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Right Decision Service newsletter: October 2024

Welcome to the Right Decision Service (RDS) newsletter for October 2024.

1.Contingency arrangements for RDS outages

Development of the contingency solutions to maximise RDS resilience and minimise risk of future outages is in progress, aiming for completion by Christmas. As a reminder, these contingency arrangements  are:

  • Optimising mobile app build process
  • Mobile app always to be downloadable.
  • Serialising builds to mobile app; separate mobile app build from other editorial and end-user processes
  • Load balancing – provides failover (also enables separation of editorial processes from other processes to improve performance.)

 

In the meantime, a gentle reminder to encourage users to download essential clinical toolkits to their mobile devices so that there is an offline version always available.

 

2. New deployment with improvements.

A new scheduled deployment with minor improvements drawn from support tickets, externally funded projects, information related to outages, and feature requests will take place in early December. Key improvements planned are:

  • Deep-linking to individual toolkits within the RDS mobile app. Each toolkit will now have its own direct URL and QR code, both accessible from the app. These can be used to download the toolkit directly where users already have the RDS app installed. If the user does not yet have the RDS app installed, they will be taken to the app store to install the app and immediately afterwards the toolkit will automatically open and download. Note that this will go live a few days later than the improvements below due to the need to link up the mobile front end to the changes in the content management system.
  • Introducing an Announcement Header field to replace the hardcoded "Announcements and latest updates" text. This will enable users to see at a glance the focus of new announcements.
  • Automated daily emptying of the recycling bin (with a 30 day rolling grace period)  in the content management system. A bug preventing complete emptying of the recycling bin contributed to one of the outages earlier this year.
  • Supporting multiple passcodes (ticket 6079)
  • Expanding accordion section to show location of a search result rather than requiring user coming from a search result to manually open all sections and search again for the term.
  • Displaying first accordion section Content text as a snippet on the search results page as a fallback if default/main content is not provided
  • Displaying the context of each search result in the form of a link to the relevant parent tool/section. This will help users to choose which search result is most likely to be appropriate for their needs.
  • As part of release of the new national benzodiazepine quality prescribing guidance toolkit sponsored by Scottish Government Effective Prescribing and Therapeutics, a digital tool to support creation of benzodiazepine tapering/withdrawal schedules.

We are also seeking approval to use the NHS Scotland logo and title for the RDS app on the app stores to help with audience engagement and clarity around the provenance of RDS.

3. RDS Search, Browse and Archive/Version control enhancements

We are still hopeful that user acceptance testing for at least the Search and browse enhancements can take place before Christmas. Thank you for your patience and understanding in waiting for these improvements. Timescales have been pushed back by old app migration challenges, work to address outages, and most recently implementing the contingency arrangements.

4. Support tickets

We are aware that there continue to be some issues around a number of RDS support tickets, in part due to constraints around visibility for the RDS team of the tickets in the existing  support portal. We are investigating the potential to move to a new support ticket requesting system from early in the new year. We will organise the proposed webinar around support ticket processes once we have confirmed the way forward with the system.

Table formatting

There is a known issue with alterations in formatting of some RDS tables which seems to have arisen as a result of the 17 October deployment. Tactuum is working on a fix and on implementing additional regression testing to prevent this issue recurring.

5. New RDS toolkits

Recently launched toolkits include:

NHS Lothian Infectious Diseases

Scottish Health Technologies Group – Technology Assessment recommendations

NHS Tayside Anaesthetics and Critical Care projects – an innovative toolkit which uses PowerAutomate to manage review and response to proposals for improvement projects.

