The mouth and palliative care

Oral candidiasis in a specialist palliative care unit: assessment, diagnosis, management

OBJECTIVES

To evaluate current clinical practices of assessment, diagnosis and management of oral candidiasis in a specialist palliative care unit to improve patient outcomes through compliance with the Australian Commission on Safety and Quality in Health Care Antimicrobial Stewardship Clinical Care Standard.

METHODS

A clinical audit cycle: review of 100 patient records preceded an educational intervention delivered over 4 weeks to clinical stakeholders, followed by a review of an additional 100 records.

RESULTS

Eleven patients in each cohort had oral candidiasis. A statistically significant improvement in documented rates of oral examination (33% to 51%, p=0.015) and appropriate microbiological testing (0% to 63.6%, p=0.004) was achieved. Documentation of oral symptoms and prescribing practices were unchanged.

CONCLUSIONS

Meaningful changes in practice relating to oral assessment and diagnosis of oral candidiasis are possible. Future iterations of the audit cycle may benefit from multimodal interventions to encourage further practice change.

A mouth rinse based on a tea solution of Salvia officinalis for oral discomfort in palliative cancer care: a randomized controlled trial

BACKGROUND

Few clinical studies evaluate interventions to reduce oral discomfort among patients in palliative care.

AIM

This study examines the efficacy of a Salvia officinalis (SO) based herbal mouth rinse compared to conventional normal saline (NS) in order to improve oral health.

DESIGN

A block-randomized controlled trial. Data were collected before and after a 4-day intervention with either SO (n=44) or NS (n=44). Numerical rating scales (NRS, 0-10) and 12 items from the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Oral Health 17 (EORTC QLQ-OH17) measured patient-reported oral symptoms. An oral examination was performed before and after the intervention.

SETTING/PARTICIPANTS

This study included adult patients with late-stage cancer in an inpatient hospice unit.

RESULTS

Of the 88 patients included (mean age=63.9 years, SD=10.6), 73 (83%) completed the study. At baseline, 78% reported dry mouth on the EORTC QLQ-OH17, and 80% rated dry mouth ≥4 on the NRS. Total oral health scores based on the 12 EORTC QLQ-OH17 items improved similarly in both groups (p<0.001). However, dry mouth ratings on both the EORTC QLQ-OH17 (p=0.036) and NRS (p=0.045) improved more in the SO group than in the NS group. Plaque on the teeth improved in both the SO (p=0.008) and NS (p=0.018) groups, but plaque on the tongue and erythema only improved with NS.

CONCLUSIONS

This study did not detect an overall significant difference between SO and NS. Both mouth rinses improved oral health parameters, indicating that systematic assessment and oral care may reduce oral discomfort.

TRIAL REGISTRATION

NCT02067572.

Oral symptoms in patients with advanced cancer: an observational study using a novel oral symptom assessment scale

PURPOSE

The aim of this study was to utilise a novel oral assessment tool (the Oral Symptom Assessment Scale/OSAS) to investigate oral symptoms in a cohort of advanced cancer patients receiving specialist palliative care.

METHODS

Participants were asked to complete the OSAS, which asks about the presence of 20 oral symptoms in the previous week (and, if present, about the frequency, the severity, and the amount of distress caused by the symptoms). Patients were also asked to complete the Memorial Symptom Assessment Scale - Short Form, and to rate their performance status.

RESULTS

Two hundred fifty participants completed the study, and 244 (97.5%) participants reported at least one oral symptom on the OSAS. The median number of oral symptoms reported was five (range, 1 to 18), with dry mouth being the most common symptom (83.5% participants). The total number of oral symptoms was higher in younger participants (p = 0.012), female participants (p = 0.048), and those with a worse performance status (p < 0.001). No other oral symptoms were reported by more than two participants. Statistical analysis identified a number of potential oral symptom clusters.

