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. 1998 Apr 18;316(7139):1246. doi: 10.1136/bmj.316.7139.1246b

Mouth care and skin care in palliative medicine

Chlorhexidine mouth washes are important in mouth care

Victoria S Lucas 1, Graham J Roberts 1
PMCID: PMC1113005  PMID: 9553020

Editor—Regnard et al did not mention the use of 2% chlorhexidine mouth rinses in the section on mouth care and the risk factors for oral problems in their article in the ABC of Palliative Care.1 We have regular contact with groups of children with chronic disorders— for example, epidermolysis bullosa—and others who are treated with high dose chemotherapy and irradiation. One of the problems from which they suffer is severely blistered oral mucosa (children with epidermolysis bullosa) and mucositis related to chemotherapy or radiation.

The most widely investigated and used mouth care regimen is 2% chlorhexidine mouth rinse daily. Many workers have reported decreases in dental bacterial plaque and gingivitis.2,3 This leads to decreased oral bacterial loading, which is important, particularly in patients who are undergoing a period of immunosuppression as part of their treatment.4 Chlorhexidine does not greatly affect the progress of mucositis, and although the 7% ethanol base does cause a burning sensation, the antibacterial and local cleaning action are of great benefit to these patients. Although tooth brushing is the ideal oral hygiene method, most patients who are debilitated are unable to do this effectively and the mouth is not cleaned effectively. Mouth rinsing may also be difficult, and this difficulty can be easily overcome by soaking pink dressing sponges in chlorhexidine. When the teeth are closed on the sponges, the chlorhexidine is carried to the oral mucosa, gingivae, and teeth.

We believe that this logical approach to mouth care is more effective than the anecdotal remedies suggested by Regnard et al. Was the recommendation to use gin a misprint?

References

  • 1.Regnard C, Allport S, Stephenson L. ABC of palliative care: Mouth care, skin care, and Iymphoedema. BMJ. 1997;315:1002–1005. doi: 10.1136/bmj.315.7114.1002. . (18 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Schiott CR, Loe H, Jensen SB, Kilian M, Davies RM, Glavind K. The effect of chlorhexidine mouthrinses on the human oral flora. J Periodontal Res. 1970;5:84–89. doi: 10.1111/j.1600-0765.1970.tb00697.x. [DOI] [PubMed] [Google Scholar]
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BMJ. 1998 Apr 18;316(7139):1246.

Surgical debridement of dead tissue may be important in skin care

J Michael Dixon 1, J Hockley 1

Editor—We were surprised that Regnard et al did not mention the role of surgical debridement of dead tissue in the treatment of pressure sores and fungating chest wall tumours in their article in the ABC of Palliative Medicine.1-1 The reason that patients get malodour from pressure sores and ulcerating or fungating tumours is the presence of dead tissue which subsequently becomes infected. Removal of dead material surgically can not only dramatically improve the smell but will reduce the amount of discharge, which means that dressings are less likely to leak and therefore need to be changed less frequently. Surgery also has a role in patients with large and often multiple tumour masses growing out through the chest wall as these can be difficult to dress and can be extremely uncomfortable for the patient. Excision of these masses makes it easier for both the patient and the carers to manage what can be a difficult problem (figure).

Figure.

Figure

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Patient with multiple recurrent breast cancer masses on chest wall anterior and posterior before (top) and after (bottom) surgical excision. After surgery, residual disease was easier to dress and was less troublesome, and patient was able to sleep more comfortably

As was pointed out in the ABC of Breast Diseases, the management of patients with M stage cancer should be multidisciplinary, and the role of the surgeon, although small, should not be forgotten.1-1,1-2

References

  • 1-1.Regnard C, Allport S, Stephenson L. ABC of palliative care: Mouth care, skin care, and lymphoedema. BMJ. 1997;315:1002–1005. doi: 10.1136/bmj.315.7114.1002. . (18 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Leonard RCF, Rodger A, Dixon JM. ABC of breast diseases: Metastatic breast cancer. BMJ. 1994;309:1501–1504. doi: 10.1136/bmj.309.6967.1501. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 1998 Apr 18;316(7139):1246.