If you would like to promote one of your new toolkits through this newsletter, please contact ann.wales3@nhs.scot

A number of toolkits are expected to go live before Christmas, including:

  • Focus on dementia
  • Highland Council Getting it Right for Every Child
  • Dumfries and Galloway Adult Support and Protection procedures
  • National Waiting Well toolkit
  • Fertility Scotland National Network
  • NHS Lothian postural care for care homes

6.Sign up to RDS Editors Teams channel

We have had a good response to the recent invitation to sign up to the new Teams channel for RDS editors. This provides a forum for editors to share learning, ideas and questions and we hope to hold regular webinars on topics of interest.  The RDS team is in the process of joining participants to the channel and we’d encourage all editors to take part, using the registration form – available in Providers section of the RDS Learning and Support area.

 

7. Evaluation projects

The RDS team has worked with colleagues in NHS Grampian and the Digital Health & Care Innovation Centre to evaluate the impact of the Prevent the progress of diabetes web and mobile app in a small-scale pilot project. This app provides access to local and national resources and services targeted at people with prediabetes, a history of gestational diabetes, or candidates for remission. After just 8 weeks of using the app, 94% of patients reported increased their knowledge and understanding of diabetes, and 88% said it had increased their confidence and motivation to make lifestyle changes, highlighting specific behaviour changes. The learning from this project is informing development of a service model based on tailored support for patient groups with, high, medium and low digital self-efficacy.

Please contact ann.wales3@nhs.scot if you would like to know more about this project.

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 29th November 3-4 pm
  • Thursday 5 December 3.30 -4.30 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

The Right Decision Service:  the national decision support platform for Scotland’s health and care

Website: https://rightdecisions.scot.nhs.uk    Mobile app download:  Apple  Android

 

 

Mouth care

Mouth care is an essential aspect of palliative care in all settings and should be considered part of daily routine patient care. Assessment and intervention should be instigated early to optimise patient comfort and prevent more serious problems and treatment complications.

Key principles

  • Plan regular effective mouth care for all patients.
  • Monitor response to interventions.
  • Identify serious oral problems that require referral, for example to palliative care specialist or a dentist.

Assessment

  • Patients who are receiving or have recently received chemotherapy or radiotherapy need careful monitoring both pre- and post-treatment.
  • Medication history is important as numerous medications can affect the oral environment:
    • opioids, diuretics and anticholinergics increase dry mouth
    • steroids increase the risk of candidiasis
    • bisphosphonates increase the risk of osteonecrosis of the jaw. Ill-fitting dentures and surgical intervention including tooth extraction increase this risk, highlighting the need for preventative oral hygiene therapy.
  • For patients who are dying, ensure that active routine assessment is carried out.
  • Ensure comfort and minimise pain when carrying out an assessment by lubricating cracked lips with a water-based product.
  • Petroleum lip balms should be avoided due to flammability and aspiration risk.
  • Previous applications of water-based lubricants should be gently removed before replacing.
  • Remove dentures before examining the mouth or performing routine mouth care.
  • Check the lining of the mouth is clean.
  • Look for signs of dryness, coating, ulceration, infection or tooth decay. Assess for pain.
  • Consider dental referral with the patient’s consent for persistent oral symptoms or if it has been more than one year since the patient has been examined by a dentist.

General Points

All patients

  • Oral care is most effective when the patient can be in a semi-upright position to avoid choking or aspiration of bacteria or debris. When positioning is not possible, care should be taken to avoid collection of fluids in the oral cavity or aspiration.
  • Looking after oral soft tissues is just as important as looking after the teeth.
  • Keep mouth and lips clean, moist and intact by removal of plaque and debris (refer to section on dry/coated mouth care).
  • Gentle tongue brushing should also be encouraged to reduce halitosis and prevent tongue coating.
  • Encourage fluid intake with frequent, small drinks.
  • Apply water-based gel to dry lips after oral care.
  • Where possible reduce intake of sugary foods and drinks between meals (refer to Anorexia/cachexia guideline). There may be additional oral care requirements as frequency of intake increases.
  • Where there is concern about oral intake and nutrition, consider referral to a dietitian with consent.
  • Encourage and support family members who wish to participate in carrying out mouth care.

