Problems of the mouth in palliative care

Having dry mucous membranes in the mouth is a common symptom that can be caused by illness, medication, or treatments. A dry mouth is susceptible to tooth cavities as well as infections of the gums and mucous membranes.

Dry mucous membranes get sore and break easily. Having a dry mouth alters the sense of taste and smell. A dry mouth may cause dentures to become ill-fitting, which makes them chafe the mucous membranes, further complicating both eating and talking.

Dry mouth

Dry mouth is usually caused by the salivary glands not producing enough saliva as a side effect of medication. Since continuing the medication often takes priority, treatment of dry mouth focuses on moistening the mouth and applying local treatment.

Reduced activity of the salivary glands can be improved by chewing more, both by using products such as xylitol chewing gum or pastilles and by adding foods that require chewing, such as fruit and raw vegetables, into the diet.

Ordinary toothpaste contains a foaming agent called sodium lauryl sulfate that has a drying effect on the mucous membranes. Mouthwash may contain alcohol and other strong ingredients that are not recommended for a sensitive mouth. Various dry mouth products (toothpaste, mouthwash, saliva substitute gel and tablets) that don’t contain irritants are available in pharmacies. When visiting a pharmacy, ask a pharmacist for more information.

Infections of the mouth

Fungal infections are a common problem associated with dry mouth and denture use. In addition, both bacterial and viral infections can occur in and around the mouth. The doctor can prescribe medication to treat the infection, if needed. There are disinfectant mouthwashes (such as ones containing chlorhexidine) available in pharmacies for treating gum inflammation. These may be necessary in situations such as if brushing the patient’s teeth is too challenging for some reason. If the mucous membranes are sensitive, mouthwashes with chlorhexidine are often too potent, in which case the mouthwash can be diluted with water (for example, 1 part mouthwash and 4 parts water). The chlorhexidine solution causes brown staining in the teeth and surface of the tongue.

Mucus

Ways to decrease secretion of thick mucus include making sure that the patient is getting enough fluids and attending to dry mouth. Some foods and drinks, such as coffee and dairy, may make the mucus thicker.

Pain

Treatment of mouth pain begins with attending to dry mouth. If this isn’t enough to relieve mouth pain, the need for pain relief medication should be assessed. Pain relief can be administered as either pills, transdermal medications (medication in patches that relieve pain by absorbing through the skin), or locally applied treatment for the mouth.

Taking care of moistening and rinsing the mouth and throat properly is the foundation of mouth health.

• Clean the mouth, teeth, and dentures every morning and evening. Rinse the mouth after each meal. Even if the patient has no teeth, the mouth is cleaned every morning and evening, either by rinsing or wiping.

• Use a soft toothbrush with a small head, or an electric toothbrush. Replace the toothbrush at least every three months. Clean between the teeth according to individual needs.

• Use a toothpaste containing fluoride. If necessary, use fluoride tablets and xylitol products as well.

• Rinse and brush dentures using soap or dishwashing liquid. Regular toothpaste damages the surface of dentures. You should always remove dentures at night, so that saliva can reach and protect the mucous membranes. Dentures can be disinfected with a mouthwash containing chlorhexidine or with cleaning products for dentures available in pharmacies.

• Make sure you’re getting enough to drink over the course of the day. If you’ve been instructed to stick to a fluid restriction, don’t go over it.

• Water is the best drink to quench your thirst. Sweet drinks containing sugar make the teeth susceptible to cavities.

• Edible oils, such as olive oil, are excellent for treating dry, sensitive mucous membranes. A good dosage to use is 1 to 2 teaspoons at a time, several times a day. The oil is spread on the mucous membranes of the mouth using the tongue, and then swallowed. This allows the oil to treat the mucous membranes in the throat and esophagus as well.

• Avoid foods that are too spicy, too hot or cold, or very coarse in texture. Other foods that may be irritating to fragile mucous membranes in the mouth include strawberries, tomatoes, bell peppers, and citrus fruits.

• Damaged mucous membranes can be treated with a salt water mouth rinse. The rinse is made by mixing 1 teaspoon of table salt (+ 1 teaspoon baking soda) with 1 litre of hot water. Let the solution cool. Take about 1 tablespoon of the solution, rinse your mouth with it, and spit the solution out. Repeat 2 to 3 times. Rinse the mouth every 2 hours each day, following these instructions. Make a new solution every day.

• If self-management isn’t enough to keep your symptoms under control, or if you develop new symptoms of the mouth, don’t hesitate to contact your doctor or nursing staff.

• If you develop a toothache, signs of a worsening infection, you find that your dentures are chafing, of you need guidance on self-management, don’t hesitate to contact your dentist. When it comes to toothache, don’t suffer in silence – it may be easy to treat!

At the end of life, bodily functions are gradually fading, which may result in an increase in symptoms. In hospice care, good symptom management is the main priority. However, if a patient is dying and a symptom doesn’t bother or disturb them, it doesn’t always require treatment. Problems of the mouth may vary from asymptomatic to severe (such as pain or bleeding). As a result, the patient’s mouth care regimen is individualised according to the patient’s wishes and needs. The care team makes a plan for how to manage severe symptoms. If the patient is conscious, they can let those responsible for their care know what kind of relief they would like when it comes to symptoms affecting the mouth.

The most common symptom is dry mouth. Having a dry mouth makes it difficult to talk or swallow. The mouth can be moistened with either the patient’s drink of choice or various mouth care products. Fluids are offered a little bit at a time. In hospice care, swallowing is often difficult. If the patient is given too much fluid at once, it may stay in the mouth or even get into the airways. To dispense fluids, use a sippy cup, a water bottle, a straw, or a spoon.

If the patient is no longer able to express their wishes or is unconscious, the mucous membranes in the mouth should be wiped clean twice per day, using a swab moistened with saline solution or a swab stick. After cleaning the mouth, wipe the mucous membranes using a moisture-retaining mouth care product or oil (fragrance-free oils for the skin and mucous membranes are available in pharmacies). As the mouth becomes dry, the lips become chapped as well, so applying lip balm (such as one containing dexpanthenol) to the lips and corners of the mouth is also a part of good mouth care.

When a patient is dying, they shouldn’t be subjected to unnecessary procedures. It’s good to keep in mind that at the end of life, symptoms affecting the mouth that used to be irritating often no longer bother the patient.