CONCLUSIONS

Oral symptoms (and related oral problems) are common in patients with advanced cancer, and are associated with significant morbidity in this group of patients.

TRIAL REGISTRATION

CancerTrials.gov registry reference number: NCT04404920.

Professional oral care in end-of-life patients with advanced cancers in a hospice ward: improvement of oral conditions

Background

In end-of-life patients with advanced cancers, oral examination, oral care, and oral re-examination are crucial. Although oral symptoms are among the major complaints of end-of-life patients, few studies have focused on oral care in these patients. In this study, the association between oral symptoms and oral dryness among end-of-life patients was examined, and improvement of oral conditions after oral care interventions by a professional dentist was quantified.

Methods

This prospective intervention study included 27 terminally ill patients with advanced cancers in a hospice ward. Professional oral care was administered every morning, and the improvement of oral conditions was assessed by comparing oral conditions before and after the intervention. Oral assessment was performed using the Oral Health Assessment Tool (OHAT) and Oral Assessment Guide. Oral dryness was evaluated through Clinical Diagnosis Classification of oral dryness and an oral moisture device. Oral cleanliness was evaluated using a bacterial counter, and tongue smears were collected for Candida examination; furthermore, oral function was recorded.

Results

The presence of oral mucositis was closely associated with severe oral dryness (odds ratio [OR] = 14.93; 95% confidence interval [CI]: 1.95–114.38). The level of oral debris retention was significantly related to the degree of oral dryness (OR = 15.97; 95% CI: 2.06–123.72). The group with higher scores (OHAT > 8), which represent poor oral conditions, showed severe oral dryness (OR = 17.97; 95% CI: 1.45–223.46). Total OHAT scores (median: 7 vs 2) and those of other subgroups (lip, tongue, gums and tissues, saliva, and oral cleanliness showed a significant decrease after the intervention. Furthermore, the occurrence of mucositis (47.1% vs 0%), candidiasis rate (68.8% vs 43.8%), oral dryness self-sensation (63.6% vs 9.1%), and severe oral debris (52.9% vs 11.8%) decreased significantly.

Conclusions

Proper oral care can improve oral health and hygiene, reduce the rate of mucositis, reduce the sensation of oral dryness, increase oral moisture, and reduce the chances of oral infections among end-of-life patients. Daily oral care is necessary and can alleviate oral discomfort, increase food intake, and increase the chances of communication between end-of-life patients and their families.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12904-020-00684-0.

Oral Hygiene Care in Patients With Advanced Disease: An Essential Measure to Improve Oral Cavity Conditions and Symptom Management

BACKGROUND

Oral problems are frequent in palliative care and can cause disabling symptoms such as orofacial pain, dysgeusia, and xerostomia. Even if oral care is an essential aspect of nursing, it is often not considered as a priority, especially when various complex patients' needs have to be managed.

OBJECTIVE

The aim of this study was to describe oral conditions and evaluate the impact of standard oral care on symptom control and patient's perceived comfort in a sample of terminally ill patients.

METHOD

A prospective cohort study was carried out among 415 patients who were admitted to hospice. Patients were recruited before undergoing standard assisted procedure for oral hygiene care. Oral cavity condition, symptoms, and comfort were assessed at the recruitment (T0) and after 3 days (T2).

RESULTS

Seventy-five eligible patients were recruited. The Oral Assessment Guide score was significantly decreased after oral standard care (P value <.0001). The average time spent by nursing staff for oral hygiene care was 5.3 minutes. Dysgeusia and xerostomia were significantly decreased after oral standard care (P = .02 and P = .03). Patients reported a high level of comfort (86.6%) after the procedures for oral hygiene care.

CONCLUSION

Patients admitted to hospice had frequent alterations in oral cavity with partial loss of its functions that can compromise their quality of life. Standard procedures for oral hygiene care are simple and fast to perform, and they may improve oral cavity conditions, symptoms control, and patients' comfort.

