Mouth care – A Quality improvement project
The Hundred House, 10 May 2016
Dr Matthew Doré What is a Quality improvement project?
An audit has the audit cycle to measure what we do against defined standards.
Not everything has standards defined, has unclear or no guidelines,
Some of these things would improve quality of patient and staff with general common sense
A QI projects allows incremental and measurable changes to make a difference to patients’ care
• More flexible and dynamic,
• if something does not work to scrap it
• employs multiple changes
Dry Mouth (aka Xerostomia)
Highly prevalent symptom in palliative care.
Incidence of 60-80% in patients with advanced cancer (PANG 2011)
Risk factors include…
1) Medications 2) Mouth breathing 3) Advanced age 4) Previous history of radiation to the head and neck 5) Sjögren’s syndrome (the SICCA syndromes) 6) Diabetes mellitus (or vascular diseases) 7) Anxiety states 8) Dehydration Medications
"Medications seem to be the significant cause of Xerostomia in palliative care” - (1)
“A median number of four drugs they were associated with xerostomia" - (2)
“Dry mouth can alter taste and make it difficult for patients to eat and swallow and may also complain of mouth pain and difficulty with speaking” – (2)
- ? Swallow tablets , eat / drink effectively
1) Davies AN, Broadley K, Beighton D. Xerostomia in patients with advanced cancer. J Pain Symptom Manage 2001; 22:820. 2) Sweeney MP, Bagg J. The mouth and palliative care. Am J Hosp Palliat Care 2000; 17:118.
• Xerostomia is a significant problem for many palliative patients, with an incidence of 60-80% in patients with advanced cancer and those being admitted to hospice units (PANG guidelines 2011)
• NICE highlights that when managing xerostomia in a palliative population individual patient preference is likely to influence product acceptability and compliance (NICE 2012 Palliative Cancer Care - Oral).
• A Cochrane review on the interventions for management of dry mouth (which was not specific to the palliative care population) did not identify any strong evidence that any
topical therapy is effective for relieving the symptoms of dry mouth (Furness S et al 2011) Literature Search
• There are to date no randomised controlled trials demonstrating a superiority of any individual mouth care products or oral saliva replacement products to each other in a palliative population.
• Systematic literature review: Xerostomia in advanced cancer patients (Supportive Care in Cancer, vol 23(3) Oct 2014).
• The aim of this review was to determine the effectiveness of pharmacological and non- pharmacological interventions in treating xerostomia in adult advanced cancer patients. • Systematic literature review: Xerostomia in advanced cancer patients (Supportive Care in Cancer, vol 23(3) Oct 2014).
• Results : – 3 RCTs and 3 prospective studies. – Compared acupuncture, pilocarpine, Saliva Orthana and chewing gum with placebo. – All interventions were considered effective in treating xerostomia, to equal effect. – However, effectiveness versus placebo often could not be demonstrated statistically significantly. – No meta analysis possible. – too small
• Conclusion: – Limited published data exists so no firm conclusions can be drawn. – However, pilocarpine, artificial saliva, chewing gum and acupuncture have 'some' evidence. – This highlights the explicit need to improve our evidence base. Properly constructed RCTs are required. • Palliative Medicine as a whole recommend a variety of oral saliva replacement products and mouth washes for the management of xerostomia, often based on familiarity and ad-hoc experience rather than guidelines or evidence.
