Palliative oral care in terminal cancer patients: Integrated review

Table 1 Summary of the articles selected in the integrative review

Ref.	Country	Title	Type	Category	Objective	Method	Sample	Results	Summary
Gillam et al[10], 2006, United Kingdom	United Kingdom	The assessment and implementation of mouth care in palliative care: a review	Systematic review	Manegement	Review existing literature published between 95 and 99 to determine whether oral care was effectively implemented in the configuration of palliative care	On a nursing basis (CINHAL), they found 11 articles (does not make clear the descriptors)	11 articles	Studies with different tools used to view oral health and many studies report lack of training of nurses (72% of nursing colleges do not teach written oral evaluation methods)	The need for physicians and nurses to have a basic knowledge about diseases and oral care, but no study speaks as. It is important to have an evaluation tool
Wilberg et al[11], 2012, Norway	Norway	Oral health is na important issue in end- of-life cancer care	Croos-sectional	Oral manifestation	Investigate the prevalence of oral and dental problems in cancer patients receiving palliative care. Specifically, it was to examine oral health and prevalencia of oral morbidity through patient reports and oral examination. Also investigating information related to oral problems was received by patients	First the interview was done through a symptom reporting tool, and then a clinical oral examination and oral mucosa swab collection. If candidiasis was confirmed, treatment was given	99 patients	Average age 64, 47% men, cancer GI 21%, lung 19% prostate. 11%. 50.5% caries. Change of palate 68%, while 56% had problem eating, xerostomia 78% and 41% for + 3 months, 70% increase in friction in mirror test, general oral discomfort 67%. No significant difference when commencing the remedies with the patients with the symptoms described. Microbiol evidence. 86%, 34% clinical and biolog. 14% use prosthesis. Average lost teeth 5.7, 22% received information about adverse cancer effects, 38% how to reduce xerostomia	Microbiological evidence of candida in 86%, 34% clinical and biological. The 9 under treatment still had (uncertain effect). 22% received information on adverse effects of cancer, 38% of how to reduce xerostomia and 31% of the importance of oral hygiene (little, but satisfied). Alt. taste and xerostomia significantly related to oral morbidity (general discomfort). Caries largest number
Davies et al[12], 2008, United Kingdom	United Kingdom	Oral candidosis in community-based patients with advanced cancer	Croos-sectional	Oral manifestation	Determine the epidemiology, etiology, clinical and microbiological characteristics of oral candidiasis among community patients	Questionnaire, clinical examination, measurement of saliva production and swab collection of those who demonstrated clinical dinal of candidiasis. They isolated the collected species, if necessary, DNA sequencing	390 patients	Mean age 73, 65% women, breast cancer 23%, bronchio and colon and prostata 11%. 70% had candida on microbionogic examination and 13% in microb. And in the clinician. 63% a species, 31% 2 species. C. albicans 75%. C.gabrata 2nd most frequent. Presence of candidiasis has not been associated with age, gender, or use of systemic antibiotic. 67% xerostomia. Presence of candidiasis associated with severity of xerostomia, use of corticosteroids, ECOG and dentures	In agreement with other studies: Candidiasis becomes more common in patients near death (ECOG), increases with the high severity of xerostomia, but not with the use of antibiotics. No agreement: association between candidiasis and the use of systemic corticosteroids
Oneschuk et al[13], 2000, Canada	Canada	A survey of mouth pain and dryness in patients with advanced cancer	Croos-sectional	Oral manifestation	Determine the prevalence of dry mouth and/or oral pain in patients with advanced cancer, and whether they were present, quantify the intensity of these symptoms, whether treatment was offered by the health team and which when symptoms were expressed, the author's main opinion on the cause of these symptoms and the relative importance to the patient compared to other symptoms or problems they experienced	11-item questionnaire on oral pain and dry mouth and its intensity and importance of symptoms. Found from the oral examination were documented verbally and/or visually and the possible cause is documented	99 patients	Average age 70, 58% women, lung cancer 28%, GI 27%. 16 of the 99 had oral pain, 10 of them in the gums, and the mean intensity was 5 on a scale from 0 to 10. 88% had dry mouth, with an average intensity of 6.3. 24% had dry mouth before cancer diagnosis and 31% pain. 28.2% saw the dentist after diagnosis. 56% mentioned pain for the caregiver and 44% for dry mouth. After reviewing the patients' medical documentation, only one of them had documented the pain complaint and 5 dry mouth complaints. Of the 44%, 69% received advice on treatment. Found most common were candidiasis and presence of denture	88% dry mouth and 16% pain. Moderate importance in relation to other symptoms - more or less half of patients report their problems, and there are few documentations of these. The recommendations for dry mouth: drinking liquids, mouthwash with bicarbonate and use of oral antifungic. Only 1 of the 2 who had candida and pain were advised to use topical antifungic