Quasi-experimental evaluation of a multifaceted intervention to improve quality of end-of-life care and quality of dying for patients with advanced dementia in long-term care institutions

BACKGROUND

Improvement in the quality of end-of-life care for advanced dementia is increasingly recognized as a priority in palliative care.

AIM

To evaluate the impact of a multidimensional intervention to improve quality of care and quality of dying in advanced dementia in long-term care facilities.

DESIGN

Quasi-experimental study with the intervention taking place in two long-term care facilities versus usual care in two others over a 1-year period. The intervention had five components: (1) training program to physicians and nursing staff, (2) clinical monitoring of pain using an observational pain scale, (3) implementation of a regular mouth care routine, (4) early and systematic communication with families about end-of-life care issues with provision of an information booklet, and (5) involvement of a nurse facilitator to implement and monitor the intervention. Quality of care was assessed with the Family Perception of Care Scale. The Symptom Management for End-of-Life Care in Dementia and the Comfort Assessment in Dying scales were used to assess the quality of dying.

PARTICIPANTS

A total of 193 residents with advanced dementia and their close family members were included (97 in the intervention group and 96 in the usual care group).

RESULTS

The Family Perception of Care score was significantly higher in the intervention group than in the usual care group (157.3 vs 149.1; p = 0.04). The Comfort Assessment and Symptom Management scores were also significantly higher in the intervention group.

CONCLUSIONS

Our multidimensional intervention in long-term care facilities for patients with terminal dementia resulted in improved quality of care and quality of dying when compared to usual care.

Characteristics of Oral Problems and Effects of Oral Care in Terminally Ill Patients With Cancer

PURPOSE

Various distresses appear in the terminal stage of cancer. Oral problems including dry mouth, stomatitis and candidiasis are one of the important problems which should be resolved. The purpose of this study was to investigate oral problems in this stage and improvement of dry mouth by oral care.

METHODS

The study subjects were consecutive terminally ill cancer patients admitted over the past 2 years. Patients were divided based on the status of oral food intake into good oral food intake group (≥30%) and poor oral food intake group. The following 3 items were retrospectively investigated: 1) The incidences of these oral problems, 2) Severity of dry mouth and complication with other oral problems, 3) Improvement of dry mouth using standard oral care by nursing staff and specialist oral care including dentists as needed.

RESULTS

There were 115 and 158 patients in good and poor oral intake groups, respectively. 1) The incidences of dry mouth, stomatitis, and candidiasis were significantly higher in poor oral intake group ( p < 0.001). 2) Severe cases of dry mouth (Grade-2&3) were noted in 20.0% and 64.8% in good and poor oral intake groups, respectively ( p < 0.0001). Candidiasis complication rate was significantly higher in poor oral intake group ( p = 0.0002). 3) The rate of dry mouth improvement by oral care was 100% in Grade-1, 86% in Grade-2 and 81% in Grade-3.

CONCLUSION

Oral problems occur in many of terminally ill cancer patients. Accurate diagnosis of oral problems and corresponding appropriate interventions are important for improving quality of end-of-life care.

The need and availability of dental services for terminally ill cancer patients: a nationwide survey in Japan

OBJECTIVE

Considering the high incidence of oral complications in terminally ill cancer patients, dental services are necessary for high-quality palliative care. However, to our knowledge, there have been no nationwide studies examining the need and availability of dental services in palliative care. In this study, a nationwide survey was conducted to clarify the need and availability of dental services for physicians and nurses engaged in palliative care in Japan.

MATERIALS AND METHODS

A questionnaire was distributed to 436 certified palliative care units and palliative care teams registered with Hospice Palliative Care Japan. The questionnaire consisted of questions related to (1) background, (2) need of dental services, and (3) availability of dental services.

