16.10 Oropharyngeal problems in palliative care

• Poor oral hygiene
• Poor oral intake : may relate to debility, dehydration or drowsiness
• Oral thrush and other infections
• Local tumour
• Dry mouth: often aggravated by medications (e.g. opioids, tricyclic antidepressants and hyoscine), mouth breathing, oxygen therapy
• Chemotherapy
• Local radiotherapy can cause decreased saliva and oral ulcers

Good mouth care is essential for the well-being of debilitated patients in order to prevent problems before they arise and to control unpleasant symptoms.

Routine mouth care as appropriate to patient needs

• a 4 hourly regime will reduce the potential for infection but not ensure comfort of patients taking reduced fluids
• a 2 hourly regime will reduce oral complications and help patient comfort
• a 1 hourly regime is indicated if the patient is unconscious, mouth breathing or receiving oxygen therapy

Mouth care for patients who are very unwell or unconscious

• Teeth are brushed using fluoride toothpaste and a small soft toothbrush or foam stick moistened with water.
• Since rinsing is difficult or impossible, the excess toothpaste is removed using a moistened foam stick.
• OraNurse® toothpaste (not available on FP10) is useful for some patients in that it is flavourless and has no foaming agent.
• The oral mucosa and tongue are cleaned using foam sticks moistened with water.
• Frequency of oral care is increased as tolerated.
• If the mouth is particularly dry a thin film of water soluble lubricating jelly may be applied to the oral mucosa with a foam stick.
• Rubbing ice cubes, frozen tonic water, frozen fruit juice or pineapple chunks on the lips of a patient who may be unable to suck or swallow can also do much to relive the sensation of dryness.

General tips:

• Review medications causing dry mouth / ulceration
• Sips of iced water or rinsing mouth with water regularly
• Sucking pieces of ice
• Salivary stimulants – fresh melon, sugar free chewing gum, sugar free fruit pastilles
• Use of saliva substitutes to keep mouth and lips moist
• Do not use petroleum based products (risk of aspiration and are contraindicated with oxygen therapy)

Artificial saliva

There are many products available and choice may dictated by patient preference and tolerance. There is some evidence that mucin-based products are better tolerated and more effective than cellulose-based ones (the mucin comes from the stomach of pigs; this may be an issue for some patients). Artificial saliva should ideally be pH neutral.

Please refer to section 12.3.5 Treatment of dry mouth for formulary preparations

Stimulation of saliva production

Pilocarpine is sometimes used as a treatment for xerostomia. It is associated with side effects. Please seek specialist advice.

See section 12.3.5 Treatment of dry mouth

Amitriptyline

• 10mg at night

Hyoscine hydrobromide

• see section 4.6 Drugs used in nausea and vertigo

Other treatment options are available, please seek specialist advice.

Miconazole oral gel 24mg/ml

• See section 12.3.2 Oropharyngeal anti-infective drugs

Nystatin oral suspension 100 000 units/ml

• See section 12.3.2 Oropharyngeal anti-infective drugs

Fluconazole

Use if nystatin or miconazole not effective or a systemic antifungal is required

• 50-100mg once daily for 7 days
• reduce dose of fluconazole by 50% if creatinine clearance is less than 50mL/minute
• be aware of potential drug interactions as a result of inhibition of various cytochrome P450 enzymes by azole antifungals
• higher doses and longer courses may be needed in immunosuppressed patients, and patients with more severe infections

Itraconazole

Not generally a first line treatment, to be reserved for more resistant infections

• capsules 100mg; 100mgs once daily for 2 weeks
• be aware of potential drug interactions as a result of inhibition of various cytochrome P450 enzymes by azole antifungals
• higher doses and longer courses may be needed in immunosuppressed patients, and patients with more severe infections

• Simple mouth washes e.g. water or 0.9% saline can be soothing & help to maintain oral hygiene, tepid mouthwashes appear to be more soothing than cold or warm ones
• Soluble aspirin 300mg to gargle and swallow 4 hourly when required, contraindications will include patients with peptic ulcers, or impaired renal function
• Soluble paracetamol 1g to gargle and swallow 4 hourly when required (maximum 4g in 24 hours)
• Oral morphine liquid 2.5mg 4 hourly when required, to gargle or to swallow
• Benzydamine 0.15% oral rinse 15ml to rinse or gargle every 2 - 3 hours, can be diluted with water if causes stinging
• Chlorhexidine gluconate mouthwash 0.2% 10ml twice a day

Oral suspension oxetacaine 10mg, aluminium hydroxide 200mg, magnesium hydroxide 100mg/5ml, 10ml 8 hourly and at bedtime (unlicensed product, available as a special order from Rosemont)

Sucralfate suspension 1 gram/5ml, 10ml 20 minutes before meals and at bedtime

Protect the ulcerated area

See section 12.3.1 Drugs for oral ulceration and inflammation

Corticosteroids are the mainstay of treatment (but avoid in oral infections)

• hydrocortisone oromucosal tablets 2.5mg 6 hourly for up to 5 days; tablets; place tablets at site of ulcers and leave to dissolve
• betametasone soluble tablets 500 microgram, dispersed in 20ml water and rinsed around the mouth 6 hourly (unlicensed use)

Prevention:

• chlorhexidine gluconate mouthwash 0.2% (see section 12.3.1 Drugs for oral ulceration and inflammation)

Treatment:

• Mix a doxycyline dispersible tablet or contents of a capsule with a small quantity of water, rinse around the mouth for 3-4 minutes and then spit out (unlicensed use)