Matsuo et al[14], 2016, Japan	Japan	Associations between oral complications and days to death in palliative care patients	Clinical trial	Oral manifestation	Investigate the association between the incidence of oral complications and DTD in patients in palliative care	They reviewed the reports and evaluations of oral conditions of terminal patients between April 2013 and March 2014. In the evaluation, clinical examination was taken and food intake was evaluated. Data from blood tests (leukocytes) for inflammation and DTD were evaluated. Divided into long and short DTD	105 patients	Cancer pancreas/bile 18%, gastrointestinal tract (16%). Carie 16.3% in long, 10.7% short 13.3%T. Xerostomia 54% long and 78% short (significantly higher). Candida 10.7 and 10.2%, 10.4%T. Inflammation of the tongue, bleeding spots and dysphagia also (43% and 20%). Long group 50% requires oral care support and 76% in short (different). The more attention needed and more xerostomia, the shorter the DTD	Major problems when arriving near the day of death and the problems began to progress with the time of hospitalization. Xerostomia, inflammation of the tongue, bleeding spots and dysphagia
Bagg et al[15], 2003, Glasgow	Glasgow	High prevalence of non-albicans yeasts and detection of anti- fungal resistance in the oral flora of patients with advanced cancer	Croos-sectional	Oral manifestation	Examine in detail the oral mycological flora in a wide range of patients with advanced cancer, receiving care in three different centers	Collected demographic details and therapy information, examination of the oral cavity by a qualified dentist and collection of a tongue swab, subsequently inoculated and incubated	207 patients	Average age 67.9, 45% men, lung cancer 18%, breast 16%, oral 5%. 81% denture, 50% edentulum. 48% with clinical evidence of xerostomia, 26% candida. No difference between denture use and fungic infection. 22% had antifungic treatment. 65% of the isolates had 1 species, 30% 2, 5%. 3. 47% with heavy density. 79%. C. albicans. 71% fluconazole, 55% for itraconazole. resistance-related xerostomia	Most of the isolates were of C. albicans in cancer patients (previous exposure to fluconazole?). By the use of immunosuppressants and antifungics, C. glabrata is now a pathological and more resistant species
Burge et al[16], 1993, Canada	Canada	Dehydration symptoms of palliative care cancer patients	Croos-sectional	Oral manifestation	Determine the severity and distribution of symptoms associated with dehydration in hospitalized palliative care patients and determine the association between the severity of these symptoms and commonly used dehydration measures.	Patients completed two questionnaires, 24 h apart. The nurses took the questionnaire as well. A blood sample was collected in the 24-h interval (sodium, urea and osmolarity). They measured how much liquid they ingested	52 patients	Average age 64.4, 50% women, gastrointestinal cancer 27%, lung 27%. Oral diseases and survival were not related. No association was found in the multivariate analysis. You can't list the meds.Fatigue was the most reported symptom. Patients who reported head and other symptoms also reported dry mouth and bad taste in the mouth (most). It's not a blind study, so it has this bias. Longer survival time is associated with less thirst	Most patients had symptoms of thirst. It's not a blind study, so it has this bias. Fatigue was the most reported symptom. No association between thirst and variables. Clinics argue that the thirst and intake of liquids decrease near death. However, longer survival time is associated with less thirst
Fischer et al[17], 2014, United States	United States	Oral health conditions affect functional and social activities of terminally ill cancer patients	Croos-sectional	Oral manifestation	To characterize oral diseases in patients with end-stage cancer in palliative care to determine the presence, severity, and social/functional impact of oral diseases, which affect quality of life	Questionnaire on xerostomia, taste change, orofacial pain and impact of diseases. "Self-report" and oral clinical examination	104 patients	29% between 50-64 yr, 59% women. 98% had salivary dysfunction and 60% had moderate to severe dysfunction. Erythema 50%, ulceration 20%, fungic infection 36%. Xerostomia was a frequent and moderate complaint. Ulcers associated with the presence of orofacial pain and social impact. Xerostomia, change in taste and orofacial pain associated with social impact. Hyposalivation associated with social and functional impact	Hyposalivation has a social and functional impact and is a frequent complaint with moderate severity. Orofacial pain and change in taste has social impact. Presence of fungic infection similar to other studies
Sweeney et al[18], 1998, United Kingdom	United Kingdom	Oral disease in terminally ill cancer patients with xerostomia	Croos-sectional	Oral manifestation	Descreve sinais e sintomas orais de um grupo de pacientes com cancer terminal, todos com xerostomia, os quais foram subsequentemente tratados com um substituto salivar em spray	Pacientes que relataram consecutivamente boca seca para o staff. Questionario, sintomas registrados por escala analogica visual 0-6, exame bucal visual e coleta de cultura da língua e assoalho e quantidade de saliva	70 patients	Mean age 66, 64% men, lung and breast cancer, 2.8% oral. 10% caries. 90% evidence xerostomia clinic, 9% C. pseudom sign.97% reported by day and 84% at night, 66% speech difficulty, 57% taste change, 51% difficulty eating, 31% pain. 40% of the prosthesis users had a problem with it. 65% had mucosal abnormalities, of these 20% erythema and 20% lingual saburra. C. albicans more common and C. glabrata 2nd most common	66% speech difficulty, 57% change in taste, 51% difficulty eating, 31% pain. 67% of the patients had fungic disease in the isolates. Good hygiene. S. aureus 26% suggested cause of mucositis, as well as coliforms (19%). Herpes was relatively low
