*2.4.4 Candidiasis*

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

is able to drink, and if not, keep the mouth moistened.

of lubricating and alleviating dessication.

sometimes to help deter plaque buildup on the teeth.

the enamel. These should be avoided.

the patient distress.

daily may wish to continue to do so.

coatings around the mouth.

in the mouth are as follows:

the patient.

time.

this to be attempted.

*2.4.3 Mucositis*

products.

sipping fluids.

And most preferential means of palliation is to provide frequent fluids when one

There is little evidence to support the use of mouthwashes, especially as they can be offensive towards the end of life; however, some individuals who have used those

Alternatives to mouthwashes, providing there is no painful thrush being treated

• Coconut oil on a toothette provides a comforting and pleasant-testing method

• Water makes an inexpensive and acceptable lubricant, but will not remove

• Normal saline (1 teaspoon of salt dissolved in 500 mls of water) is also inexpensive and mildly antiseptic, but may not be acceptable if it is nauseating to

• Chlorhexidine mouthwash is an antibacterial and antifungal prescription used

• Sodium bicarbonate can help treat a dry, coated tongue for short periods of

• Commercially available glycerin and lemon mouthwash or oral swabs will actually increase dryness, as they draw water out of the mouth and my damage

Alternatives for dry mouth which can nicely simulate "feeding" and "bonding" between caregiver and the patient who can no longer swallow or manage liquids are to swab the mouth with toothette sponges dipped into such solutions as the patient may find pleasurable. These may include such items as semi-frozen tonic water and gin, semi-frozen fruit juices, coffees or teas, cold yogurts, and small dollops of coconut oil. Having the patient suck on ice chips or small pieces of frozen pears, peaches, or berries may also be soothing. The patient would best be sitting up for

If the mouth is tender and sore, a topical teething anesthetic or an oral palliative mouthwash containing equal parts of xylocaine viscous, milk of magnesia, and Benadryl maybe used before and/or after application of foods and drinks.

This typically presents as dry, burning, and/or reddened tissues. It is by advis-

able to discontinue spicy, minty or cinnamon-containing foods and oral care

Those at the end of life are vulnerable to all problems such as Candidiasis, no matter how well the mouth is cared for. It is important to check the mouth for any sore places or coatings that could indicate thrush and to treat expediently if causing

Saliva can be stimulated by sucking mints and candies, preferably those containing xylitol (cavity-fighting) sugar. Artificial salivas are available for purchase over-the-counter, but the effect is typically found to be no better than

**72**

Often times, especially in those with poor diabetic control issues or in those using antibiotics, a fungal coating, typically white, can form on the tongue, throat, and other parts of the mouth. This "opportunistic" infection is called *Candida albicans*, and can cause a burning sensation within the mouth as well as at the corners of the lips; a palliative prescription can be administered for an antifungal medication by a dental or medical professional.

To treat the tissues, dentures must be removed during medication application to the oral tissues, and topical agents may be used on the dentures themselves. Sponge swabs maybe used to apply the medications for hospice patients who may be unable to rinse with liquid suspensions.

Systemic agents including ketoconazole, fluconazole, and/or amphotericin B may be required for severe or intractable cases. Candidiasis may be treated according to severity by one or more of the following medicinal agents:


## *2.4.5 Dysphagia (difficulty with swallowing)*

Dysphagia is defined as difficulty in swallowing. It may be an acute or chronic condition that affects oral intake and is usually indicative of some disease process.

Because this condition is common with a patient's deconditioning near the end of life, many healthcare providers consider it relatively trivial and it is therefore unreported or underestimated. It is also frequently overlooked due to the presence of more prominent symptoms, such as pain or shortness of breath.

Difficulty swallowing liquids can indicate poor muscular control, and difficulty swallowing solids may indicate physiologic abnormality, such as a tumor. Sudden onset may be indicative of a psychogenic etiology.

Dysphasia has been detected in approximately 30% of patients with stroke, and 40 to 60% of patients with neurodegenerative disease, and in approximately 20% of patients with cancer, all of which may be treated with palliative care. It can cause or exacerbate other problems, such as weight loss, debility, and aspiration pneumonia, and in some cases it can hasten death.

Other routes of food administration (intravenous nutrition or gastrostomy feeding tubes) may be used in patients who are unable to eat. Often times, because patients may present with difficulty swallowing, the caregiver must be cautious in cleaning the mouth with use of too much liquid or lubricants such as coconut oil (which rapidly liquidates). Therefore, proceed with care when swabbing food/drinks substances during "feeding", as well as in cleaning and lubrication of the mouth.