RESULTS

The response rate was 48.2% (n = 210). As a whole, 93% of all respondents indicated that dental services were absolutely necessary, highly necessary, or necessary. In addition, 94% of respondents thought dental treatment by dentists was often or sometimes necessary; 96% of respondents thought oral care provided by specialists was often or sometimes necessary. As a whole, 71% of the respondents reported that dental services were always available, but 28% reported that dental services were available only sometimes. In actuality, in 31% of the institutions, dental services were available 1 day/week or less, and in 39%, dental services were dispatched from outside the institution.

CONCLUSION

The results of this study revealed that Japanese palliative care units and teams have a markedly high need of dental services, but there is insufficient availability. To improve oral complications of terminally ill cancer patients, dentistry professionals should be more available in palliative care.

Dental caries in older adults in the last year of life

OBJECTIVES

To examine dental caries severity (measured by number of carious teeth) in older adults in the last year of life.

DESIGN

Cross-sectional study based on dental records.

SETTING

Community-based geriatric dental clinic.

PARTICIPANTS

One thousand two hundred sixteen individuals aged 65 and older, including 168 individuals in the last year of life (e.g., individuals died within 1 year after their new-patient examinations).

MEASUREMENTS

Information on socioeconomic, medical history, medication, functional status, and oral health measures, including number of carious teeth, was abstracted from dental records. End-of-life status was determined using the National Death Index. Propensities of death were calculated using a logistic regression and then adjusted together with mobility and oral care function in the multivariable regression model to examine the effect of end-of-life status on dental caries.

RESULTS

Caries severity differed in end-of-life participants with different oral care function. Of those needing help with oral care, end-of-life participants had only a slightly higher and nonstatistically significant risk (7.5 vs 6.1, adjusted incidence density ratio (IDR) = 1.12, 95% confidence interval (CI) = 0.85-1.48) of having more carious teeth than those not in the last year of life. On the other hand, caries severity was lower in end-of-life participants without impaired oral care function (IDR = 0.53, 95% CI = 0.30-0.92).

CONCLUSION

Oral care function modifies the association between caries severity and end-of-life status. Individuals who could maintain oral hygiene independently had a low level of caries at the end of life, however, dental caries had increased before functionally dependent individuals entered their last year of life.

Antifungal, cytotoxic, and immunomodulatory properties of tea tree oil and its derivative components: potential role in management of oral candidosis in cancer patients

Candida albicans forms oral biofilms that cause disease and are difficult to treat with conventional antifungal agents. Tea tree oil (TTO) is a natural compound with reported antimicrobial and immunomodulatory activities. The aims of the study were to evaluate the antifungal efficacy of TTO and key derivatives against C. albicans biofilms, to assess the toxicological effects of TTO on a clinically relevant oral cell line, and to investigate its impact on inflammation. TTO and its derivatives were examined against 100 clinical strains of C. albicans. Planktonic minimum inhibitory concentrations (MICs) were determined using the CLSI M-27A broth microdilution method. Sessile MICs were determined using an XTT reduction assay. Inhibition, time-kill, and mode of action studies were performed. OKF6-TERT2 epithelial cells were used for cytotoxicity and cytokine expression assays. Planktonic C. albicans isolates were susceptible to TTO, terpinen-4-ol (T-4-ol), and α-terpineol, with an MIC₅₀ of 0.5, 0.25, and 0.25%, respectively. These three compounds also displayed potent activity against the 69 biofilm-forming strains, of which T-4-ol and α-terpineol displayed rapid kill kinetics. For all three compounds, 1 × MIC₅₀ effectively inhibited biofilm growth when C. albicans were treated at 0, 1, and 2 h post adhesion. By scanning electron microscopy analysis and PI uptake, TTO and derivative components were shown to be cell membrane active. TTO and T-4-ol were cytotoxic at 1 × MIC₅₀, whereas at 0.5 × MIC₅₀ T-4-ol displayed no significant toxicity. Transcript and protein analysis showed a reduction of IL-8 when treated with TTO and T-4-ol. These data provide further in vitro evidence that TTO and its derivative components, specifically T-4-ol, exhibit strong antimicrobial properties against fungal biofilms. T-4-ol has safety advantages over the complete essential oil and may be suitable for prophylaxis and treatment of established oropharyngeal candidosis. A clinical trial of T-4-ol is worthy of consideration.

