.................... ARTICLE
.........................................
Michael J. Aldred BDS, PhD, FDS RCS, MRCPath; Martin Addy BDS, MSc, PhD, FDS RCS; Jeremy Bagg BDS, PhD, FDS RCS, MRCPath; llora Finlay MB BS, MRCS, LRCP, MRCGP, DRCOG, DCH
Oral health in the terminally ill: a cross-sectional pilot survey This study of 20 hospice patients provided baseline information on oral and dental status in the terminally ill. For each patient, a questionnaire was completed, the mouth was examined, and an oral rinse and imprint cultures were collected to establish the prevalence and intra-oral density of yeasts, staphylococci and coliforms. Oral symptoms reported included disturbance of taste (26%),dysphagia (37%),soreness (42%),and dryness (58%).Of the 75%who wore dentures, 71% had difficulty with their prosthesis (es). A clinical diagnosis of oral candidiasis was made in 70%of subjects. The high prevalence of oral symptoms, denture problems, and candidiasis clearly affect the quality of remaining life in terminally ill patients.
erminally ill patients may have a number of signs and symptoms related to the mouth. These include mucosal soreness and ulceration, candidiasis, glossitis, and xerostomia.' Such conditions may seriously reduce the quality of remaining life for these patients, but few published studies have addressed the problem. Candidal carriage is higher in terminally ill people than in healthy subjects and acute pseudomembranous candidiasis is more commonly diagnosed in the ill population than in ~ontrols,2-~ but further information is required before the effects of standardized treatment regimes can be accurately assessed. This study gathered baseline information about oral signs, symptoms, and microbiology from a group of terminally ill patients. These data were analyzed and used in planning definitive studies to assess the value of specific treatment items for mouth care in the terminally ill.
Methods and materials Twenty patients with terminal illness were studied in this ethically approved investigation. The patients were all suffering from advanced malignant disease and formed, therefore, a homogeneous group. Patients with other forms of life-threatening pathology such as AIDS or cardiac disease were not included. All the individuals studied were inpatients at the Holme Tower Marie Curie Home, Penarth, South Glamorgan, Wales, UK, a hospice dedicated to the care of those dying from cancer. The study group was chosen at random from the patients resident at the time of visits to the hospice, with the exception of those who were
too ill to cooperate at all. Thus, three to five patient records were blindly chosen from those available on the ward at the beginning of each visit. The study period was five evenings arbitrarily chosen in the hope of providing a representative cross-section of in-patients in the hospice. Collection of clinical information
A standard form was completed for each patient. The diagnosis, previous medical and drug histories were obtained from the medical records. These were entered on the first part of the form, together with the smoking history. All other information was gained through interview of each patient by two of the authors (MJA,MA). The second section of the form was concerned with symptoms and made reference to disturbance of taste; dysphagia; oral soreness; dryness of the mouth; difficulty in wearing dentures; and any other miscellaneous problems offered by the patient. A third component of the survey dealt with clinical signs. Patients' mouths were examined by two of the authors (MJA,MA) with a dental mirror and probe under fiber optic light illumination. Each of the two clinicians performed separate parts of the examination for all patients, rendering controls for inter-examiner variability unnecessary. Both examining clinicians were experienced in their respective specialties of oral medicine (MIA) and periodontology (MA) and were adjudged reliable. Measurement of salivary flow rates was deemed inappropriate in view of the general condition of the participants, with reliance being based on clinical experience for its assessment.
Special Care in Dentistry, Vol 11 No 2 1991 59
However, mouth dryness was only ascribed to the extreme situations, in that there was an almost total lack of saliva at any site in the mouth. The following information was recorded: edentulous/teeth present/ partial denture; presence of dental caries (decayed teeth); oral hygiene using the criteria of the Debris Index' recorded from the buccal surfaces of all teeth present; gingivitis based on gingival inflammation: graded as no or minimal inflammation, mild gingivitis, moderate gingivitis, or severe gingivitis; xerostomia; mucosal abnormalities; and denture type and quality of fit (good, moderate, poor). For the latter, good fit implied that the dentures were well adapted to the tissues or adjacent teeth and not readily displaced by the examining clinician. Dentures that appeared well adapted to tissues or adjacent teeth but were easily displaced by the examining clinician were graded as a moderate fit, while those that became spontaneously displaced when the mouth was opened were described as a poor fit. Four final questions inquired after the measures used by patients to clean their teeth and/or dentures, whether dentures were worn at night, and whether they had difficulty wearing their dentures. Microbiological methods
incubated at 37°C for 48 hours aerobically, with added 5%CO, for the TYCSB plates. Counts of the relevant organisms were made. Yeasts were identified on the basis of germ tube tests, formation of hyphae and chlamydospores and carbohydrate assimilation tests (Minitek, BBL Microbiology Systems, Becton Dickinson). Staphylococcus aureus was identified by means of the Staphaurex test (Wellcome Diagnostics), which detects the presence of coagulase and protein A. Coagulase negative staphylococci were tested for novobiocin resistance. All coliforms were identified using the Analytical Profile Index (API 20E, API Laboratory Products). Streptococcus mutans was identified by its characteristic colonial morphology on TYCSB medium. For patients who had clinical evidence of an intra-oral candidal infection, imprint culturesHwere taken from affected sites, and for all patients an imprint culture was taken from the posterior dorsum of the tongue. Any yeasts recovered were counted and the isolates identified as described earlier.