• Last year I organised with Dr Conn Haughey for all of MDT to try a large selection of mouthcare products and contrasted our current clinical practice before trying the products and after. (approx 60 different health care professionals tried the products)
Before and After: Top 5 & Top 3
Top 5 rankings Top 5 rankings Top 3 rankings Top 3 rankings before after before after Oral balance Biotene Oral balance Biotene (Biotene) gel (47) moisturising (Biotene) gel (33) moisturising mouthwash (36) mouthwash (29)
Biotene Sugar free chewing Biotene Sugar free chewing moisturising gum (35) moisturising gum (21) mouthwash (35) mouthwash (30) Glandosane Salivix sugar free Glandosane Oral balance (natural) spray (34) pastilles (30) (natural) spray (16) (Biotene) gel/Sips of water (16/16)
Sugar free chewing Oral balance Sips of water (13) Salivix sugar free gum (24) (Biotene) gel/Sips pastilles (13) of water (25/25) Sips of water (21) Sugar free chewing gum (9)
29/5/15 and overall dryness score 2/6/15 13
overall 10 dryness patient score COB 0 MG 4 8 RM 4 overall dryness score KS 5 DF 5 5 GS 5 EH 6 SM 6 EM 8 3 MG 8 MP 9 AM 9 0 FH 10 COB MG RM KS DF GS EH SM EM MG MP AM FH
Mean 6.2
Removed 4 patients, 2 could not respond, 1 0 – not dry - normal inappropriate, 1 confused 10 – as dry as can be Mouthcare Pre
Patient Biotene Nystatin Salivex other
COB 0 0 0 0
MG 0 0 0 0
RM 0 1 0 0
KS 1 0 0 chewing gum
DF 1 0 1 0
GS 0 0 0 0
EH 1 0 1 Daktarin
SM 1 1 1 0
EM 1 1 0 0
MG 0 0 0 0
MP 0 0 0 0
AM 1 1 1 0
FH 1 0 1 occasional lollies
7 4 5
Most had no product
13 It became clear a local guideline needed to be constructed to consolidate this new information and create consistency across our practice in Northern Ireland, Bedford, Cambridge, Shrewsbury
I searched and collated other sources of information and guidelines on Xereostomia, including…
1) PCF5 (p599), 11) Addenbrooks - Good oral care 2) Dental and Oral Care chart (RVH), 12) BMJ – oral care 3) Dental and Oral Hygiene Chart (Dental School) 4) Marie Curie Oral Assessment tool, 5) Oxford handbook on Palliative Care, 6) PANG guidelines (p64) 7) uptodate website 8) European Essential Palliative Care certificate 9) Belfast Dental School 10)Bedford Mouthcare protocol
Failed flow diagram
16 It also became evident there was huge overlap between xerostomia and other aspects of mouth care in particular including management of Thrush, management of painful mouth and Denture care.
These aspects where all inseparable
Issues raised and noted..
1) Difficulty diagnosis of thrush (? coating) 2) Denture care (using toothbrushes, masking thrush/ulcers) 3) Vaseline - not with oxygen 4) Brushing teeth once / day 5) Unclear guidelines on painful mouth
The guideline clearly also had to incorporate and clarify these aspects Petroleum Jelly and Oxygen
This myth is based on the National Fire Protection Association's (NFPA) 1996 edition of its Standard for Health Care Facilities, which states, "Oil, grease, or other flammable contaminants shall not be used with oxygen equipment" (item 8-6.2.2.2), and "Flammable and combustible liquids shall not be permitted within the site of intentional expulsion" (item 8-6.2.2.3).
There is no evidence of any danger
1) Winslow EH, Jacobson AF. Dispelling the petroleum jelly myth. AM J Nurs1998:98(11):16)
2) Phippen ML. Is petroleum jelly safe? AM J Nurs 1999: 99(8):24
3) Woodrow P. Petroleum jelly myth. Nurs Older People 2004: 16(6): 41 Are there any adverse incidents reported in the literature?
There are NO case reports of adverse incidents with Vaseline applied to lips
1) Ocak I1, Raffensperger J, Turkbey B, Fuhrman C. Lipid pneumonia secondary to Petroleum jelly use in a patient with tympanic membrane perforation. JBR-BTR. 2009 Nov-Dec;92(6):280-2.
2) Gorospe L1, Gallego-Rivera JI, Hervás-Morón A. Exogenous lipoid pneumonia secondary to Petroleum jelly application to the tracheostomy in a laryngectomy patient: PET/CT and MR imaging findings. Clin Imaging. 2013 Jan-Feb;37(1):163- 6. doi: 10.1016/j.clinimag.2012.02.002. Epub 2012 Jun 8.
Is there a fire risk?
There have been some reports of surgical ignitions of various materials such as Chlorhexidine and Tracheostomy plastic. These took place in a surgical setting with high concentrations of oxygen and with a clear ignition source, most commonly diathermy / cauterization.
NOT Vaseline!
1) Gorphe P1, Sarfati B2, Janot F2, Bourgain JL3, Motamed C3, Blot F3, Temam S2. Airway fire during tracheostomy. Eur Ann Otorhinolaryngol Head Neck Dis. 2014 Jun;131(3):197-9. doi: 10.1016/j.anorl.2013.07.001. Epub 2014 Apr 1.
