Clinical PRACTICE The Treatment of Oral Problems in the Palliative Patient Contact Author Michael Wiseman, BSc, DDS, M SND RCS (Edin), FASGD Dr. Wiseman Email: michael.wiseman@ staff.mcgill.ca ABSTRACT Palliative care patients require special dental attention, ranging from operative and preventive care to support for emotional needs. The dentist’s role in palliative care is to improve quality of life of the patient. This paper describes some common problems encountered in palliative care dentistry for adults with terminal cancer and the appro- priate treatment of these problems. MeSH Key Words: dental care for chronically ill; mouth diseases/therapy; palliative care; quality of life © J Can Dent Assoc 2006; 72(5):453–8 This article has been peer reviewed. alliative care dentistry has been defined as tissues leading to ulceration, which may be fur- the study and management of patients ther complicated by microbial invasion.3 Pwith active, progressive, far-advanced dis- Mucositis occurs within 5–7 days of chemo- ease in whom the oral cavity has been compro- therapy with drugs such as 5-fluorouracil and mised either by the disease directly or by its methotrexate, which are potent mucositis treatment; the focus of care is quality of life.1 agents. Radiotherapy to treat cancers of the This approach not only involves the provision head and neck result in xerostomia due to of support for the patient’s physical needs but destruction of the salivary tissues within the also extends to support of the patient’s and treatment zone. The decrease in lubrication family’s spiritual needs. This article presents and the protective agents in saliva render some common problems encountered in pal- the tissues more susceptible to trauma and liative care dentistry in relation to adults with invasion by pathogens. The tissues become terminal cancer and the appropriate treatment ulcerated and erythemic. of these problems. The oral problems associ- Treatments for mucositis and stomatitis are ated with palliative care are illustrated in Fig. 1. primarily aimed at relieving pain (Box 1). Xylocaine and dyclonine topical anesthetics Mucositis and Stomatitis provide comfort but must be used with caution Mucositis and stomatitis are common in as they will block the gag reflex and increase patients who receive chemotherapy and radio- the risk of aspiration. Dyclonine has been therapy (Fig. 2) Chemotherapy acts on tissues shown to have anti-inflammatory activity that have a high rate of mitosis, and the oral in addition to its anesthetic qualities.4 The cavity is frequently affected. An estimated use of diphenhydramine hydrochloride 5% 40% of chemotherapy patients suffer from (Benadryl, Pfizer Inc., New York, N.Y.) and mucositis.2 Reducing mitosis causes atrophy of loperamide (Kaopectate, Pfizer Inc., New York, JCDA • www.cda-adc.ca/jcda • June 2006, Vol. 72, No. 5 • 453 ––– Wiseman ––– Social isolation Chemotherapy Depression Radiotherapy Nausea Antidepressants Poor oral hygiene Stomatitis Antiemetics Mucositis Candidiasis Periodontal Caries disease Poor nutrition Taste alterations Xerostomia Halitosis Dehydration Figure 2: Oral mucositis Narcotics Alcohol Pain Mouthwashes Figure 1: Oral problems in palliative care N.Y.; Maalox, Novartis Consumer Health Canada Inc., properties. It has been reported to relieve radiation- Mississauga, Ont.) as a rinse to relieve pain has been used induced stomatitits9;however, its benefit in the treatment for herpetic stomatitis.5 Milk of Magnesia (Rougier of burning mouth syndrome has not been demonstrated.10 Pharma, Mississauga, Ont.) should not be used as a After teaching patients to expectorate completely by substitute as it will dry the mouth. practising with saline solution, a 0.2% morphine solution The use of sucralfate suspension to palliate radiation- can be used topically to relieve the discomfort associated induced mucositis has had mixed results.6–8 Sucralfate with mucositis. Patient selection is important, as they should be used on a case-by-case basis, and the clinician must be able to follow directions carefully to prevent over- must not only assess the clinical signs of mucositis but also dosing.11 seek the patient’s evaluation of his or her status. Before any of the above measures is initiated, it is Many oncologists prescribe a concoction termed important to identify local traumatic factors such as frac- “magic mouthwash.” It contains many ingredients, often tured restorations or teeth, or an impinging removable varied; it has been known to contain antihistamines, anti- prosthesis. Patients should also be advised to avoid spicy fungals, topical anesthetics and even antibiotics. I believe foods, smoking and alcohol.11 that these products should not be used as a panacea, but instead treatments should