Results Study group
five of the patients (26%)were completely free of oral symptoms and the mean number of symptoms for the remainder was 2.2. Denture status
Details of the types of dentures worn by members of the study group, and of their denture wearing habits, are summarized (Table 2). Fifteen (75%)of the patients wore dentures, of whom 71% reported some difficulty in wearing their prosthesis(es). Dentures were worn overnight by 60% of the patients while 60% of the dentures were considered to be clinically unsatisfactory by the examining clinician. The age of the dentures varied from 4 months to 40 years, with a mean age of 16.5 years. Many of the patients wearing dentures considered there had been a deterioration in fit since the onset of their terminal illness. Dental and gingival status
Ten (50%)of the study group had some of their natural teeth remaining. The mean oral hygiene index, scored on a scale of 0-3, was 1.97, and all the patients exhibited some degree of gingival inflammation. Active caries was detected in only two of the partially dentate group.
Details of the 20 patients studied are shown (Table 1).Thirteen of the patients were male and seven were feSoft tissue abnormalities male, with ages ranging from 51 to 83 Pathological changes in the oral muVears (mean age 70.3 vears). Seven of cosa and at the commissures were dethe patients were tobacco smokers, three were ex-smokers and Seven were nonsmokers' A Table 1.Personal details, smoking history, and smoking history was not resymptoms of the study population corded for three of the pa13:7 tients. All of the patients were Male to female ratio taking personalized cocktails M~~~ age 70.3 years of drugs including narcotic 51-83 years Age range analgesics (predominantly 7 (41%) morphine sulphate), Number of smokers 7 (41%) dexamethasone, anti-emetics, Number of nonsmokers and anti-depressants. Number of ex-smokers 3 (lS%J Y
The concentrated rinse culture method6 was used to sample the oral flora. Each patient was asked to rinse the mouth for 30 seconds with 10 mL of sterile phosphate buffered saline (PBS) (pH 7.2) and to expectorate the washing. These specimens were stored for no longer than 14 hours at 4" C before being processed in the laboratory. The rinses were centrifuged at 1,700 8 for 10 minutes, the supernatant discarded and the pellet resuspended in 1 mL of PBS. A spiral plater (Don Whitley Scientific) was used to inoculate the concentrated rinses onto individual plates of Sabouraud dextrose agar (Oxoid) for yeasts, mannitol-salt agar (Oxoid) for staphylococci, MacConkey agar (Oxoid) for coliforms and tryptone, yeast extract, cystine, sucrose, bacitracin (TYCSB)agar7for Streptococcus mutans. All plates were
60 Special Care in Dentistry, Vol 11No 2 1991
Oral symptoms The oral symptoms de-
scribed by the patients are shown l).The . symp. . toms reported included disturbance of taste (26%), dysphagia (37%),soreness of the oral mucosa (42%),and intra-oral dryness (58%).Only ~
Smoking history not recorded Number with taste disturbance' Number with dysphagia' Number with mucosal soreness* Number with oral dryness' *
3 5 (26%)
7 (37%) 8 (42%) 11 (58%)
Presence or absencc of these symptoms could not he established for one patient. The percentages are, thereforc, based on a total of 19 responscs.
