Mouth care at the end of life

Common mouth problems

Common mouth problems in palliative care include:

Mouth care is a very important aspect of palliative care in all care settings. When they're not managed, mouth problems can affect:

• self esteem
• ability to communicate
• ability to socialise
• ability to enjoy food and drinks
• comfort, and can cause pain.

Any mouth problems should be assessed and treated as soon as possible. 

Causes of mouth problems

Factors which contribute to mouth problems include:

• dry mouth (xerostomia), which can be caused by medicines, breathing through the mouth, and oxygen therapy
• dehydration which can be caused by eating and drinking less
• radiotherapy to the head and neck
• chemotherapy
• medications which can lead to changes in taste
• mouth or neck cancers
• poor oral hygiene – especially if weakness or fatigue means the patient is less able to keep their mouth clean.

Assessing mouth problems

Every patient with a terminal illness should be assessed for mouth problems regularly. Ask patients frequently if they have any of the common mouth problems listed above.

Ask them whether it’s painful to speak or swallow. Assess whether the patient is able to manage their own mouth care or if they need any help.

Check what medicines the patient is taking as many cause mouth problems:

• Dry mouth can be caused by opioids, antidepressants, medicines for Parkinson’s disease and epilepsy, and others.
• Chemotherapy and radiotherapy can cause mouth problems.
• Steroids can increase the risk of mouth infections.
• Bisphosphonates (which are commonly prescribed to slow down bone thinning) can increase the risk of damage to the jaw bone.

If it’s within your role, you should carry out an examination. Make sure the patient has privacy before you start. Explain to them what you're going to do. Remove any dentures and use a torch so you can thoroughly examine the mouth, including the lips, teeth and tongue. Look for signs of:

• dryness
• redness
• bleeding
• coating of the mouth and tongue
• ulceration or other sores
• infection including abscesses
• tooth decay.

Mouth problems can usually be diagnosed on examination alone. Blood tests can help to assess bleeding, and you might need to take swabs if you suspect an infection.

Giving basic mouth care

All patients should have basic mouth care every day. Good mouth care in someone’s last days and hours can help to keep them comfortable. Encourage patients to do as much as they can by themselves. Carers and family members can also help.

There are things you can do for all patients:

• Keep mouth and lips clean and moist.
• Help them to take frequent small drinks.
• Apply gel to dry lips after brushing teeth. Petroleum gel such as Vaseline shouldn’t be used in patients having oxygen therapy as this is a fire hazard.
• Encourage them to avoid sugary foods and drinks between meals.
• Give mouth care when the patient is semi-upright, to avoid choking. If that’s not possible, make sure fluid isn’t building up in their mouth as you give mouth care.

For patients who have their own teeth:

• Clean teeth with fluoride toothpaste at least twice daily if the patient can manage.
• Encourage patients to spit out excess toothpaste after brushing.
• Not rinsing after brushing can protect the teeth but it can also be drying and uncomfortable. Advise the patient to do what feels the most comfortable.
• Remove partial dentures and clean them separately.
• Use silk or baby toothbrushes, as these have softer bristles and can be helpful for patients with a painful mouth.
• Use non-foaming toothpaste if the patient has difficulty swallowing.

For patients with dentures:

• Remove dentures at night, and soak them in cleaning solution for the amount of time stated in the manufacturer's guidelines.
• Rinse dentures thoroughly before putting them back in the mouth.
• Brush dentures at least once daily using a toothbrush and running water.
• Rinse dentures thoroughly after meals.
• Check dentures for cracks, sharp edges and missing teeth every day.
• Check whether dentures still fit properly – if the patient has lost weight, this can affect how dentures fit and they may become uncomfortable.

Managing specific mouth problems

If you have any concerns about specific mouth problems, speak to the patient’s GP, district nurse or specialist nurse, and consider referring them to a dentist. Below are some ways you can help manage mouth problems.  