2) Bengezi O2. Third-degree burns caused by ignition of chlorhexidine: A case report and systematic review of the literature. Plast Surg (Oakv). 2014 Winter;22(4):264-6. Vo A1,
Vaseline is flammable right?
The Material Safety Data Sheets by Sasol demonstrate the flash point of petroleum jelly to be around 150 degrees Celsius and an autoignition temperature of around 320 degrees Celsius.
This is way above normal environmental encounters and consistent with plastics considered very safe.
(For example Polyvinyl chloride (PVC): Flash point 250 degrees and Ignition temp 450 degrees)
1) Sasol Material Safety Data Sheet – Petroleum Jelly Revision date 11/4/2011 Created by B.Shamase approved by Ephraim Papo Petroleum jelly without oxygen - blow torch
https://www.youtube.com/watch?v=8hAUKTnHlcg Petroleum jelly mixed with oxygen - blow torch
https://www.youtube.com/watch?v=yLqixjvTD7s Oxygen Tubing
https://www.youtube.com/watch?v=asumR-n2e6k Ignition with lighter Ignition with blow torch Petroleum jelly on Melted, never ignited Melted, 120 seconds to it own ignite Petroleum jelly Melted, never ignited Melted, 111 second to mixed with oxygen ignite 10min (high flow) Cotton wool on its Ignition 3 seconds, burn Ignition instant, burn time own time 45 seconds 40 seconds Cotton wool mixed Ignition 11 seconds, Ignition instant, burn time with petroleum jelly burn time 197 seconds 113 seconds Oxygen tubing Ignition 18 seconds, Ignition instant, burn time burn time 10 seconds 8 seconds A lot of resistance… Why?
In gathering the opinions of 52 carers and nursing colleagues in Bedford Hospital, Addenbrooks and Sue Ryder Hospice in relation to the use of petroleum Jelly with oxygen the following concerns were highlighted:
1) Risk of blame if anything untoward happens,
2) Potential to be told off by seniors,
3) Must not challenge policy even if I personally disagree,
4) The change would not be sustained by my colleagues. There is no evidence that Vaseline is superior to aqueous products at maintaining moisture in the mouth.
However…
In my expereince (and I would argue the vast majority of carers and nurses) would use vaseline for themselves and think its superior to aquos products.
What do you think? Brushing teeth
There is clear consensus throughout dental literature regarding the importance of regular brushing with a fluoride toothpaste - generally recommending after every meal.
1 Hale KJ, American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics 2003; 111:1113. 2 Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis--United States, 1988-1994 and 1999-2002. MMWR Surveill Summ 2005; 54:1. 3 NIDR: the prevalence of dental caries in United States children: The National Caries Prevalence Survey: 1979-1989. NIH Publication 82-2245. National Instutute of Dental Research, National Caries Program, 1981. 4 Brunelle JA. Oral health of United States children: The National Survey of Dental Caries in US School Children: 1986-1987. NIH Publication 9-2247. National Institute of Dental Research, Epidemiology and Disease Prevention Program, 1989. 5 Kelly JE, Harvey CR. Basic data on dental examination findings of persons 1-74 years. United States, 1971-1974. Vital Health Stat 11 1979; :1. 28 Are we brushing teeth?
NI Hospice I was assured we were brushing teeth at least twice / day
So I measured it… A single night 7 out of the 13 patients got their teeth brushed twice– NI hospice
St Johns Hospice Sue Ryder That would never happen to us, we definitely do it twice / day
So I measured it… 13 out of 20 patients got their teeth brushed twice - St Johns Hospice
? Severn Hospice ? Community
Of also interesting note do not rinse your mouth afterwards to allow fluoride to act Non foaming toothpaste
Sodium laureth sulfate (SLS), or sodium lauryl ether sulfate (SLES), is a detergent and surfactant found in many personal care products (soaps, shampoos, toothpastes, etc.).
• It makes the toothpaste froth
• SLS Free toothpastes are available
• Make sure they are fluoride based
• Less drying than normal toothpaste
• Take a while to get used to Denture Care
• A huge area and confusing
• A lot of different products and makes
• Dependent upon what the denture is made of, i.e. type of plastic and if contains metal or ceramic or not
• All do come with their own recommendations
• Recommend taking dentures out and soaking overnight with…
• Chlorhexadine 0.2% M/W is safe with all (however risks staining the teeth pink) • Steradent is also very safe as a cleaning agent
• Toothpaste (with or without fluoride) is corroding and dentures should not be brushed with this, rather use soap and water and rinse well.