Table 2. The dental status, denture-wearing habits, and gingival condition of the study population
Previous studies at the about the relationship between oral symptoms and candidiasis, the regular University of Wales College use of antifungal medication would of Medicine Dental School Number of edentulous patients 10 ( 5 0 % ) seem appropriate. have shown carrier rates for Mean number of teeth in dentate 15 In earlier studies of patients with Candida albicans in the individuals terminal illness, xerostomia has been mouths of healthy dentate reported as a frequent symptom.’-4 subjects of 29.6% by salivary Number of denture wearers 15 (75%) samples and 44.4% by imDrug-induced xerostomia would cer10 (71YO) Number of denture wearers having tainly be anticipated in this group of print cultures.’”These figures difficulty with dentures increased to 44.4% and 55.6% patients. Of those examined, 58% comNumber wearing dentures overnight 9 (60%) for the respective sampling plained of oral dryness, though the inMean age of dentures 16.5 years methods in healthy complete vestigators did not think that frank Age range of dentures 4 mos.-40 yrs denture wearers.*In the xerostomia was a common feature of present study of terminally ill the patients when examined clinically. Numher of clinically unsatisfactory 9 (40%) patients, the high rate of isoAnalysis of the denture problems dentures lation of Candida s p p (79%), experienced by the 15 denture wearers Prevalence of gingivitis in those with 100% and clinical evidence of oral in the study showed an area of signifisome remaining teeth candidiasis in 70% of those cant treatment need, in agreement ’ This could not be cstablishcd for one patient. Thc with the findings of Gordon and examined confirm work by percentage is, thcreforc, based on 14 responses other author^.^-^ Although others.’The majority of the dentures were old and poorly fitting which, tothere is some disagreement tected in 15 (75%)of the patients (Table Table 3. Pathological changes of the oral mucosa in the study population 3). A clinical diagnosis of oral candidiasis was made tentatively in 70% Study number Oral mucosa and commissures Tongue of patients. 1 Microbiology 2 The pattern of isolation of yeasts, Erythema of labial mucosa Erythema and 3 staphylococci,coliforms and S. mutans depapillation is summarized (Table 4). The yeast isoErythema of buccal mucosa Cobblestone tongue 4 lation rate was 79% by both imprint with depapillation Denture stomatitis and thrush culture and concentrated oral rinse Plaque on posterior palate technique. All of the yeast isolates 5 were identified as Candida albicans, Mild trauma in occlusal plane 6 with the single exception of that from 7 Median rhomboid one patient, which was an glossitis ascosporeforming organism, identified Cobblestone tongue 8 as either Pichia pijperilquercum or with depapillation Hansensiaspora uz~arum.Staphylococci Debris on palate 9 were isolated from 50% of mouths sampled and, with the exception of Angular cheilitis R>L 10 isolates from two of the patients, were 11 Mucosal plaques all coagulase positive. Coliforms were 12 Angular cheilitis R>L detected in 47% of mouths sampled. Thrush - soft palate and buccal 13 Thrush The identities of these isolates are mucosa. Denture trauma shown (Table 4). Streptococcus mutans lower ridge and posterior palate was identified in nine (47%)of the patients and Sfreptococcus sobrinus in one 14 patient (5%). 15 Debris ++ on palate 16 Discussion Minor trauma from mandibular 17 Atrophic glossitis Three quarters of the patients examdenture ined complained of at least one oral Thrush - soft palate and buccal 18 symptom, indicating a high prevalence mucosa. Debris ++ of oral signs and symptoms among patients with terminal illness. This findThrush - R and L buccal mucosa 19 ing is in keeping with two previous re20 ports’r2which stressed the importance of mouth care in such patients. - No clinical abnormality detected.
Special Care in Dentistry, Vol 11 No 2 1991 61
ill patients in the current study. An increased prevaMicroorganism Isolation rate lence of coliforms has also been reported in the oral Yeasts 79 Yo flora of patients on cytotoxic Staphylococci 50% therapy for malignant disColiforms 47% ease," in patients who have Enterobacter cloacae 2 isolates received radiotherapy for Serratia marcescens 2 isolates oral and laryngeal cancer,I2 Klebsiella pneumoniae 1 isolate and in patients with acute ssp pneumoniae leukemia,13where their imAcinetobacter calcoaceticus 1 isolate portance as a potential var anitratus source of systemic infection Klebsiella oxytoca 1 isolate has been implied. Escherichia coli 1 isolate The role of such coloniza47% Streptococcus mutans tion in causing oral mucosal signs and symptoms is unclear and merits further investigation. gether with loss of bulk of the facial Evidence suggests that primary colonimusculature, resulted in significant zation of mucosal surfaces by colifproblems of retention and stability. orms promotes subsequent yeast