Patients with natural teeth

  • Clean natural teeth with fluoride toothpaste (1350 to 1500ppm fluoride) after every meal, but at least twice daily if tolerated.
  • Mechanical brushing of teeth and gums to remove plaque and debris is as important as application of toothpaste or chlorhexidine digluconate 1%w/w dental gel.
  • Encourage patients to spit out excess toothpaste after brushing.
  • The mouth should not be rinsed with water after brushing.
  • Remove partial dentures and clean separately.
  • A dental hygienist or dentist can provide professional advice on oral hygiene for those with complex dental needs.
  • Very soft toothbrushes (for example silk toothbrush or baby toothbrush) can be used to perform oral daily care for patients with a painful mouth.

Denture care

  • Mark all dentures with the patient’s name.
  • A denture fixative may provide relief from extensive movement of dentures.
  • Brush dentures at least twice a day over a sink of water to guard against splashing and prevent them from breaking if they are dropped.
  • Use of a personal toothbrush and running water are adequate for the physical cleaning of dentures. Denture cream or unperfumed soap may be used but not regular toothpaste.
  • Rinse dentures thoroughly after meals and before replacing in the mouth.
  • Remove dentures at night and soak in a suitable cleansing solution for
    20 minutes, then overnight in plain water. Recommended soaking solutions are:
    • dilute sodium hypochlorite solution for plastic dentures
    • chlorhexidine gluconate 0.2% solution for dentures with metal parts.
  • Check dentures for cracks, sharp edges and missing teeth daily.

Mouth care if receiving chemotherapy/radiotherapy – key difference

  • Refer to local cancer centre/cancer network guidelines.
  • Patients may be advised to avoid anti-pyretic analgesics (paracetamol, aspirin) if at risk of neutropenia as this can mask fever due to sepsis.
  • Patients receiving head and neck radiotherapy should avoid oil-based products.

Mouth care in the last days of life

  • The guidance below summarises the national “Mouth Care Matters” guideline produced by the Royal College of Nursing, which can be accessed in full at Mouth Care Matters in End-of-Life Care | Publications | Royal College of Nursing (rcn.org.uk)

    • Include mouth care in the patient’s care or support plan.
    • Encourage family members who may wish to participate in mouth care activities with guidance and support from the team looking after the person.
    • Consider changing or stopping medicines that are causing a dry mouth.
    • Carry out mouth care as often as necessary to maintain a clean and comfortable mouth.
    • In people who are conscious, the mouth can be moistened every 30 minutes with water from a water spray or dropper or ice chips can be placed in the mouth.
    • In people who are unconscious, moisten the mouth frequently, when possible, with water from a water spray or dropper. Avoid spraying directly onto the back of the throat.
    • Consider referral to a speech and language therapist if a swallow assessment is required.
    • To prevent cracking of the lips, a water-soluble lubricant should be applied.
    • When the weather is hot and dry, if possible, use a room humidifier or air conditioning.
    • Ensure help is offered to clean teeth or dentures.
    • Manage oral pain symptomatically, using analgesics via a suitable route.
    • Review treatment of the underlying cause of oral pain when the burden of treatment outweighs the benefits. 

Dry/coated mouth care

  • If the person requires assistance with oral care:

    • Oral care should be offered at least four times daily or as tolerated. Some people may need more frequent care, particularly when they are no longer able, or have reduced ability to eat or drink.
    • Where possible, identify and manage the underlying cause, for example, review medication, manage anxiety, treat intraoral infection, humidify oxygen and if appropriate encourage hydration.
    • Gently remove coatings, debris and plaque from soft tissues, lips and mucosa.
    • Failing to remove dried secretions, debris and plaque gently can cause pain, ulceration and bleeding, and predispose to infection.
    • Use a soft bristle, small-headed toothbrush to remove debris. Alternative toothbrushes for people with limited ability to open their mouths are available. For example, the Oralieve 360 toothbrush is designed for people with limited mouth opening.
    • An alternative is to use damp non-fraying gauze (that has been thoroughly wetted in clean, running water) wrapped around a gloved finger to gently soak coated areas, provided it is safe to do so.
    • Oral swabs with foam heads SHOULD NOT be used as heads may detach during use.

