Oral Problems in Palliative Care

Impact of Oral Problems in Palliative Care

• Physical Impact
  • Difficulty in eating/drinking
  • Taste disorders
  • Xerostomia
  • Fungal/viral infections
  • Mouth ulcers, Pain
• Social Impact
  • Difficult to speak
  • Self-conscious of cancer
  • Difficult to socialize
  • Halitosis
• Emotional Impact
  • Emotional pain
  • Fear of dying
  • Depressed
  • Physically unable to display emotions (e.g., kiss)

Multidisciplinary Palliative Care

• Whole-person Comfort Care
• Emotional Support
• Spiritual Support
  • Chaplains, Social Workers, Psychologists
• Physical Support
  • Speech Pathologists, Dieticians, Physicians, Nurses, Dentists, Pharmacists, Family
• Goal: Quality of Life

Definition of Palliative Care Dentistry (Wiseman M 2000)

• The study of patients with active, progressive, far advanced disease for whom the oral cavity has been compromised by the disease directly or by its treatment.
• The focus of care is the quality of life.

Prevalence of Oral Problems

• *Amongst those wearing dentures

Radiotherapy/Chemotherapy and Oral Problems

• Nausea
• Stomatitis/Mucositis
• Poor Nutrition
• Dehydration
• Candidiasis
• Taste Alterations
• Depression
• Social Isolation
• Poor Oral Hygiene
• Periodontal Disease
• Caries
• Xerostomia
• Halitosis
• Pain
• Delirium

Contributing Factors

• Antiemetics
• Antidepressants
• Opioids
• Alcohol
• Mouthwash

Mucositis and Stomatitis

• Related to Therapeutic Measures and Patient Factors:
  • Therapeutic Measures
  • Type and duration of pharmacologic agent used, dose and field of irradiation
  • Patient Factors
  • Local Factors
    • Poor fitting dentures and rough restorations increase irritations and plaque accumulation
  • Systemic Factors
    • Immunosuppressed patients have increased microbial invasion.

Mucositis

• Mucosal barrier injury characterized by erythema, ulceration, and pain.
• Affects the quality of life of patients in their ability to swallow, eat, and talk.

Mucositis and Stomatitis: Timeline and Impact

• Oral mucosa have a life span of < 1 week
• Chemotherapy will affect the oral cavity within 3 days of treatment
• Chemotherapy induced mucositis is greatest in patients < 20 y.o., as older patients have a decreased rate of cell renewal
• Radiation damage occurs 7-14 days after starting head and neck radiotherapy

Index for Oral Mucositis (WHO)

Key Objective of Mouth Care

• Maintain the mouth in good condition
  • Keep it Clean, Moist, and Infection Free

Treatment for Mucositis/Stomatitis

1. Xylocaine 2% Viscous*
2. Xylocaine Spray 10%*
3. Dyclonine Hydrochloride 0.5% or 1%*
4. Diphenyhydramine hydrochloride (Benadryl) 12.5 mg/5 ml elixir in Kaopectate or Maalox in equal parts. Dyclonine 0.5% can be added for increased potency*†

• *Caution reduces gag reflex
• †Avoid MOM - anesthetic properties => difficult to swallow

1. Magic Mouthwash
2. Sucralfate Suspension
3. Capsaicin Cream 0.025%
4. Capsaicin Taffy (spicy)

Magic Mouthwash Formulations

1) RVH

• Hydrocortisone (100mg/2ml) use 1ml = 50mg
• Nystatin suspension (100,000 IU/ml) use 25 ml = 2.5mU
• Diphenhydramine (6.25mg/5ml) use 200 ml = 250 mg
• N.B. Alcohol free
• Rx 15ml q 4-6 h