coloThe value of rapid chairside relining nization14and may therefore be of materials for use in these circumstances seems worthy of investigation. indirect importance in candidiasis, although no clear relationship was eviDespite professional recognition of the importance of leaving dentures out dent in the current study. The identities of the coliforms isolated were at night, 60% of the denture wearers similar to those detected among the wore their prostheses continuously. The value of leaving dentures in a den- oral flora of patients with acute leukemia,13 possibly reflecting a similar ture cleaner overnight should be exmechanism for the reduction of coloniplained to such patients, particularly zation resistance in these two groups in view of their high rate of candidal of seriously ill patients. carriage and candidiasis. Although radiographs were not Conclusion taken, untreated dental caries did not The oral problems experienced by appear to be a significant problem. terminally ill patients clearly affect This is in contrast to an earlier study' their quality of remaining life. Attenthat reported an average of 3.5 teeth tion to relatively small details includwith untreated caries in each member ing the relining and cleaning of denof the study group. However, all the tures, introduction of procedures to patients with some remaining teeth moisten the oral mucosa, improvehad a degree of gingivitis, and would ments in oral hygiene practices, and benefit from simple measures to imreduction of the microbial load of the prove oral hygiene. Similarly, meamouth may significantly reduce oral sures to improve denture hygiene symptoms. In light of the information would be most appropriate. Pathological changes of the oral mu- gained from this study, which indicates that many terminally ill patients cosa were evident clinically in a high suffer from substantial oral and dental proportion of the patients examined. problems, investigation is now underMany of these abnormalities could be way to evaluate the effectiveness of diagnosed as candidal in origin. Both specific mouth care regimes among coliforms and staphylococci are conterminally ill patients. sidered to be transient oral colonizers under normal conditions. The prevaThe authors thank Mrs. J. Garratt for her lence of oral coliform carriage in a invaluable laboratory assistance and Dr. C.M. group of healthy adults (median age Philpott for her help with the yeast identifica62 years) has been reported as 12%"' tions. compared with 47% of the terminally Table 4. Summary of microbiological data
~~
~~
62 Special Care in Dentistry, Vol 11No 2 1991
~
Dr. Aldred is lecturer, oral pathology; Dr. Addy is professor, periodontology; Dr. Bagg is lecturer, oral medicine and oral pathology, Dental School, University of Wales College of Medicine, Heath Park, Cardiff, CF4 4XY, Wales UK. Dr. Finlay is medical director, Holme Tower Marie Curie Home, Penarth, Cardiff, Wales, UK. Address requests for reprints to Dr. Addy. 1. Gordon SR, Berkey DB, Call RL. Dental need among hospice patients in Colorado: A pilot study. Gerodontics 1985;l: 125-9. 2. Finlay IG. Oral symptoms and candida in the terminally ill. Br Med J 1986;292:592-3. 3. Pople J, Oliver D. Oral thrush in hospice patients. Nurs Times 3986;82:34-5. 4 Clarke JMG, Wilson JA, von Haacke NP, Milne LJR. Oral candidiasis in terminal illness. Health Bull (Edinb) 1987;45:268-71. 5 Greene JC, Vermillion JR . The oral hygiene index : a method of classifying oral hygiene status. JADA 1960;61:172-9. 6 Samaranayake LP, MacFarlane TW, Lamey PJ, Ferguson MM. A comparison of oral rinse and imprint sampling techniques for the detection of yeast, coliform and Stnphylococcus aurcus carriage in the oral cavity. J Oral Pathol 1986;15:386-8. 7 Wade WG, Aldred MJ, Walker DM. An improved medium for isolation of StuqJtococcus ttititans. J Med Microbiol 1986;22:31923. 8 Arendorf TM, Walker DM. Oral candidal populations in health and disease. Br Dent J 1979;147:267-72. 9 Arendorf TM, Walker DM. The prevalence and intra-oral distribution of Cnrididn nlhicaris in man. Arch Oral Biol 1980;25:1-10. 10 Samaranayake LP, Lamb AB, Lamey PJ, MacFarlane TW. Oral carriage of Carididn species and coliforms in patients with burning mouth syndrome. J Oral Pathol Med 1989;18:233-5. 11 Samaranayake LP, Calman KC, Ferguson MM, Kaye SB, MacFarlane TW, Main B, Welsh J, Willox J. The oral carriage of yeasts and coliforms in patients on cytotoxic therapy. J Oral Pathol 1984;13:390-3. 12 Martin MV, Al-Tikriti U, Bramley P. Yeast flora of the mouth and skin during and after irradiation for oral and laryngeal cancer. J Med Microbiol 1981;14:457-61. 13 Wahlin YB, Holm AK. Changes in the oral microflora in patients with acute leukaemia and related disorders during the period of induction therapy. Oral Surg Oral Med Oral Pathol 1988;65:411-7. 14 Centeno A, Davies CP, Cohen MS, Warren MM. Modulation of Gzrididn nlhicnris attachment to human epithelial cells by bacteria and carbohydrates. Infect lmmun 1983;39:1354-9.
