Medical Manuscript
Characteristics of Oral Problems and Effects of Oral Care in Terminally Ill Patients With Cancer
American Journal of Hospice & Palliative Medicine® 1-5 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909116633063 ajhpm.sagepub.com
Nobuhisa Nakajima, MD, PhD1
Abstract Purpose: Various distresses appear in the terminal stage of cancer. Oral problems including dry mouth, stomatitis and candidiasis are one of the important problems which should be resolved. The purpose of this study was to investigate oral problems in this stage and improvement of dry mouth by oral care. Methods: The study subjects were consecutive terminally ill cancer patients admitted over the past 2 years. Patients were divided based on the status of oral food intake into good oral food intake group (30%) and poor oral food intake group. The following 3 items were retrospectively investigated: 1) The incidences of these oral problems, 2) Severity of dry mouth and complication with other oral problems, 3) Improvement of dry mouth using standard oral care by nursing staff and specialist oral care including dentists as needed. Results: There were 115 and 158 patients in good and poor oral intake groups, respectively. 1) The incidences of dry mouth, stomatitis, and candidiasis were significantly higher in poor oral intake group (p < 0.001). 2) Severe cases of dry mouth (Grade-2&3) were noted in 20.0% and 64.8% in good and poor oral intake groups, respectively (p < 0.0001). Candidiasis complication rate was significantly higher in poor oral intake group (p ¼ 0.0002). 3) The rate of dry mouth improvement by oral care was 100% in Grade-1, 86% in Grade-2 and 81% in Grade-3. Conclusion: Oral problems occur in many of terminally ill cancer patients. Accurate diagnosis of oral problems and corresponding appropriate interventions are important for improving quality of end-of-life care. Keywords oral care, palliative care, end-of-life care, terminally ill patients with cancer, oral problems, dry mouth
Introduction Cancer is the most frequent cause of death in Japan. About 800,000 people develop it and more than 360,000 patients die every year.1 The most important consideration in the terminal stage of cancer is how individual patients peacefully spend their final moments. Various physical and psychosocial distresses appear in this stage. Oral problems including dry mouth, stomatitis (ie, oral mucositis), and oral candidiasis develop and aggravate as the disease progresses, and the patient gradually becomes unable to eat.2-5 However, medical professionals including physicians and nurses are less interested in these problems in the palliative and terminal care of patients with cancer excluding head and neck cancers, compared to other distresses and symptoms including pain, nausea, vomiting, and fatigue, and there is no systematic intervention program aiming at solving this problem.2 Moreover, only a few studies on oral problems have been performed involving patients with cancer in a terminal care setting, excluding patients with head and neck cancers.2,3,6 Oral problems in this stage cause diverse physical, mental, and social problems, not limited to the problems in the oral cavity, and these should be resolved.7
The purpose of this study was to investigate oral problems in the terminal stage of cancer and improvement by oral care focusing on dry mouth.
Patients and Methods The study patients were consecutive terminally ill patients with cancer admitted to the Department of Palliative Medicine (palliative care unit and general ward) of Higashi Sapporo Hospital over the past 2 years (October 2011September 2013). The following 3 items were retrospectively investigated in these patients: 1.