• If remaining teeth they should be brushed as normal with fluoride toothpaste
• Dentures should be taken out at night unless strong patient preference to leave in 31 Painful mouth
I collated a local guideline on the evidence available from the sources mentioned earlier and then expert opinion from my colleagues as to the order and preferences.
• Is it mucositis ? (Recent chemo or radiotherapy)
• Recommendations of a baby (soft) toothbrushes to examine a mouth and clean a mucky mouth
• Some evidence for Benzydamine Hydrochloride 0.15% oral rinse (Difflam) 10-15ml rinse/gargle for 20-30sec QDS, Benzydamine Hydrochloride Oromucosal spray 0.15% QDS
• Most common problem is battling on…. If treatment stings stop and re-assess!
• Many other options
32 Thrush
It is very difficult on occasion to differentiate between a coated mouth and thrush.
A couple of possible useful differentiating factors (although none are certain) - open for discussion!
1) plaques on soft/hard palate (anywhere but tongue) - more likely thrush 2) Isolated on tongue - less likely thrush 3) plaques easily cleaned away with soft toothbrush - less likely thrush 4) mucky plaques - less likely thrush
With all considerations made and there could be duel pathology consider a trail of treatment in conjunction with good oral hygiene care.
Initial poster went up for 5 days 10th -17th June 2015 after all nursing staff and medical staff had, had an input
Re audited the ward on the 17th June
35 36 17/7/15 overall dryness score 13 overall dryness patient score 10 MO 5 JM 5 EMC 5 8 EMc 5 overall dryness score WW 6 JS 6 5 JK 7 AM 7 MW 8 RS 10 3 JSM 10 BS 10 0 MO JM EMC EMc WW JS JK AM MW RS JSM BS
Mean 6.9 7.2
Removed 3 patients – 2 could not 0 – not dry respond, 1 confused 10 – as dry as can be Mouthcare post
Patient Biotene Nystatin Salivex other
CO 1 0 0 0
MG 0 0 0 0
RM 1 0 0 Chlorhexadine
KS 1 1 0 Daktarin
DF 1 0 1 chewing gum
GS 0 0 0 vaseline
EH 0 0 0 0
SM 0 1 0 0
EM 1 1 1 0
MG 1 1 0 fluconazole
MP 0 1 0 0
AM 1 0 0 0
FH 0 0 0 0
7 5 2
We prescribed more!
38 Pre Post
13 Pre Post
0 5 10 4 5 4 5
5 5 8 5 6 5 6 6 7 5 6 7 8 8 3 8 10 9 10 9 10 0
10
The Mean went up from 6.2 pre to 7.2 post
People thought their mouth was drier after the poster was up for a week!
39 My rating on how dry their mouths seemed
Pre Post mild 8 7
Moderate 6 5
Severe 3 3
Total 17 15
Pre Post
mild 0-3 Moderate 3-7 Severe 8-10 mild 0-3 Moderate 3-7 Severe 8-10
18% 20% 41% 47%
41% 33%
40 Pre Patient Post Patient
mild 0-3 7 1 7 0
Moderate 3-7 7 7 5 8
Severe 8-10 3 5 3 4
Total 17 13 15 12
Pre My assesment Pre Patients subjective opinion Post My Assessment Post Patients subjective opinion
mild 0-3 mild 0-3
Moderate 3-7 Moderate 3-7
Severe 8-10 Severe 8-10
0 1.75 3.5 5.25 7 8.75 0 2 4 6 8 10
Patients are subjectively experiencing a dryer mouth than I was seeing 41 42
Conclusion
• I believe this is the most up to date and evidence based approach to mouthcare
• It has been implemented in Northern Ireland, Bedford Hospital, and 3 hospices
• It is a quality improvement project, therefore is flexible! I would love your feedback and suggestions
• Mouthcare is not just a nursing or carer thing, it is all the MDT responsibility
• A good access point to help relatives care for their loved ones and built a trusting rapor with staff.
• Would a leaflet help
• Is part of (and demonstrates well) patient focused care
• Don’t underestimate the symptom burden of your mouth
any questions??
51