be prescribed to remedy specific Nausea and Vomiting symptoms. Nausea and vomiting in palliative care patients may Benzydamine (Tantum, 3M Pharmaceuticals, London, have many causes, including chemotherapy, opioid use, Ont.) is a nonsteroidal analgesic with anti- inflammatory bowel obstruction, pancreatitis and electrolyte imbalance, Box 1 Treatments for stomatitis and mucositis or they may be movement induced or even an emotional reaction. Vomiting has a caustic effect on the hard tissues •Viscous xylocaine 2% and can also increase the morbidity of mucositis. It may •Xylocaine spray 10% also delay healing if the patient cannot consume nutrients •Diphenhydramine hydrochloride 5% and lopera- essential for tissue repair. Many of the drugs prescribed to mide in equal parts (dyclonine 0.5% may be added control nausea and vomiting have oral side effects to increase potency) (Table 1), the most notable being tardive dyskinesia and •Dyclonine hydrochloride 0.5% or 1% xerostomia. Tardive dyskinesia usually occurs with long- •Magic mouthwash term dosing and its presentation may affect denture wear. •Sucralfate suspension, 10 mL 4 times a day, Xerostomia affects nutrition, communication and oral swished and swallowed or expectorated tissues. Although the oral effects of the antiemetics are •Benzydamine, 15 mL 3–4 times a day, rinsed great, the inability to consume foods and medications and expectorated orally has more serious implications. Emotional outbursts •Morphine 2% are treated by the palliative care team by listening to the •Reduction of potential localized factors patient’s concerns and suggesting relaxation techniques. 454 JCDA • www.cda-adc.ca/jcda • June 2006, Vol. 72, No. 5 • ––– Palliative Care ––– Table 1 Oral side effects of antiemetics prescribed to control nausea and vomiting Agent Oral side effect Haloperidol Tardive dyskinesia Metoclopramide Tardive dyskinesia Hyoscine butylbromide Xerostomia Promethazine Xerostomia Table 2 Treatments for candidiasis Topical Figure 3: Pseudomembranous candidiasis Nystatin suspension, 200 000–500 000 IU, swished and swallowed 3–5 times a day Nystatin suspension frozen (200 000–500 000 IU) in sugarless fruit juice Nystatin vaginal suppository, 100 000 IU 4 times a day Clotrimazole vaginal suppository, 100 mg/day for 7 days Clotrimazole troche, 10 mg, 5 times a day for 14 days Clotrimazole vaginal cream 1%, applied to denture 3–4 times a day for 7 days Figure 4: Angular cheilitis Systemic Ketoconazole, 200–400 mg orally for 7–14 days Fluconazole, 100–200 mg on day 1, then plaques do not wipe off. Angular cheilitis appears as white 50–100 mg/day orally for 7–14 days and red fissures emanating from the corners of the mouth. Itraconazole, 100–200 mg/day orally for 7–14 days It commonly has a bacterial and fungal component (Fig. 4).14 In palliative care patients, candidiasis is Amphotericin B, 0.25–1.5 mg/kg a day intravenously primarily a result of xerostomia. Higher salivary Candida levels are more frequently Candidiasis encountered in denture wearers than in dentate patients.15 The incidence of candidiasis in palliative care patients The use of commercial hydrogen peroxide releasing agents has been estimated to be 70% to 85%. Predisposing factors has been found to be ineffective in the disinfection of the for fungal infections include poor oral hygiene, xeros- denture.16,17 Soaking the denture in bleach (15 mL) and tomia, immunosuppression, use of corticosteroids or water (250 mL) for 30 minutes will help rid the denture of broad-spectrum antibiotics, poor nutritional status, dia- odours. Partial dentures should not be soaked in bleach betes and the wearing of dentures. Candida albicans is the solution, as it will lead to metal fatigue. Dentures can also most common infectious organism encountered in can- be soaked in benzalkonium chloride (1:750) for 30 min- didiasis. It is a natural inhabitant of the oral cavity whose utes. Benzalkonium chloride should be formulated daily as overgrowth is normally suppressed by other nonpatho- Gram-negative bacteria can proliferate within 24 h.17 logic microorganisms and natural host defense mecha- Boiling the denture will cause denture base distortion18; nisms. The mere presence of a positive culture without however microwaving it in water at high power for 5 min- clinical symptoms is not indicative of Candida infection.13 utes can disinfect the denture base. Repeated microwaving Candida infections are manifested as pseudomembra- can result in hardening of PermaSoft denture linings.19 nous, erythematous or hyperplastic candidiasis or angular Dentures should be stored in well-identified vessels in cheilitis. Pseudomembranous candidiasis (thrush) is char- solutions of water, mouthwash, 0.12% chlorhexidine, acterized by small white or yellow