#### *2.4.6 Orally-related impediments to verbal communication*

Please attend to this as is possible by applying lubrication consistently to the lips and oral cavity when they are dry.

(See section on Xerostomia for more in-depth discussion on methods of alleviating dry mouth.)

#### *2.4.7 Poor Oral hygiene*

Proper oral care is important, as it maintains self-esteem, comfort, a sense of well-being, and our ability to communicate, socialize, and enjoy taking in sustenance.

An additional significant problem among palliative care patients is poor oral hygiene. This is likely due to a number of factors, including the patient's cognitive and physical disabilities; a lack of optimal preventive devices and supplies; and the caregiver's inadequate knowledge, attitudes, and experience regarding provision of oral care to people other than themselves.

Finding particles of food, accumulated plaque and calculus (tartar), and mucus and saliva on the patient's teeth, palatal and buccal tissues, and dentures is common, yet is objectionable to many individuals.

Preventive care protocols should be established early and maintained throughout the palliative care process. A number of preventive protocols are appropriate for these patients:

Basic palliative oral care protocol

Keep lips moist at all times with a lip balm, coconut oil, or some such substance.

1.Keep intra-oral tissues moist at all times using saliva substitutes or coconut oil, applying with oral sponges or by the having patient rinse where possible.

**75**

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient*

2.Clean the teeth with a manual or power brush and fluoridated toothpaste

3.Clean between teeth with floss, and if necessary, using floss-aiding holders and devices. Brushes that fit between teeth are also available and can be very helpful. Perform this daily. Avoid use of water jet devices to clean food from

4.Clean soft tissues of the inside of the mouth to remove adherent debris with a soft brush or oral sponge dipped in coconut oil or a saliva substitute.

5.Clean dentures (full coverage or partial) after eating with a denture brush while holding the appliance low in the sink and under a gentle stream of running cool (or slightly warm) water. They may be soaked in commercial denture cleaning solutions. Do not soak in harsh or toxic chemicals.

Poor oral hygiene can lead to aspiration pneumonia, a leading cause of death in nursing homes. It involves aspiration of bacteria from the teeth, dentures, and oral tissues into the lungs, complicated by difficulty swallowing and loss of protective reflexes such as coughing. Pneumonia presents with fever, altered mental status, and decreased oral intake. It eventually leads to fatal respiratory

Other factors leading to aspiration pneumonia are immunocompromised status; Alzheimer's; psychotropic and sedative drug administration; active periodontal disease; bedridden status; history of CVA, bulbar palsies; esophageal disease, COPD, CHF, GERD; intubator/ventilator use; aspirators; dysphasia, and other abnormalities of the protective airway mechanism; poorly fitting oral prostheses;

Caries, or cavities, are caused by an adequate cleansing of the bacteria from around and between the teeth. Hygiene must be performed properly by cleaning around and between the teeth as frequently and thoroughly as is possible after

Exposed root surfaces, being softer than the enamel on the crown of the tooth, are especially susceptible to decay, and should be afforded appropriate

*2.4.9 Periodontal disease (loss of the supportive tissues around the teeth)*

We are seeing new trends emerge in the dental health needs of older adults as life expectancy and dentate status continue to change through the years, and we must

Periodontal disease is a bacterial control issue in which the spaces between the teeth and gums can harbor damaging bacteria that, if not cleaned properly or frequently enough, will result in loss of bone, loosening of teeth, and life-threatening

Signs and symptoms which are indicative of periodontal disease include:

(avoiding those that may be more irritating, such as mint or cinnamon-or those that tend to be dessicating, such as those with detergents like sodium laurel sulfate). Make a watery toothpaste slurry in instances where patients may risk choking on thick dentifrices. Perform this after each meal as is possible.

*DOI: http://dx.doi.org/10.5772/intechopen.95606*

between teeth.

failure or sepsis.

and xerostomia.

meals.

attention.

*2.4.8 Caries (tooth decay)*

continue meeting these challenges.

infections in the mouth and around the body.

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient DOI: http://dx.doi.org/10.5772/intechopen.95606*


Poor oral hygiene can lead to aspiration pneumonia, a leading cause of death in nursing homes. It involves aspiration of bacteria from the teeth, dentures, and oral tissues into the lungs, complicated by difficulty swallowing and loss of protective reflexes such as coughing. Pneumonia presents with fever, altered mental status, and decreased oral intake. It eventually leads to fatal respiratory failure or sepsis.