    If the person is able to take part in oral care:

    • Encourage hydration. Cold, unsweetened drinks (such as sips of water) should be offered frequently throughout the day if desired and safe. Sucking crushed ice or frozen tonic water may provide relief.
    • Saline mouthwashes may help to clean the mouth. People in hospital may use 0.9% sodium chloride from a vial followed by rinsing with cold or warm water. For people at home, 1 teaspoon of salt may be added to a pint of cold or warm water. A fresh supply should be made daily.
    • Saline nebulisers may help with thick or crusty secretions.
    • Saliva stimulation (for example, sugar-free chewing gum, sugar-free boiled sweets, pastilles, mints) should be considered if the person is able to understand how they are used and use them safely.

    Denture care

    Denture wearers in the last days of life may have specific mouth care needs.

    Comfort considerations:

    • Consider whether continuous denture use is necessary for comfort and dignity. Dentures can be left out at night or for extended periods to improve comfort, especially if the mouth is sore. Always discuss this option with the person and their family and get their consent.
    • Address potential concerns from family members who might be unfamiliar with seeing their loved one without dentures. Clear communication and explanation about comfort being a priority is important.

    Denture hygiene:

    • If dentures are being worn, continue cleaning them daily with a soft brush and a denture cleanser following the manufacturer's instructions. Denture hygiene is still important to prevent fungal infections.
    • When not in use, dentures should be soaked in a denture cleaning solution overnight.

    Communication:

    • Ensure clear communication with the person and family about denture care options and address any questions or concerns they may have.

    Additional points:

    • If the person is unable to clean their dentures themselves, a caregiver or healthcare professional can assist them.
    • If the person has dentures with clasps or other metal parts consult your dentist about appropriate cleaning solutions to avoid damage.
    • Regularly inspect dentures for cracks or chips, as these can irritate the gums.

    Saliva substitute products:

    • Saliva substitutes (for example, oral gel, spray or mouth rinse) may be used if other measures are insufficient. Refer to local formulary and the British National Formulary (BNF).
    • There is no strong evidence that topical therapy is effective for relieving xerostomia, but many people find it useful. The ideal product should be acceptable to the person, be of neutral pH and contain electrolytes (including fluoride) to correspond approximately to the composition of saliva.
    • Some preparations for dry mouth are derived from animal products and may be unsuitable for vegetarians and people from certain religious groups (for example, AS Saliva Orthana® products contain mucin of porcine origin).
    • Topical artificial saliva and saliva stimulant products should be used as frequently as needed, including before and during meals.
    • Enough artificial saliva should be used to cover the whole mouth. Applying artificial saliva under the tongue can help spread the artificial saliva around the whole mouth.
    • Attention should also be paid to the lips. Applying a water-based product will help to prevent or treat cracked lips.
    • Some preparations with an acidic pH (for example, Glandosane®) should be avoided in dentate patients as long-term use of an acidic product may demineralise tooth enamel.
    • If a preparation without fluoride is used, a daily fluoride mouthwash should also be used in dentate patients.
    • Fluoride mouthwash (0.05%) can be used at a different time from brushing.
    • A dry mouth can contribute to tooth decay. Where appropriate, people should be encouraged to attend their dentist regularly for assessment and necessary treatment.