Oral health is an important issue in end-of-life cancer care

PURPOSE

This study aims to assess the prevalence of oral morbidity in patients receiving palliative care for cancers outside the head and neck region and to investigate if information concerning oral problems was given.

METHODS

Patients were recruited from two Norwegian palliative care inpatient units. All patients went through a face-to-face interview, completed the Edmonton Symptom Assessment System (ESAS) covering 10 frequent cancer-related symptoms, and went through an oral examination including a mouth swab to test for Candida carriage.

RESULTS

Ninety-nine of 126 patients (79 %) agreed to participate. The examined patients had a mean age of 64 years (range, 36-90 years) and 47 % were male. Median Karnofsky score was 40 (range, 20-80) and 87 % had metastatic disease. Estimated life expectancy was <3 months in 73 %. Dry mouth was reported by 78 %. The highest mean scores on the modified 0-10 ESAS scale were 4.9 (fatigue), 4.7 (dry mouth), and 4.4 (poor appetite). Clinical oral candidiasis was seen in 34 % (86 % positive cultures). Mouth pain was reported by 67 % and problems with food intake were reported by 56 %. Moderate or rich amounts of dental plaque were seen in 24 %, and mean number of teeth with visible carious lesions was 1.9. One patient was diagnosed with bisphosphonate-related osteonecrosis of the jaw. Overall, 78 % said they had received no information about oral adverse effects of cancer treatment.

CONCLUSION

Patients in palliative care units need better mouth care. Increased awareness among staff about the presence and severity of oral problems is necessary. Systematic information about oral problems is important in all stages of cancer treatment.

Symptoms of the oral cavity and their association with local microbiological and clinical findings--a prospective survey in palliative care

PURPOSE

Symptoms of the oral cavity clearly encompass more than radiation or chemotherapy-induced mucositis. Still, the burden of oral symptoms in palliative care has hardly been addressed directly, and considerations towards underlying disease processes have often been extrapolated from oncology patients.

METHODS

We therefore conducted a prospective explorative survey with pilot character on patients on a specialized palliative care unit, describing symptom pattern (self assessment), clinical signs, bacteriological, mycological and virological findings, and correlating features of clinical history.

RESULTS

Taste disturbances, dry mouth and the presence of Candida were found to be the most prevalent and correlating items. The broad spectrum of further symptoms, signs and findings did not show relevant correlations and did not permit any unilateral causal attributions.

CONCLUSIONS

Apart from the described focus on Candida colonisation/infections, a symptom-guided polypragmatic approach therefore seems to be justifiable for patients with oral symptoms in palliative care.

Oral discomfort in palliative care: results of an exploratory study of the experiences of terminally ill patients

An exploratory qualitative study was undertaken with the aim of examining oral discomfort from the perspective of terminally ill patients. Interviews focusing on the experiences and perceptions of oral discomfort and effects on day-to-day functioning among 14 palliative care patients from a mid-size hospital in a regional city in Australia were conducted. The findings reveal that a range of oral problems significantly impact on the physical, social and psychological wellbeing of terminally ill patients to varying degrees, sometimes over extended periods of time. In particular, dry mouth (xerostomia) was experienced as a significantly troubling and ongoing symptom, and bouts of ulceration and infection were also commonly discussed. Furthermore, participants reported a lack of oral assessment and virtually no input from dental experts to assist with palliating oral problems. A better understanding of the impact of oral discomfort among terminally ill patients is a significant care issue for hospice and palliative care teams, especially nursing staff, and further research of this significant issue is required. The results of the current study provide preliminary evidence to support raising the clinical focus and priority of oral care for terminally ill patients in all settings.