2) JGH

• Nystatin suspension (100,000 IU/ml) use 39 ml = 3.9 MU
• Diphenhydramine (12.5mg/5ml) use 153 ml = 383 mg
• Solu-Cortef (250mg/5ml) use 0.5 ml = 62.5 mg
• Distilled water 307.5ml
• Makes 500ml
• Rx 15ml q 4-6 h

3) Regie de QC

• Hydrocortisone (250mg/2ml) use 0.8ml = 100 mg
• Nystatin suspension (100,000 IU/ml) use 60 ml = 6.0 mU
• Hydroxyzine syrup (Atarax) 10mg/5ml use 300 ml = 600 mg
• Distilled water use 140 ml
• N.B. Alcohol free
• Rx 15ml q 4-6 h

Treatment for Mucositis/Stomatitis (Cont.)

9. Benzydamine (Tantum) – Non-steroidal analgesic with anti-inflammatory and antimicrobial properties.
10. Topical 2% morphine – Pt. is instructed to rinse 15 ml and expectorate q 3h.
11. Glutamine supplements may increase cell proliferation and repair.
12. Vitamin E
    • Topical vitamin E acts as an antioxidant and may decrease the effects of chemotherapy-induced mucositis.
13. Localized Factors:
    • Decrease potential trauma from restorations, prosthesis, and teeth.
    • Spicy or hard foods may increase trauma
    • Avoid alcohol and smoking

Morbidity Associated with Mucositis

• Decreased hydration – Increased xerostomia and delirium
• Decreased nutrition – Lack of nutrients to repair tissues
• Pain – More opioids needed for pain relief

Factors Which Increase the Severity of Mucositis

• Vomiting – Besides the obvious effect of the low pH on oral tissues, vomiting can deplete the body’s stores of water-soluble vitamins and proteins required for epithelial repair.

Causes of Vomiting

• Chemotherapy
• Bowel obstruction, constipation
• Electrolyte imbalances
• Malignancy-associated gastric paresis
• Brain metastasis
• Opioids
• Most patients will have at least two factors

Medications to Treat Vomiting

• Anticholinergic medications e.g. scopolamine causes xerostomia
• Dexamethasone causes mood swings and insomnia
• Serotonin receptor antagonists e.g. (Zofran) ondansetron
• Haldol – Can yield tardive dyskinesia

Non-pharmaceuticals to Treat Vomiting

• Ginger
• Acupuncture

Oral Problems Associated with Vomiting

• Erosion of teeth
• Vomiting robs the patient of nutrients needed for cellular repair
• Nausea can limit the patient’s ability to wear dentures. This affects their ability to eat, but can also affect their social interactions

Delirium

• Characterized as a quick onset decline in cognition versus dementia which is usually a slow gradual decline.
• Causes of delirium:
  • Accumulation of opioid metabolites
  • Decreased hydration will affect urine output and allow for decreased drug clearance

Xerostomia

• Major etiology is a side-effect of medications.
• Patients with dry mouths will often eat foods that are cariogenic
• It affects a patient’s ability to speak, chew, swallow, taste food, wear dentures and perhaps of greater concern kiss.

Survey of Xerogenic Medications Prescribed to Palliative Care Patients (n=25)

Classes:

• Anticholinergics
• Bronchodilators
• Narcotic Analgesics
• Diuretics
• Antihypertensives
• Antipsychotics
• Antiemetic
• Antidepressants
• Anxiolytics

Characteristics of Surveyed Palliative Care Patients

• Average Age: 78
• Average Number of Drugs: 5

Incidence of Xerostomia in Palliative Care Patients (n=25)

• All of the patients questioned complained of a dry mouth

Herpes Infections

• Commonly seen in immunocompromised palliative care patients.
• Acyclovir (Zovirax) 200 mg 5x’s/d for 7d
• Kaopectate and Benadryl Elixir 50:50 painted onto lesions provide relief.

Herpes Zoster

• Caused by the reactivation of the varicella zoster virus within the sensory ganglia.
• Once activated it follows a unilateral dermatome.
• The CDC has estimated that 32% of the USA will have shingles.