.........................................
Michael J. Aldred BDS, PhD, FDS RCS, MRCPath; Martin Addy BDS, MSc, PhD, FDS RCS; Jeremy Bagg BDS, PhD, FDS RCS, MRCPath; llora Finlay MB BS, MRCS, LRCP, MRCGP, DRCOG, DCH
Oral health in the terminally ill: a cross-sectional pilot survey This study of 20 hospice patients provided baseline information on oral and dental status in the terminally ill. For each patient, a questionnaire was completed, the mouth was examined, and an oral rinse and imprint cultures were collected to establish the prevalence and intra-oral density of yeasts, staphylococci and coliforms. Oral symptoms reported included disturbance of taste (26%),dysphagia (37%),soreness (42%),and dryness (58%).Of the 75%who wore dentures, 71% had difficulty with their prosthesis (es). A clinical diagnosis of oral candidiasis was made in 70%of subjects. The high prevalence of oral symptoms, denture problems, and candidiasis clearly affect the quality of remaining life in terminally ill patients.
erminally ill patients may have a number of signs and symptoms related to the mouth. These include mucosal soreness and ulceration, candidiasis, glossitis, and xerostomia.' Such conditions may seriously reduce the quality of remaining life for these patients, but few published studies have addressed the problem. Candidal carriage is higher in terminally ill people than in healthy subjects and acute pseudomembranous candidiasis is more commonly diagnosed in the ill population than in ~ontrols,2-~ but further information is required before the effects of standardized treatment regimes can be accurately assessed. This study gathered baseline information about oral signs, symptoms, and microbiology from a group of terminally ill patients. These data were analyzed and used in planning definitive studies to assess the value of specific treatment items for mouth care in the terminally ill.
Methods and materials Twenty patients with terminal illness were studied in this ethically approved investigation. The patients were all suffering from advanced malignant disease and formed, therefore, a homogeneous group. Patients with other forms of life-threatening pathology such as AIDS or cardiac disease were not included. All the individuals studied were inpatients at the Holme Tower Marie Curie Home, Penarth, South Glamorgan, Wales, UK, a hospice dedicated to the care of those dying from cancer. The study group was chosen at random from the patients resident at the time of visits to the hospice, with the exception of those who were
too ill to cooperate at all. Thus, three to five patient records were blindly chosen from those available on the ward at the beginning of each visit. The study period was five evenings arbitrarily chosen in the hope of providing a representative cross-section of in-patients in the hospice. Collection of clinical information
A standard form was completed for each patient. The diagnosis, previous medical and drug histories were obtained from the medical records. These were entered on the first part of the form, together with the smoking history. All other information was gained through interview of each patient by two of the authors (MJA,MA). The second section of the form was concerned with symptoms and made reference to disturbance of taste; dysphagia; oral soreness; dryness of the mouth; difficulty in wearing dentures; and any other miscellaneous problems offered by the patient. A third component of the survey dealt with clinical signs. Patients' mouths were examined by two of the authors (MJA,MA) with a dental mirror and probe under fiber optic light illumination. Each of the two clinicians performed separate parts of the examination for all patients, rendering controls for inter-examiner variability unnecessary. Both examining clinicians were experienced in their respective specialties of oral medicine (MIA) and periodontology (MA) and were adjudged reliable. Measurement of salivary flow rates was deemed inappropriate in view of the general condition of the participants, with reliance being based on clinical experience for its assessment.
Special Care in Dentistry, Vol 11 No 2 1991 59
However, mouth dryness was only ascribed to the extreme situations, in that there was an almost total lack of saliva at any site in the mouth. The following information was recorded: edentulous/teeth present/ partial denture; presence of dental caries (decayed teeth); oral hygiene using the criteria of the Debris Index' recorded from the buccal surfaces of all teeth present; gingivitis based on gingival inflammation: graded as no or minimal inflammation, mild gingivitis, moderate gingivitis, or severe gingivitis; xerostomia; mucosal abnormalities; and denture type and quality of fit (good, moderate, poor). For the latter, good fit implied that the dentures were well adapted to the tissues or adjacent teeth and not readily displaced by the examining clinician. Dentures that appeared well adapted to tissues or adjacent teeth but were easily displaced by the examining clinician were graded as a moderate fit, while those that became spontaneously displaced when the mouth was opened were described as a poor fit. Four final questions inquired after the measures used by patients to clean their teeth and/or dentures, whether dentures were worn at night, and whether they had difficulty wearing their dentures. Microbiological methods
incubated at 37°C for 48 hours aerobically, with added 5%CO, for the TYCSB plates. Counts of the relevant organisms were made. Yeasts were identified on the basis of germ tube tests, formation of hyphae and chlamydospores and carbohydrate assimilation tests (Minitek, BBL Microbiology Systems, Becton Dickinson). Staphylococcus aureus was identified by means of the Staphaurex test (Wellcome Diagnostics), which detects the presence of coagulase and protein A. Coagulase negative staphylococci were tested for novobiocin resistance. All coliforms were identified using the Analytical Profile Index (API 20E, API Laboratory Products). Streptococcus mutans was identified by its characteristic colonial morphology on TYCSB medium. For patients who had clinical evidence of an intra-oral candidal infection, imprint culturesHwere taken from affected sites, and for all patients an imprint culture was taken from the posterior dorsum of the tongue. Any yeasts recovered were counted and the isolates identified as described earlier.