    Information relating to allergens, dietary or cultural aspects of most frequently used saliva substitutes:

    AS Saliva Orthana® Spray Use 2–3 sprays as required onto oral and pharyngeal mucosa. Contains pig mucin so it is not suitable for vegetarians, vegans or those following Halal or Kosher diets.
    BioXtra® Dry MouthSpray Spray onto gums, tongue and lips as required.
    BioXtra® Dry Mouth Oral Gel Apply with a clean finger or swab onto gums, tongue and under dentures. Apply as required particularly at night. Contains gluten and traces of milk and egg white proteins.
    Biotene® Moisturising Mouthwash Use approximately 15mL, rinse for 30 seconds then spit out. Use up to a maximum of five times per day unless otherwise instructed.
    Biotene® Oral Balance Moisturising Gel Place 1–2 cm of gel directly onto the tongue and spread thoroughly inside the mouth. This can be repeated as often as necessary. Gel can also be placed on a clean or gloved finger and applied directly into the mouth

    For further information, please refer to:
    https://www.sps.nhs.uk/articles/what-should-be-considered-when-choosing-or-prescribing-saliva-substitutes/

    NHS England summarises the evidence for diseases linked to poor mouth care.

    https://youtu.be/Ge9WGTp5y3o?si=zjCprwMXvaMQwQpD NHS England - clear message on pink sponges (oral swabs with foam head) and demonstration of alternatives 

    https://youtu.be/nKN6-HbZ_D8?si=2q9VgfqYsx9d-GPb 

Painful mouth care

  • Causes of mouth pain include trauma (from sharp teeth), haematinic deficiency, viral infection (herpes simplex), aphthous ulceration, oral malignancy and mucositis.
  • Oral pain may be relieved by benzydamine 0.15% oral mouthwash or benzydamine 0.15% oromucosal spray. The mouthwash may be diluted 1:1 with water if stinging occurs.
  • Other agents include choline salicylate (Bonjela®) or a variety of proprietary preparations for use in the mouth containing the local anaesthetic, lidocaine. Lidocaine ointment (5%) or spray (10%) may be used but may increase the risk of choking if used before meals due to anaesthesia of the pharynx.
  • Consider oral mucositis as a possible cause, particularly in patients receiving chemotherapy or radiotherapy. Oral mucositis is a condition characterised by pain and inflammation of the mucous membrane which may present as painful mouth ulceration affecting any or all intra-oral surfaces. Refer to local cancer centre guidelines or the current version of the UKOMIC (United Kingdom Oral Mucositis in Cancer Group) guidelines for recommended treatment based on the WHO assessment tool and grading scale.
  • Soluble paracetamol and/or aspirin used as a mouthwash provides no topical effect. Do not advise patients to use this as a mouthwash. If topical analgesia on its own is not effective, systemic analgesia may be required, refer to Pain management guideline.
  • Corticosteroids are not advised for the management of oral mucositis.
  • Salt water mouthwashes are effective in maintaining oral hygiene and are advised for the prevention and management of mucositis. They should be used at least four times in 24 hours to clean the mouth and remove debris.
  • Patients in hospital may use 0.9% sodium chloride from a vial to be followed by rinsing with cold or warm water. For patients at home, 1 teaspoon of salt may be added to a pint of cold or warm water. A fresh supply should be made daily.
  • Gelclair® is a viscous gel specially formulated to aid in the management of lesions of the oral mucosa. It forms a protective film that, by coating and sticking to the lining of the mouth and throat, offers rapid and effective pain management. The contents of one sachet should be diluted with 40ml of water and used as a mouthwash. Repeat three times a day, 1 hour before eating or drinking.
  • Carmellose paste (Orabase®) is a mucoadhesive paste that will adhere to lesions forming a protective barrier.
  • Coating agents will not relieve persistent inflammatory pain but may reduce contact pain, for example from eating or drinking. The coating/barrier may prevent penetration of orally applied medicines, for example nystatin, which will need to be given prior to applying the coating agent.
  • Chlorhexidine gluconate 0.2% mouthwash can be considered to treat secondary infections or when pain limits other mouth care methods; 10ml used twice daily may be useful to inhibit plaque formation in patients unable to tolerate other mouth care measures. Dilute 1:1 with water if it stings. Alcohol-free preparations are available.
  • If the patient is unable to rinse and expectorate or there is an aspiration risk, soak gauze in chlorhexidine gluconate 0.2% mouthwash and gently wipe over coated surfaces, teeth and gums.
  • Consider referral to a palliative care specialist or dentist with consent if there is refractory oral pain or severe mucositis.