Xu et al[19], 2013, China	China	Investigation of the oral infections and manifestations seen in patients with advanced cancer	Croos-sectional	Oral manifestation	To investigate the focus of oral infections between cancer groups and treatment methods, in addition to describing and comparing epidemiology, independent risk factors	Data collection, oral examination and oral cavity swab collection for microbiological isolation	850 patients	Average age 48, 57% men, cancer GI 17%, hematological 15%, 13% head and neck. Oral infections 46%, of these 52% with candidiasis (72% had fungal colony), 20.5% mucositis, 15.4% herpes. A logistic regression analysis showed that malnutrition and prosthesis use are independent risk factors for oral infection.Head and neck cancer had more infections and hematologic the second. Chemo and radiotherapy had higher infection	Candidiasis more prevalent, followed by mucositis. Disparity in oral infection data in these patients (various possible reasons). Head and neck cancer and hematologic. Prosthesis and nutrition are risk factors
Thanvi et al[20], 2014, India	India	Impact of dental considerations on the quality of live of oral cancer patients	Croos-sectional	Quality of live	Understand the role of the dentist and the impact on quality of life in a patient with oral cancer in a palliative care unit	History of oral cancer treatment, clinical examination and quality of life questionnaire	50 patients	64% women. Age measured 57. All oral cancer. 98% of the patients had some deleterious habit, 58% smokers. 12% had information before therapy. 74% had sensitivity and 50% limitation in mouth opening (evaluated root carie, atrition and sharp cuspides). 78% worsened The QOL, of these only 2% had dental considerations	Dental treatment was not done in 76% of patients who had already undergone treatment, 2% received consideration. Mouth opening sensitivity and limitation (did not evaluate xerostomia, mucositis, but evaluated "sharp cusps", atrition and root caries). 78% worsened QOL
Bagg et al[21], 2005, United Kingdom	United Kingdom	Voriconazole susceptibility of yeasts isolated from the mouths of patients with advanced cancer	Croos-sectional	Treatment	Determine the susceptibility of voriconazole to a large collection of well-characterized fungal isolates from the oral cavity of patients with advanced cancer	199 oral samples isolated from swab and oral rinse. Susceptibility test for fluconazole, itraconazole and voriconazole	199 patients	Breast cancer, bronchio, prostata and large intestine. 270 yeast species, C. albicans 59%, C. glabrata 19%, C. dubliniensis 7%. 76% flucona, and 14% fluconazole resistant. Of the fluconazole resistant, 7 sensitive to itraconazole and 41 resistant. Of the 49 resistant to itraconazole, 41 was also fluconazole and 8 senseless. 15% resistant to fluconazole and itraconazole, mostly C. glabrata and C. albicans. C. glabrata was 54% of fluconazole resistant	Voriconazol é mais potente que fluconazol ou itraconazol contra leveduras isoladas de boca de pacientes com cancer avançado, e é mais potente com aqueles resistentes a fluconazol e itraconazol
Bagg et al[22], 2006, United Kingdom	United Kingdom	Susceptibility to Melaleuca alternifolia (tea tree) oil of yeasts isolated from the mouths od patients with advanced cancer	Croos-sectional	Treatment	Examine in vitro susceptibility to TTO from a collection of well-characterized yeasts, including azol-resistant strains isolated from the mouth of patients with advanced cancer	301 Yeasts isolated and MIC measurement for TTO	199 patients	Breast cancer, bronchio, prostata and large intestine. MIC 50 was 0.5% for C. albicans and C. dubliniensis and 0.25% for C. glabrata, C. tropicalis and S. cerevisiae. MIC 90 for C. albicans, glabrata and dubliniensis was 1%. All itraconazole and fluconazole resistant were susceptible to TTO at commercially available concentrations	Treatment should be considered a potent preventive or therapeutic agent of oral candidiasis in these patients. As a water-based filler or adjuvant the regular washing
Nakajima et al[23], 2017, Japan	Japan	Characteristics of oral problems and effects od oral care in terminally ill catient with cancer	Clinical trial	Treatment	Investigate oral problems in the terminal stage of cancer and improves through oral care focusing on dry mouth	Divided into good oral and bad intake (115A and 158B) to 30% for good. Incidence of dry mouth and its severity (0-3), stomatitis, candidiasis.Standard oral care for dry mouth by nurses (hydration, brushing and cleaning or massage), and therapy for dry mouth and stomatitis. Special care if it did not improve	273 patients	Average age 62.4A and 66.2B, 144 men and 129 women. Lung cancer 38A 48B, Liver/bile/pancreas 18A 30B, Head and neck 5A 8B. Dry mouth 38.3%A 81%B 63%T. Stomatitis 10.4%A 16.5%B 13.9%T. Candidiasis 6.1%A 22.8%B 15.8%T. All with stomatitis and candidiasis had dry mouth. Severe dry mouth 20%A 64%B. Dry mouth treatment: grade 2 B needed specialist (85%A 83%B), grade 3 also (80%A 81%B) Overall improved 80% or more	B significantly higher than A: Dry mouth and candidiasis. Interventions improved 80% or more dry mouth. Importance of oral care before the problem worsens. Oral care is better than artificial hydration for dry mouth. The registration of oral conditions by staff is not 100% (limitations, improve)
Ezenwa et al[24], 2016, United States	United States	Caregiver's perspectives on oral health problems of end-of-life cancer patients	Cross-sectional study	Management	Describe caregivers' awareness of oral health problems, compare caregivers' problems with patients' problems and explore the influence of caregivers' socio-demographic characteristics on their awareness of oral problems	Caregivers and patients answered questionnaires separately. Caregivers and patients completed the scale of oral problems	104 patients104 caregivers	Patients: 29-112, 29% between 50-64 yr, 59% women, Lung cancer 26%, colorectal 14%, head and neck 3%. 48% of caregivers(C) were not trained, 30% of c evaluated the problems only when necessary and 13% never evaluated. C underestimated xerostomia and overestimated the social impact. C with 65+ had lower accuracy in reporting the problems. C with health problem were less aware	48% C without training. C underestimate xerostomia, but is aware of orofacial pain. No difference in race, gender, C's education