Risk Factors

• Age- 50% of elderly >85 yrs will be affected

Compounding Pharmacist: Dosage Forms

• Troches
  • Corticosteroids (Hydrocortisone, Dexamethasone)
  • Anesthetics (Lidocaine)
  • Anti-Fungals (Nystatin, Clotrimazole)
  • Narcotic Analgesics (Hydromorphone, Morphine, Fentanyl)
  • Hormones (Estrogens, Progesterone)
  • Saliva Stimulants (Pilocarpine)
• Lip Balms
  • Corticosteroids (Hydrocortisone, Dexamethasone)
  • Antihistamines (Hydroxyzine, Diphenhydramine)
  • Anti-Virals (Acyclovir)
  • Anesthetics (Lidocaine)
• Lollipops
  • Corticosteroids (Hydrocortisone, Dexamethasone)
  • Antihistamines (Hydroxyzine, Diphenhydramine)
  • Anti-Virals (Acyclovir)
  • Anesthetics (Lidocaine)
  • Anti-Fungals (Nystatin, Clotrimazole)
  • Narcotic Analgesics (Hydromorphone, Morphine)

Chlorhexidine Substantivity

• Binds to oral tissues (30% retained)
• Slowly released over time providing a prolonged effect
• Inhibits bacterial growth

Chlorhexidine as Plaque Removal

• A chlorhexidine soaked foam brush is as effective as a toothbrush in removing plaque
• It is recommended for patients not able to use a conventional toothbrush

Topical Candidiasis Treatments

1. Nystatin suspension 100,000 IU/ml (Nadostine)
   • sig: 5 ml qid swished for 20 secs then swallowed
2. Nystatin vaginal tablets 100,000 IU (Nadostine)
   • sig: one tablet sucked and swallowed qid
3. Clotrimazole 10 mg troches
   • sig: one tablet 5x/day

Nystatin and Sugar Content

• Nystatin contains a lot of sugar.
• As we kill fungus, we also feed it!

Topical Candidiasis Treatments (Cont.)

4. Nystatin suspension 100,000 IU/ml (Nadostine) 5ml mixed into water soluble lubricant (KY Jelly) 5 ml
   • sig: Painted thinly onto oral tissues and inside of dentures with a foam brush aid
5. Nystatin suspension 100,000 IU (Nadostine) 5 ml into fruit juice and frozen into popsicles.
   • sig: one popsicle sucked and swallowed qid
6. Miconazole vaginal cream 2% (Monistat 7 )
   • sig: Painted thinly onto tissue side of dentures with a foam brush
7. Clotrimazole vaginal cream 1% (Gyne-Lotrimin)
   • sig: Painted thinly onto tissue side of dentures with a foam brush qid

Use Case

• End stage renal disease.
• Prescribed: Vaginal Canesten plus 2% viscous Xylocaine Mixed 50:50. Applied bid x 7 days

Systemic Candidiasis Treatments

1. Ketoconazole tablets 200 mg (Nizoral)*†
   • sig: one tablet daily with food
2. Fluconazole tablets 100 mg (Diflucan)*‡
   • sig: two tablets stat, then one tablet daily
   • * Caution for use with patients with liver disease
   • † Frequent drug interactions
   • ‡ Costly

Systemic Antifungals CAUTION

• If patients are receiving midazolam or triazolam as a sedative agent, giving a systemic antifungal could raise the level of these agents to toxic levels.

Angular Cheilitis

Treatment:

• Use antibacterial soap
• Nystatin topical ointment 100,000 IU

Taste Disorders

• 25-50% of cancer patients have either ageusia, hypogeusia, or dysgeusia.

Taste Changes Study Prevalence

Taste Perception with Advanced Disease

• With advanced disease, higher concentrations of sugar are required to be recognized.

