 minutes. If anything is unclear, discuss it with a colleague. Senior Physiotherapist
Dorothy Mathews,
• If you think any information is wrong or out of date let us know Senior Nurse
Northgate Hospital Learning Disability
• Take this learning into your workplace using the activity on the back page. Claud Regnard
Case study
Consultant in Palliative Medicine St. Oswald’s Hospice, Newcastle John is a 54 year old man who had a surgery for a carcinoma of the
colon. For the past week he has been eating less and less and now has
swallowing problems.
Today John is complaining of a sore mouth.
INFORMATION PAGE: Oral problems
Principles of Oral Hygiene
We take oral health for granted because we live with a mouth that is moist and pain free. But consider the opposite- a
mouth that is full of oral debris, ulcerated, dry or painful.
− regular mouth care is essential and the objective of such care is simple i.e. to achieve a clean, moist, pain free
− oral assessment can identify sites of infection and chronic irritations in the mouth, which is important, as oral dysfunction significantly affects the client’s quality of life. − frequent mechanical cleansing of the mouth is more important in oral care than the antiseptic qualities of Four Phases of Oral Status
unable to wear dentures. Frequent dental pain. Risk factors and Prevention

Risk factors
Prevention is a priority
To establish a healthy mouth regime the following are recommended: - ‰ Regular tooth and denture brushing twice daily ‰ Regular use of anti-bacterial and anti-fungal mouthwash ‰ Check fit of dentures, remembering nightly soak ‰ Regular mouth care: frequency dictated following assessment eg. for general care treat 6-12 hourly, for at risk patients treat 2-hourly, for high risk patients or for serious problems treat hourly. Possible problems and solutions
• Dry mouth: Frequent sips or sprays of water, use of artificial saliva (but avoid acidic solutions), ensure frequent mouthcare, vaseline to lips, iced drinks, ice cubes, pineapple juice. Chewing gum helps some patients. Pilocarpine 5mg 8-hourly helps some patients. • Dirty mouth: remove dentures if used and soak/clean accordingly. If they have their own teeth regular brushing is important. Alternatively, clean the mouth with sponge swabs or gauze over a gloved finger. • Candida (candidiasis, thrush): ketoconazole (200mg once daily for 5 days), fluconazole (150mg as single dose), nystatin (2mls 6- hourly for at least 10 days). -virus infections: acyclovir 200mg 4-hourly for 1 week (400mg if immunosuppressed). –apthous ulcers: topical corticosteroid (triamcinalone in Orabase or betamethasone tablets), or tetracycline suspension mouthwash (disperse a 250mg capsule in water and rinse in the mouth for 2 minutes then swallow 6-hourly) –malignant ulcers: if anaerobic infection present (ie foul smell) use systemic metronidazole 12-hourly 500mg PO or 1g PR, or use 1% topical gel if not tolerated systemically (topical gel is expensive). • Sore mouth: benzydamine (Difflam) spray or mouthwash, sucralfate suspension mouthwash, choline salicylate gel (Bongela), benzocaine lozenges (100mg sucked as required), or a lidocaine spray. WORK PAGE: Oral problems
• Think about what actions might reduce the chance
of John getting a sore mouth?
• What would ‘ring an alarm’ that something is wrong with John’s mouth?
Area affected
Early warning
Serious problem
• Think about what factors would increase the risk of oral problems
• Write down treatments for these problems

Problem Treatments
FURTHER ACTIVITY: Oral problems
• What do you think should be involved in establishing a healthy mouth regime? • Taste a variety of fluids e.g. coffee, soda water, pineapple juice etc and consider what is the FURTHER READING: Oral problems
Journal articles
Bagg J. Oral candidosis: how to treat a common problem. European Journal of Palliative Care, 2003; 10(2): 54-6.
Coleman P. Improving oral health care for the frail elderly: A review of widespread problems and best practices. Geriatric Nursing. 2002; 23(4): 189-
99.
Fiske J. Shafik HH. Down's syndrome and oral care. Dental Update. 2001; 28(3):148-56, Freer, SK Use of Oral Assessment tool to improve practice – Professional Nurse 2000; 15: 635-637.
Haddad P. Karimi M. A randomized, double-blind, placebo-controlled trial of concomitant pilocarpine with head and neck irradiation for prevention of
radiation-induced xerostomia. Radiotherapy & Oncology. 2002: 64(1):29.
Lee L. White V. Ball J. Gill K. Smart L. McEwan K. Chilton P. Pickering P. An audit of oral care practice and staff knowledge in hospital palliative
care. International Journal of Palliative Nursing. 2001; 7(8): 395-400.
Mercadante S. Dry mouth and palliative care. European Journal of Palliative Care, 2002; 9(5): 182-5.
Milligan S. McGill M. Sweeney MP. Malarkey C. Oral care for people with advanced cancer: an evidence-based protocol. International Journal of
Palliative Nursing. 2001; 7(9): 418-26.
Miller M. Kearney N. Oral care for patients with cancer: a review of the literature. Cancer Nursing. 2001: 24(4):241-54.
Rawlins CA. Trueman IW. Effective mouth care for seriously ill patients. Professional Nurse. 2001; 16(4): 1025-8.
Regnard CFB, Gillham L, Fitton S. Mouth care, skin care, lymphoedema. In, O'Neill WM, Hanks G eds. "ABC Series of Palliative Care". British
Medical Journal, 1997: 315; 1002 -5.
Roberts H. Mouthcare in oral cavity cancer. Nursing Standard. 1990; 4(19):26-9.
Scully C. Shotts R. ABC of oral health: mouth ulcers and other causes of orofacial soreness and pain. British Medical Journal, 2000; 321: 162-165.
Xavier G. The importance of mouth care in preventing infection. Nursing Standard. 2000: 14(18):47-51.
Resource books and websites
A Guide to Symptom Relief in Palliative Care, 5th ed. Regnard C, Hockley J. Abingdon: Radcliffe Medical Press, 2004 Oxford Textbook of Palliative Medicine 3rd ed. Doyle D, Hanks G, Cherny NI, Calman K eds. Oxford : Oxford University Press, 2003. PCF2- Palliative Care Formulary, 2nd ed. Twycross RG, Wilcock A, Charlesworth S. Abingdon: Radcliffe Medical Press, 2003. Also on Symptom Management in Advanced Cancer, 3rd edition. 2001. Twycross RG, Wilcock A. Abingdon: Radcliffe Medical Press.
CLIP Fifty seven 15 minute worksheets are available on:
• An introduction to palliative care (3 worksheets) • Helping the patient with pain (9 worksheets) • Helping the patient with symptoms other than pain (11 worksheets) • Moving the ill patient (2 worksheets) Learning
• Helping patients with reduced hydration and nutrition (8 worksheets) • Procedures in palliative care (4 worksheets) Palliative care
• Understanding and helping the person with alternative communication An accessible
• The last hours and days (4 worksheets) learning programme • Bereavement (3 worksheets)
for health care
professionals
Helping the Patient with Advanced Disease: a Workbook Regnard C. ed.

Source: http://www.helpthehospices.org.uk/clip/pdf/hpsp-4.pdf