DNA: Deoxyribonucleic acid; DTD: Days to death; GI: Gastrointestinal; ECOG: Electrocorticography; MIC: Minimal important change; QOL: Quality of life; TTO: Tea Tree Oi.

Table 2 Prevalence of oral complications in examined patients (%)

Ref.	Xerostomia	Eat/Swallowing problems	Mucositis	Dysgeusia	Oral pain
Fischer et al[17], 2014	91	61	-	71	23
Sweeney et al[18], 1998	90	-	-	-	31
Oneschuk et al[13], 2000	88	-	-	-	16.1
Wilberg et al[11], 2012	78	56	-	68	-
Davies et al[12], 2008	67	-	-	-	-
Matsuo et al[14], 2016	64.7	29.5	-	-	-
Nakajima[23], 2017	63	-	13.9	-	-
Bagg et al[15], 2003	48	-	-	-	-
Xu et al[19], 2013	-	-	20.5	-	-
Mean	73.7	48.8	17.2	70	23.3

Table 3 Suggested palliative care protocol based on the literature available for some frequent oral complications in terminal patient’s with cancer

Oral complications	Therapeutical measures
Oral candidiasis	Fluconazole: 100 to 200 mg/d
	In case of resistance: Itraconazole or variconazole and mouth rinsing with melaleuca oil after oral hygiene
Xerostomia	Daily and frequent water sip intake
	Artificial saliva use
	In severe cases: Discuss the possibility of replacing causative drugs
Dysgeusia	Discontinues 10 mo after antineoplastic therapy, on average
	In severe cases: Discuss the possibility of replacing causative drugs
Mucositis	Cryotherapy: Ice stones and ice cream kept in mouth decrease risk of mucositis and relieve pain (prescription according to chemotherapy)
	Low-level laser therapy
	Cold chamomile-based tea solutions