Other factors leading to aspiration pneumonia are immunocompromised status; Alzheimer's; psychotropic and sedative drug administration; active periodontal disease; bedridden status; history of CVA, bulbar palsies; esophageal disease, COPD, CHF, GERD; intubator/ventilator use; aspirators; dysphasia, and other abnormalities of the protective airway mechanism; poorly fitting oral prostheses; and xerostomia.

#### *2.4.8 Caries (tooth decay)*

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

of more prominent symptoms, such as pain or shortness of breath.

Dysphagia is defined as difficulty in swallowing. It may be an acute or chronic condition that affects oral intake and is usually indicative of some disease process. Because this condition is common with a patient's deconditioning near the end of life, many healthcare providers consider it relatively trivial and it is therefore unreported or underestimated. It is also frequently overlooked due to the presence

Difficulty swallowing liquids can indicate poor muscular control, and difficulty swallowing solids may indicate physiologic abnormality, such as a tumor. Sudden

Dysphasia has been detected in approximately 30% of patients with stroke, and 40 to 60% of patients with neurodegenerative disease, and in approximately 20% of patients with cancer, all of which may be treated with palliative care. It can cause or exacerbate other problems, such as weight loss, debility, and aspiration pneumonia,

Other routes of food administration (intravenous nutrition or gastrostomy feeding tubes) may be used in patients who are unable to eat. Often times, because patients may present with difficulty swallowing, the caregiver must be cautious in cleaning the mouth with use of too much liquid or lubricants such as coconut oil (which rapidly liquidates). Therefore, proceed with care when swabbing food/drinks substances during "feeding", as well as in cleaning and lubrication of

Please attend to this as is possible by applying lubrication consistently to the lips

(See section on Xerostomia for more in-depth discussion on methods of

Proper oral care is important, as it maintains self-esteem, comfort, a sense of well-being, and our ability to communicate, socialize, and enjoy taking in

An additional significant problem among palliative care patients is poor oral hygiene. This is likely due to a number of factors, including the patient's cognitive and physical disabilities; a lack of optimal preventive devices and supplies; and the caregiver's inadequate knowledge, attitudes, and experience regarding provision of

Finding particles of food, accumulated plaque and calculus (tartar), and mucus and saliva on the patient's teeth, palatal and buccal tissues, and dentures is common,

Preventive care protocols should be established early and maintained throughout the palliative care process. A number of preventive protocols are appropriate for

Keep lips moist at all times with a lip balm, coconut oil, or some such substance.

1.Keep intra-oral tissues moist at all times using saliva substitutes or coconut oil, applying with oral sponges or by the having patient rinse where possible.

*2.4.5 Dysphagia (difficulty with swallowing)*

onset may be indicative of a psychogenic etiology.

*2.4.6 Orally-related impediments to verbal communication*

and in some cases it can hasten death.

and oral cavity when they are dry.

oral care to people other than themselves.

yet is objectionable to many individuals.

Basic palliative oral care protocol

alleviating dry mouth.)

*2.4.7 Poor Oral hygiene*

the mouth.

sustenance.

these patients:

**74**

Caries, or cavities, are caused by an adequate cleansing of the bacteria from around and between the teeth. Hygiene must be performed properly by cleaning around and between the teeth as frequently and thoroughly as is possible after meals.

Exposed root surfaces, being softer than the enamel on the crown of the tooth, are especially susceptible to decay, and should be afforded appropriate attention.

We are seeing new trends emerge in the dental health needs of older adults as life expectancy and dentate status continue to change through the years, and we must continue meeting these challenges.

#### *2.4.9 Periodontal disease (loss of the supportive tissues around the teeth)*

Periodontal disease is a bacterial control issue in which the spaces between the teeth and gums can harbor damaging bacteria that, if not cleaned properly or frequently enough, will result in loss of bone, loosening of teeth, and life-threatening infections in the mouth and around the body.

Signs and symptoms which are indicative of periodontal disease include:


Adequately maintained oral care can alleviate this disease's progression and symptomatology.

*2.4.10 Care of partial denture patients (and when is it okay not to wear the partials any longer?)*

Independent mouth care for those with teeth or partial dentures:


Discontinuation of denture-wearing is acceptable, if they are providing less benefit than they are creating discomfort and frustration for the patient. Usually, the hospice patient can maintain his same level of nourishment after discontinuing the use of his complete or partial dentures by changing the textures of foods eaten and by eating/being fed more slowly.

If the patient in fact is distressed while wearing his dentures, but is also having trouble functioning without them, a dental professional should examine the dentures for sore spots, poor fit, need for reline, and the like, as is possible.