Results Study group
five of the patients (26%)were completely free of oral symptoms and the mean number of symptoms for the remainder was 2.2. Denture status
Details of the types of dentures worn by members of the study group, and of their denture wearing habits, are summarized (Table 2). Fifteen (75%)of the patients wore dentures, of whom 71% reported some difficulty in wearing their prosthesis(es). Dentures were worn overnight by 60% of the patients while 60% of the dentures were considered to be clinically unsatisfactory by the examining clinician. The age of the dentures varied from 4 months to 40 years, with a mean age of 16.5 years. Many of the patients wearing dentures considered there had been a deterioration in fit since the onset of their terminal illness. Dental and gingival status
Ten (50%)of the study group had some of their natural teeth remaining. The mean oral hygiene index, scored on a scale of 0-3, was 1.97, and all the patients exhibited some degree of gingival inflammation. Active caries was detected in only two of the partially dentate group.
Details of the 20 patients studied are shown (Table 1).Thirteen of the patients were male and seven were feSoft tissue abnormalities male, with ages ranging from 51 to 83 Pathological changes in the oral muVears (mean age 70.3 vears). Seven of cosa and at the commissures were dethe patients were tobacco smokers, three were ex-smokers and Seven were nonsmokers' A Table 1.Personal details, smoking history, and smoking history was not resymptoms of the study population corded for three of the pa13:7 tients. All of the patients were Male to female ratio taking personalized cocktails M~~~ age 70.3 years of drugs including narcotic 51-83 years Age range analgesics (predominantly 7 (41%) morphine sulphate), Number of smokers 7 (41%) dexamethasone, anti-emetics, Number of nonsmokers and anti-depressants. Number of ex-smokers 3 (lS%J Y
The concentrated rinse culture method6 was used to sample the oral flora. Each patient was asked to rinse the mouth for 30 seconds with 10 mL of sterile phosphate buffered saline (PBS) (pH 7.2) and to expectorate the washing. These specimens were stored for no longer than 14 hours at 4" C before being processed in the laboratory. The rinses were centrifuged at 1,700 8 for 10 minutes, the supernatant discarded and the pellet resuspended in 1 mL of PBS. A spiral plater (Don Whitley Scientific) was used to inoculate the concentrated rinses onto individual plates of Sabouraud dextrose agar (Oxoid) for yeasts, mannitol-salt agar (Oxoid) for staphylococci, MacConkey agar (Oxoid) for coliforms and tryptone, yeast extract, cystine, sucrose, bacitracin (TYCSB)agar7for Streptococcus mutans. All plates were
60 Special Care in Dentistry, Vol 11No 2 1991
Oral symptoms The oral symptoms de-
scribed by the patients are shown l).The . symp. . toms reported included disturbance of taste (26%), dysphagia (37%),soreness of the oral mucosa (42%),and intra-oral dryness (58%).Only ~
Smoking history not recorded Number with taste disturbance' Number with dysphagia' Number with mucosal soreness* Number with oral dryness' *
3 5 (26%)
7 (37%) 8 (42%) 11 (58%)
Presence or absencc of these symptoms could not he established for one patient. The percentages are, thereforc, based on a total of 19 responscs.