Taste Disorders Management

1. Rinse mouth with artificial saliva agents prior to eating as xerostomia can precipitate a salty or metallic taste.
2. Zinc supplements 220 mg (Orazinc) tid

Effects of Medications Upon Taste (Dysgeusia)

Effect of Chemotherapy and Radiotherapy on Taste

• Cellular receptors are reduced on the tongue and nasal cavity
• Flavor enhancers improve the patient’s sense of taste resulting in improved nutrition.
• MSG will increase the perceived taste of foods. Foods with gravy improve swallowing and taste for xerostomic patients.

Dysphagia in Palliative Care Patients

• Physical obstruction by tumor or nodes
• Reduction in tongue mobility by either tumor, surgery, or hypoglossal nerve paralysis
• Trismus of masticatory muscles
• Xerostomia
• Soft palate paralysis

Dentist Surveys on Patient Deaths

• Survey of 234 dentists:
  • 72% had ≥1 deaths in their practice last 12 months
  • 72% of dentists send sympathy cards
  • 27% of dentists attend the funeral of their patient
  • 26% of dentists visited the surviving spouse
  • 3% of dentists received bereavement training
    Dentists and Dying Patients
• Survey of 87 dentists
  • 86% had ≥1 deaths in their practice last 12 months
  • 79% of dentists send sympathy cards
  • 20% of dentists attend the funeral of their patient
  • 10% of dentists visited the surviving spouse
  • 3% of dentists received bereavement training

Mouthwashes

1. Alcohol-free mouthwashes
   • Clear Choice
   • Crest Pro Health
   • Rembrandt Rinse
2. Hydrogen Peroxide and saline 1:1
3. Magic Mouthwash
4. Alkaline saline
5. Chlorhexidine 0.12%

Hydrogen Peroxide

• Hydrogen peroxide can destroy granulating tissues. This effect noted even at a 50% dilution

Oral Care Recommendations

• Toothpaste – Sodium Lauryl Sulfate, a product found in most pastes can cause ulcerations. In this case, a variety of toothpastes may be a good alternative.

Definitions of Pain

• Pain is perceived along a pathway that runs from pain receptors in tissues to the brain and is modified at every step along its travel.
• Pain is an unpleasant, complex, physical and emotional experience.
• Pain is what the patient says it is.

Concept of Total Pain

• Physical Pain: Sickness, Treatments
• Emotional Pain: Isolation, Fear, Depression
• Social Pain: Money, Family, Work
• Spiritual Pain: Culpability, Regrets, Thoughts of Dying

Bleeding Control Measures

• 4.8% Transexamic Acid (Cyklokapron)
• Aminocaproic Acid (Amicar)
• Electrocautery
• Silver Nitrate
• Ethamsylate (restores platelet function)
• 1% Alum solution
• Laser
• Cryotherapy
• Sulcralfate paste 2g in 5ml KY jelly
• Sulcralfate suspension
• Epinephrine soaked 2x2’s

H&N Cancer Nurse’s Perception

• The functional, psychological and psycho-social implications of disfigurement in the head and neck region have a significant effect upon both the patient and professional staff
• “I must admit that once the cancer is on the surface it is hard to handle”

Ethical Considerations

• Is it ethical to tell a white lie?
• Do little white lies count as truly lying?

Case History: Mr. A

• 83 y.o. with a swelling in his lower right side of his mandible
• After discussion with family, it was decided to provide the patient with palliative care radiotherapy
• Radiation therapy affects both normal and diseased tissues.
• Patient developed a fistula within his cheek.
• Pills, food would pass through his fistula.

Case History: Mrs. F

• 68 yo , living at home with metastatic breast cancer
• C.C: Painful throat
• Current meds: Nystatin, opioids

Diagnosis from St. Mary's Hospital Center: Presence of Herpes Simplex virus type 1.

• Treatment: Benadryl:Kaopectate 50:50 elixir applied to lesions & Valtrex 500mg bid x 5d