Simple antiseptic mouthwashes are best for infection

Mike Pemberton 1, M H Thornhill 1

Editor—Regnard et al’s article on mouth care in palliative care patients requires some comment.2-1

Aphthous ulcers are not thought to be of infective origin, although they may become secondarily infected with oral commensal bacteria.2-2 Discussion of their management under the subheading of infection creates confusion in the table on local measures for oral problems. Although the corticosteroid and tetracycline mouthwashes advocated for treating infected mouth are appropriate for aphthous ulceration, their inappropriate use in infected mouths is far more likely to exacerbate rather than improve the situation. Both mouthwashes are predisposing factors to oral candidal infection,2-3 a problem recognised elsewhere in the article as a concern in palliative care patients. A simple antiseptic mouthwash such as chlorhexidine would be more appropriate in most cases of superficial mucosal infection.

In their discussion on the management of dry mouth the authors identify several saliva substitutes, some of an acidic nature such as fruit juice. Although these may be an option for some patients, caution is required as they will rapidly precipitate dental caries if used in a dry mouth for any length of time. Another aspect of management which was not mentioned is the stimulation of residual salivary function. Patients often prefer salivary stimulation to substitution.2-4 Several chemical and mechanical salivary stimulants are available, of which sugar free chewing gum is effective and widely available.2-4 As a final point, we suggest that candidiasis is far more often a complication of a dry mouth than its cause.2-5

References

  • 2-1.Regnard C, Allport S, Stephenson L. ABC of palliative care. Mouth care, skin care, and lymphoedema. BMJ. 1997;315:1002–1005. doi: 10.1136/bmj.315.7114.1002. . (18 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Ship JA. Recurrent aphthous stomatitis: an update. Oral Surg Oral Med Oral Pathol. 1996;81:141–147. doi: 10.1016/s1079-2104(96)80403-3. [DOI] [PubMed] [Google Scholar]
  • 2-3.Lewis MAO, Larney PJ. Clinical oral medicine. London: Wright; 1993. [Google Scholar]
  • 2-4.Davis AN. The management of xerostomia: a review. Eur J Cancer Care. 1997;6:209–214. doi: 10.1046/j.1365-2354.1997.00036.x. [DOI] [PubMed] [Google Scholar]
  • 2-5.Streebny LM. Xerostomia: diagnosis, management and clinical complications. In: Edgar WM, O’Mullane DM, editors. Saliva and dental health. 2nd ed. London: British Dental Journal; 1996. pp. 43–66. [Google Scholar]
BMJ. 1998 Apr 18;316(7139):1246.

Clinically proved treatments for xerostomia were ignored

Andrew Davies 1

Editor—Regnard et al’s suggestions for improving xerostomia are based almost entirely on anecdotal evidence.3-1 Furthermore, these suggestions ignore the evidence from numerous clinical trials.

The symptoms of xerostomia are managed with both saliva substitutes and saliva stimulants. In studies that have compared saliva substitutes and stimulants patients have generally preferred the saliva stimulants.3-2 The choice of saliva stimulant depends on several factors including the aetiology of xerostomia, the patient’s general condition and prognosis, the presence of teeth, and, most importantly, the patient’s preference. Examples of saliva stimulants that have been found effective in clinical trials include mints, chewing gum, malic acid, and pilocarpine.3-3

Saliva has several functions, and hyposalivation may result in poor oral hygiene, oral discomfort, and oral infections. Pineapple is a natural saliva stimulant. Its effect on oral hygiene is probably related more to a non-specific increase in salivary flow than to a specific effect of the enzyme ananase. Indeed, other saliva stimulants have a similar effect on “dirty mouths” and “coated tongues.” It should be noted that oral candidiasis is a complication of hyposalivation and not, as stated in the article, a cause of hyposalivation.3-4

References

  • 3-1.Regnard C, Allport S, Stephenson L. ABC of palliative care. Mouth care, skin care and lymphoedema. BMJ. 1997;315:1002–1005. doi: 10.1136/bmj.315.7114.1002. . (18 October.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Bjornstrom M, Axell T, Birkhed D. Comparison between saliva stimulants and saliva substitutes in patients with symptoms related to dry mouth. A multicentre study. Swed Dent J. 1990;14:153–161. [PubMed] [Google Scholar]
  • 3-3.Davies AN. The management of xerostomia: a review. Eur J Cancer Care. 1997;6:209–214. doi: 10.1046/j.1365-2354.1997.00036.x. [DOI] [PubMed] [Google Scholar]
  • 3-4.Bowen WH. Salivary influences on the oral microflora. In: Edgar WM, O’Mullane DM, editors. Saliva and dental health. 2nd ed. London: British Dental Journal; 1996. pp. 95–103. [Google Scholar]

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