Table 2. The dental status, denture-wearing habits, and gingival condition of the study population
Previous studies at the about the relationship between oral symptoms and candidiasis, the regular University of Wales College use of antifungal medication would of Medicine Dental School Number of edentulous patients 10 ( 5 0 % ) seem appropriate. have shown carrier rates for Mean number of teeth in dentate 15 In earlier studies of patients with Candida albicans in the individuals terminal illness, xerostomia has been mouths of healthy dentate reported as a frequent symptom.’-4 subjects of 29.6% by salivary Number of denture wearers 15 (75%) samples and 44.4% by imDrug-induced xerostomia would cer10 (71YO) Number of denture wearers having tainly be anticipated in this group of print cultures.’”These figures difficulty with dentures increased to 44.4% and 55.6% patients. Of those examined, 58% comNumber wearing dentures overnight 9 (60%) for the respective sampling plained of oral dryness, though the inMean age of dentures 16.5 years methods in healthy complete vestigators did not think that frank Age range of dentures 4 mos.-40 yrs denture wearers.*In the xerostomia was a common feature of present study of terminally ill the patients when examined clinically. Numher of clinically unsatisfactory 9 (40%) patients, the high rate of isoAnalysis of the denture problems dentures lation of Candida s p p (79%), experienced by the 15 denture wearers Prevalence of gingivitis in those with 100% and clinical evidence of oral in the study showed an area of signifisome remaining teeth candidiasis in 70% of those cant treatment need, in agreement ’ This could not be cstablishcd for one patient. Thc with the findings of Gordon and examined confirm work by percentage is, thcreforc, based on 14 responses other author^.^-^ Although others.’The majority of the dentures were old and poorly fitting which, tothere is some disagreement tected in 15 (75%)of the patients (Table Table 3. Pathological changes of the oral mucosa in the study population 3). A clinical diagnosis of oral candidiasis was made tentatively in 70% Study number Oral mucosa and commissures Tongue of patients. 1 Microbiology 2 The pattern of isolation of yeasts, Erythema of labial mucosa Erythema and 3 staphylococci,coliforms and S. mutans depapillation is summarized (Table 4). The yeast isoErythema of buccal mucosa Cobblestone tongue 4 lation rate was 79% by both imprint with depapillation Denture stomatitis and thrush culture and concentrated oral rinse Plaque on posterior palate technique. All of the yeast isolates 5 were identified as Candida albicans, Mild trauma in occlusal plane 6 with the single exception of that from 7 Median rhomboid one patient, which was an glossitis ascosporeforming organism, identified Cobblestone tongue 8 as either Pichia pijperilquercum or with depapillation Hansensiaspora uz~arum.Staphylococci Debris on palate 9 were isolated from 50% of mouths sampled and, with the exception of Angular cheilitis R>L 10 isolates from two of the patients, were 11 Mucosal plaques all coagulase positive. Coliforms were 12 Angular cheilitis R>L detected in 47% of mouths sampled. Thrush - soft palate and buccal 13 Thrush The identities of these isolates are mucosa. Denture trauma shown (Table 4). Streptococcus mutans lower ridge and posterior palate was identified in nine (47%)of the patients and Sfreptococcus sobrinus in one 14 patient (5%). 15 Debris ++ on palate 16 Discussion Minor trauma from mandibular 17 Atrophic glossitis Three quarters of the patients examdenture ined complained of at least one oral Thrush - soft palate and buccal 18 symptom, indicating a high prevalence mucosa. Debris ++ of oral signs and symptoms among patients with terminal illness. This findThrush - R and L buccal mucosa 19 ing is in keeping with two previous re20 ports’r2which stressed the importance of mouth care in such patients. - No clinical abnormality detected.
Special Care in Dentistry, Vol 11 No 2 1991 61
ill patients in the current study. An increased prevaMicroorganism Isolation rate lence of coliforms has also been reported in the oral Yeasts 79 Yo flora of patients on cytotoxic Staphylococci 50% therapy for malignant disColiforms 47% ease," in patients who have Enterobacter cloacae 2 isolates received radiotherapy for Serratia marcescens 2 isolates oral and laryngeal cancer,I2 Klebsiella pneumoniae 1 isolate and in patients with acute ssp pneumoniae leukemia,13where their imAcinetobacter calcoaceticus 1 isolate portance as a potential var anitratus source of systemic infection Klebsiella oxytoca 1 isolate has been implied. Escherichia coli 1 isolate The role of such coloniza47% Streptococcus mutans tion in causing oral mucosal signs and symptoms is unclear and merits further investigation. gether with loss of bulk of the facial Evidence suggests that primary colonimusculature, resulted in significant zation of mucosal surfaces by colifproblems of retention and stability. orms promotes subsequent yeast