Dry mouth

Dry mouth (xerostomia) is the subjective feeling of a dry mouth. It’s often associated with difficulties with speech, chewing, or swallowing, the need to keep drinking and changes in taste. People with dry mouth can develop a thick coating over the tongue and lining of the mouth.

To help someone with a dry or coated mouth, you can:

• encourage them to drink cold unsweetened drinks
• suggest sugar-free chewing gum or sucking on sweets, as these can stimulate saliva production
• suggest ice chips if the patient has difficulty swallowing
• help them use saliva replacements or oral gel to keep the mouth moist
• gently remove coatings and debris from the lips, tongue and lining of the mouth using a soft toothbrush.

Dry mouth at the end of life

Towards the end of life, people often become less interested in eating and drinking. If the patient’s mouth becomes dry, you can moisten it to keep them comfortable.

If the patient is conscious, moisten their mouth every 30 minutes with water from a spray or dropper, or by placing ice chips in their mouth. If the patient is unconscious, use a spray, dropper or ice chips every hour.

Read more about caring for someone at the end of life.

Painful mouth

Get advice from the patient’s doctor or dentist if they're having radiotherapy or chemotherapy.

The following can help to soothe sore mouths:

• Painkillers, including lozenges containing lidocaine (a local anaesthetic).
• Saline mouthwash.
• Chlorhexidine mouthwash (chlorhexidine gluconate 0.2%).
• Topical corticosteroids and occasionally a low dose doxycycline mouthwash can be used for ulcers.
• Avoiding alcohol and very hot drinks.
• Avoiding dry foods like crisps and biscuits.
• Trying softer, cold foods such as yoghurts, custards, chilled soups.
• Using a straw or teaspoon to eat and drink can avoid irritating the sorest parts of the mouth.
• Having a drink or rinsing after eating can help make sure there’s no food debris which might agitate the mouth.
• Avoiding acidic foods if the patient has mouth ulcers.

Infections

Oral thrush (candidiasis) is a common fungal infection for people living with a terminal illness. It looks like thick white patches coating the tongue and mouth. It can also be present in the throat and oesophagus (gullet).

Thrush can cause pain, and difficulty with swallowing and chewing. Treat it with antifungal tablets, liquids or topical mouth sprays. Ask the patient’s GP, district nurse or specialist nurse to arrange treatment.

Cold sores (herpes simplex) are also common when someone's unwell. A patient can only get cold sores if they already have the herpes simplex virus. Cold sores can happen when a patient is feeling run-down or has another infection.

The patient’s GP, district nurse or specialist nurse can provide anti-viral treatment. You can also support the patient by encouraging good fluid intake, changing the toothbrush regularly , keeping the mouth moist and giving painkillers if appropriate.

Bad breath (halitosis)

Bad-smelling breath can feel embarassing, so approach the topic sensitively. It can be caused by infections including abscesses, local tumours and poor oral hygiene. Good mouth care should improve bad breath but antibiotics might be needed for local infections and abscesses. 

Changes in taste

Patients might experience changes in taste. They might not want to eat the food  they usually enjoy. Make sure they still eat and drink enough. Encourage them to eat what they do enjoy and offer foods and drinks they find appealing.

Drooling

Drooling (excess saliva) is usually caused by difficulty swallowing saliva. It's common in patients with neurodegenerative disorders such as motor neurone disease (MND), Parkinson’s disease and multiple sclerosis.

Ask the patient's GP, district nurse or specialist nurse about treatment. Physiotherapy can help with positioning and suctioning. Speech and language therapists can advise on safe swallowing techniques.

When to ask for help

Mouth problems can cause physical complications and be distressing for the patient. Involve the following specialists if you’re worried:

• A speech and language therapist if the patient has difficulty with communication or swallowing.
• A dietician if the patient's not eating or drinking enough, or if they're experiencing changes in taste.
• Refer to the patient’s GP or medical team if there are signs of infection, bleeding or uncontrolled pain.