1
The incidences of dry mouth, stomatitis, and oral candidiasis were investigated as oral problems at the time
Department of Palliative Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
Corresponding Author: Nobuhisa Nakajima, MD, PhD, 1-1, Seiryo-machi, Aoba-ku, Sendai, 9808574, Japan. Email: [email protected]
Downloaded from ajh.sagepub.com at CHINESE UNIV HONG KONG LIB on February 24, 2016
American Journal of Hospice & Palliative Medicine®
2 Table 1. Clinical Diagnosis Classification.10 Grade
Condition
0 1 2 3
Nondry (does not show condition 1-3) Saliva shows viscosity Saliva shows tiny bubbles on tongue Dry tongue without viscosity, little or no saliva shown
of admission. The patients were divided based on the status of oral food intake prior to admission into good oral intake group (oral food intake was 30% or more) and poor oral intake group (oral food intake was less than 30%) for comparison. In terminally ill patients having cancer with a limited prognosis, a decreased oral intake was frequently observed, in addition to deteriorated oral conditions. However, clear standards to classify the oral intake as good or poor were not available. When predicting the prognosis of such patients using multiple indices, including the Palliative Prognostic Score8 and the Palliative Prognostic Index (PPI),9 the oral intake was regarded as a factor influencing it. The PPI classified the oral intake into 3 levels: normal, 20 to 30% or lower, and only a few mouthfuls. Among these, 20 to 30% or lower was likely to be a borderline influencing the prognosis of terminally ill patients with cancer. Therefore, in the present study, patients were divided into ‘‘good’’ and ‘‘poor’’ groups: those whose oral intake levels were maintained at higher and lower than 30%, respectively. 2. Of the oral problems, the severity of dry mouth and complication with other oral problems (stomatitis and oral candidiasis) were investigated on admission and compared between the above 2 groups. For diagnosis of the severity of dry mouth, Kakinoki’s classification (grade 0-3) was used (Table 1).10 3. Standard oral care was performed to treat dry mouth by nursing staff of the wards. Intervention by specialist oral care team (specialist oral care) was performed as needed. Standard oral care included moisturizing, brushing, and oral cleaning (such as tongue coating removal) or oral massage performed by ward staff on a regular basis to resolve dry mouth; and pharmacotherapy to address oral candidiasis and stomatitis. Specialist oral care referred to intervention by the oral care team consisting of dentists, oral surgeons, and dental hygienists when the condition did not improve despite these standard approaches, when oral candidiasis or stomatitis was severe, or when caries treatment, denture adjustments, or the management of tumorrelated frequent hemorrhage was necessary.7,10 Improvement of dry mouth by these interventions was investigated. Whether these interventions were to be performed was comprehensively decided based on each patient’s general condition, prognosis, possibility of improvement by
Table 2. Patients’ Characteristics. Group A good Group B poor oral intake oral intake group (n ¼ 115) group (n ¼ 158) P Value Age (mean: min-max) Sex (male/female) Performance status (ECOG) 0 1 2 3 4 Primary site Esophagus Stomach Colon/rectum Liver/bile duct/ pancreas Head and neck Lung Breast Uterus/ovary Kidney/bladder Others
62.4 (42-83) 63/52
66.2 (48-89) 81/77
Characteristics of Oral Problems and Effects of Oral Care in Terminally Ill Patients With Cancer
American Journal of Hospice & Palliative Medicine® 1-5 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909116633063 ajhpm.sagepub.com
Nobuhisa Nakajima, MD, PhD1
Abstract Purpose: Various distresses appear in the terminal stage of cancer. Oral problems including dry mouth, stomatitis and candidiasis are one of the important problems which should be resolved. The purpose of this study was to investigate oral problems in this stage and improvement of dry mouth by oral care. Methods: The study subjects were consecutive terminally ill cancer patients admitted over the past 2 years. Patients were divided based on the status of oral food intake into good oral food intake group (30%) and poor oral food intake group. The following 3 items were retrospectively investigated: 1) The incidences of these oral problems, 2) Severity of dry mouth and complication with other oral problems, 3) Improvement of dry mouth using standard oral care by nursing staff and specialist oral care including dentists as needed. Results: There were 115 and 158 patients in good and poor oral intake groups, respectively. 1) The incidences of dry mouth, stomatitis, and candidiasis were significantly higher in poor oral intake group (p < 0.001). 2) Severe cases of dry mouth (Grade-2&3) were noted in 20.0% and 64.8% in good and poor oral intake groups, respectively (p < 0.0001). Candidiasis complication rate was significantly higher in poor oral intake group (p ¼ 0.0002). 3) The rate of dry mouth improvement by oral care was 100% in Grade-1, 86% in Grade-2 and 81% in Grade-3. Conclusion: Oral problems occur in many of terminally ill cancer patients. Accurate diagnosis of oral problems and corresponding appropriate interventions are important for improving quality of end-of-life care. Keywords oral care, palliative care, end-of-life care, terminally ill patients with cancer, oral problems, dry mouth
Introduction Cancer is the most frequent cause of death in Japan. About 800,000 people develop it and more than 360,000 patients die every year.1 The most important consideration in the terminal stage of cancer is how individual patients peacefully spend their final moments. Various physical and psychosocial distresses appear in this stage. Oral problems including dry mouth, stomatitis (ie, oral mucositis), and oral candidiasis develop and aggravate as the disease progresses, and the patient gradually becomes unable to eat.2-5 However, medical professionals including physicians and nurses are less interested in these problems in the palliative and terminal care of patients with cancer excluding head and neck cancers, compared to other distresses and symptoms including pain, nausea, vomiting, and fatigue, and there is no systematic intervention program aiming at solving this problem.2 Moreover, only a few studies on oral problems have been performed involving patients with cancer in a terminal care setting, excluding patients with head and neck cancers.2,3,6 Oral problems in this stage cause diverse physical, mental, and social problems, not limited to the problems in the oral cavity, and these should be resolved.7
The purpose of this study was to investigate oral problems in the terminal stage of cancer and improvement by oral care focusing on dry mouth.