coloThe value of rapid chairside relining nization14and may therefore be of materials for use in these circumstances seems worthy of investigation. indirect importance in candidiasis, although no clear relationship was eviDespite professional recognition of the importance of leaving dentures out dent in the current study. The identities of the coliforms isolated were at night, 60% of the denture wearers similar to those detected among the wore their prostheses continuously. The value of leaving dentures in a den- oral flora of patients with acute leukemia,13 possibly reflecting a similar ture cleaner overnight should be exmechanism for the reduction of coloniplained to such patients, particularly zation resistance in these two groups in view of their high rate of candidal of seriously ill patients. carriage and candidiasis. Although radiographs were not Conclusion taken, untreated dental caries did not The oral problems experienced by appear to be a significant problem. terminally ill patients clearly affect This is in contrast to an earlier study' their quality of remaining life. Attenthat reported an average of 3.5 teeth tion to relatively small details includwith untreated caries in each member ing the relining and cleaning of denof the study group. However, all the tures, introduction of procedures to patients with some remaining teeth moisten the oral mucosa, improvehad a degree of gingivitis, and would ments in oral hygiene practices, and benefit from simple measures to imreduction of the microbial load of the prove oral hygiene. Similarly, meamouth may significantly reduce oral sures to improve denture hygiene symptoms. In light of the information would be most appropriate. Pathological changes of the oral mu- gained from this study, which indicates that many terminally ill patients cosa were evident clinically in a high suffer from substantial oral and dental proportion of the patients examined. problems, investigation is now underMany of these abnormalities could be way to evaluate the effectiveness of diagnosed as candidal in origin. Both specific mouth care regimes among coliforms and staphylococci are conterminally ill patients. sidered to be transient oral colonizers under normal conditions. The prevaThe authors thank Mrs. J. Garratt for her lence of oral coliform carriage in a invaluable laboratory assistance and Dr. C.M. group of healthy adults (median age Philpott for her help with the yeast identifica62 years) has been reported as 12%"' tions. compared with 47% of the terminally Table 4. Summary of microbiological data
~~
~~
62 Special Care in Dentistry, Vol 11No 2 1991
~
Dr. Aldred is lecturer, oral pathology; Dr. Addy is professor, periodontology; Dr. Bagg is lecturer, oral medicine and oral pathology, Dental School, University of Wales College of Medicine, Heath Park, Cardiff, CF4 4XY, Wales UK. Dr. Finlay is medical director, Holme Tower Marie Curie Home, Penarth, Cardiff, Wales, UK. Address requests for reprints to Dr. Addy. 1. Gordon SR, Berkey DB, Call RL. Dental need among hospice patients in Colorado: A pilot study. Gerodontics 1985;l: 125-9. 2. Finlay IG. Oral symptoms and candida in the terminally ill. Br Med J 1986;292:592-3. 3. Pople J, Oliver D. Oral thrush in hospice patients. Nurs Times 3986;82:34-5. 4 Clarke JMG, Wilson JA, von Haacke NP, Milne LJR. Oral candidiasis in terminal illness. Health Bull (Edinb) 1987;45:268-71. 5 Greene JC, Vermillion JR . The oral hygiene index : a method of classifying oral hygiene status. JADA 1960;61:172-9. 6 Samaranayake LP, MacFarlane TW, Lamey PJ, Ferguson MM. A comparison of oral rinse and imprint sampling techniques for the detection of yeast, coliform and Stnphylococcus aurcus carriage in the oral cavity. J Oral Pathol 1986;15:386-8. 7 Wade WG, Aldred MJ, Walker DM. An improved medium for isolation of StuqJtococcus ttititans. J Med Microbiol 1986;22:31923. 8 Arendorf TM, Walker DM. Oral candidal populations in health and disease. Br Dent J 1979;147:267-72. 9 Arendorf TM, Walker DM. The prevalence and intra-oral distribution of Cnrididn nlhicaris in man. Arch Oral Biol 1980;25:1-10. 10 Samaranayake LP, Lamb AB, Lamey PJ, MacFarlane TW. Oral carriage of Carididn species and coliforms in patients with burning mouth syndrome. J Oral Pathol Med 1989;18:233-5. 11 Samaranayake LP, Calman KC, Ferguson MM, Kaye SB, MacFarlane TW, Main B, Welsh J, Willox J. The oral carriage of yeasts and coliforms in patients on cytotoxic therapy. J Oral Pathol 1984;13:390-3. 12 Martin MV, Al-Tikriti U, Bramley P. Yeast flora of the mouth and skin during and after irradiation for oral and laryngeal cancer. J Med Microbiol 1981;14:457-61. 13 Wahlin YB, Holm AK. Changes in the oral microflora in patients with acute leukaemia and related disorders during the period of induction therapy. Oral Surg Oral Med Oral Pathol 1988;65:411-7. 14 Centeno A, Davies CP, Cohen MS, Warren MM. Modulation of Gzrididn nlhicnris attachment to human epithelial cells by bacteria and carbohydrates. Infect lmmun 1983;39:1354-9.