Patients and Methods The study patients were consecutive terminally ill patients with cancer admitted to the Department of Palliative Medicine (palliative care unit and general ward) of Higashi Sapporo Hospital over the past 2 years (October 2011September 2013). The following 3 items were retrospectively investigated in these patients: 1.
1
The incidences of dry mouth, stomatitis, and oral candidiasis were investigated as oral problems at the time
Department of Palliative Medicine, Graduate School of Medicine, Tohoku University, Sendai, Japan
Corresponding Author: Nobuhisa Nakajima, MD, PhD, 1-1, Seiryo-machi, Aoba-ku, Sendai, 9808574, Japan. Email: [email protected]
Downloaded from ajh.sagepub.com at CHINESE UNIV HONG KONG LIB on February 24, 2016
American Journal of Hospice & Palliative Medicine®
2 Table 1. Clinical Diagnosis Classification.10 Grade
Condition
0 1 2 3
Nondry (does not show condition 1-3) Saliva shows viscosity Saliva shows tiny bubbles on tongue Dry tongue without viscosity, little or no saliva shown
of admission. The patients were divided based on the status of oral food intake prior to admission into good oral intake group (oral food intake was 30% or more) and poor oral intake group (oral food intake was less than 30%) for comparison. In terminally ill patients having cancer with a limited prognosis, a decreased oral intake was frequently observed, in addition to deteriorated oral conditions. However, clear standards to classify the oral intake as good or poor were not available. When predicting the prognosis of such patients using multiple indices, including the Palliative Prognostic Score8 and the Palliative Prognostic Index (PPI),9 the oral intake was regarded as a factor influencing it. The PPI classified the oral intake into 3 levels: normal, 20 to 30% or lower, and only a few mouthfuls. Among these, 20 to 30% or lower was likely to be a borderline influencing the prognosis of terminally ill patients with cancer. Therefore, in the present study, patients were divided into ‘‘good’’ and ‘‘poor’’ groups: those whose oral intake levels were maintained at higher and lower than 30%, respectively. 2. Of the oral problems, the severity of dry mouth and complication with other oral problems (stomatitis and oral candidiasis) were investigated on admission and compared between the above 2 groups. For diagnosis of the severity of dry mouth, Kakinoki’s classification (grade 0-3) was used (Table 1).10 3. Standard oral care was performed to treat dry mouth by nursing staff of the wards. Intervention by specialist oral care team (specialist oral care) was performed as needed. Standard oral care included moisturizing, brushing, and oral cleaning (such as tongue coating removal) or oral massage performed by ward staff on a regular basis to resolve dry mouth; and pharmacotherapy to address oral candidiasis and stomatitis. Specialist oral care referred to intervention by the oral care team consisting of dentists, oral surgeons, and dental hygienists when the condition did not improve despite these standard approaches, when oral candidiasis or stomatitis was severe, or when caries treatment, denture adjustments, or the management of tumorrelated frequent hemorrhage was necessary.7,10 Improvement of dry mouth by these interventions was investigated. Whether these interventions were to be performed was comprehensively decided based on each patient’s general condition, prognosis, possibility of improvement by
Table 2. Patients’ Characteristics. Group A good Group B poor oral intake oral intake group (n ¼ 115) group (n ¼ 158) P Value Age (mean: min-max) Sex (male/female) Performance status (ECOG) 0 1 2 3 4 Primary site Esophagus Stomach Colon/rectum Liver/bile duct/ pancreas Head and neck Lung Breast Uterus/ovary Kidney/bladder Others
62.4 (42-83) 63/52
66.2 (48-89) 81/77