 

Management of oral infections

Fungal infections

The most common types are candidiasis, denture stomatitis and angular cheilitis (soreness, redness and fissures at corners of mouth). Risk factors include wearing dentures, concomitant antibiotic or steroid use and xerostomia.

  • Maintain oral hygiene.
  • Systemic treatments are likely to be more effective than topical treatments. In many cases, a systemic antifungal such as fluconazole (capsules or suspension) 50mg daily for 7 days will be indicated with review and extension as necessary. Higher doses may be necessary in immunocompromised patients. Doses may need to be reduced in renal impairment. Topical miconazole oral gel 2% may also be used. Apply 2.5ml topically four times daily, retained near lesions before swallowing. Continue use for at least a week after lesions have healed. Topical miconazole should be considered for treating angular cheilitis.
  • In patients where this treatment is contra-indicated, or for mild oral candidiasis in non‑immunocompromised patients, nystatin oral suspension 100,000 units/ml can be considered. Prescribe 1ml four times daily after food, usually for 7 days. Rinse around mouth and hold in contact with affected areas as long as possible. Continue use for 48 hours after lesions have healed. Some patients may be unable to comply with the administration instructions for nystatin and require a systemic antifungal.
  • Always check the BNF or seek advice from a pharmacist before prescription of antifungal medication as there is a risk of serious drug interactions. Fluconazole and miconazole (including topical route) should be avoided in patients prescribed warfarin and statins.
  • Swab angles, tongue and nostrils to investigate possible Staphylococcal infection. If present, adjust treatment accordingly.
    • If a fungal infection is present, dentures must be cleaned thoroughly – soak in chlorhexidine 0.2% mouthwash (if dentures have metal components) or dilute sodium hypochlorite for 20 minutes twice a day. Toothbrushes should also be replaced.
    • If symptoms persist, consider referral to a dentist with consent or a palliative care specialist.

Viral infections

Herpes simplex is the most common viral infection.

  • Treat infections inside the mouth with oral aciclovir: 200mg five times a day for at least 5 days (or until healing is complete). Soluble preparations are available.
  • The dose of aciclovir may be doubled or intravenous treatment considered if the patient is immunocompromised or if absorption is impaired. In this case seek advice. Doses may need to be reduced in renal impairment.
  • The use of antimicrobial mouthwashes (either chlorhexidine 0.2% mouthwash or hydrogen peroxide mouthwash, 6%) controls plaque accumulation if toothbrushing is painful and also helps to control secondary infection in general.
  • Immunocompetent patients in the early stages of an uncomplicated herpes simplex infection in the lips (cold sore) should receive a topical antiviral preparation, for example acyclovir 5% cream applied 5 times a day for 5 days.
  • Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water-based lubricant, antipyretic medication and analgesia.
  • Viral infections are highly contagious. Strict adherence to infection control measures is essential.

Bacterial infections

  • The mouth may become infected and malodorous particularly if there is an oral cancer infected with anaerobic organisms. Poor dental hygiene may also encourage infection. Oral metronidazole (400mg every 8 hours for 3 to 7 days or longer if necessary) is recommended to control anaerobic infection and the associated odour.

Halitosis

  • Regular oral hygiene, fluid intake and modification of diet should be encouraged where possible.
  • Regular use of a gargle or mouthwash containing an antimicrobial agent (for example chlorhexidine) may reduce breath odour.
  • Consider artificial saliva if the mouth is very dry.
  • Treat any underlying cause.

Sialorrhoea (excessive drooling)

  • Excessive drooling of saliva is common in neurodegenerative disorders such as motor neurone disease (MND), Parkinson’s disease and multiple sclerosis. The cause is usually impaired swallowing of saliva rather than excessive saliva production.
  • Advice should be given on posture, diet and oral care.
  • For bed-bound patients, consider regular positional changes by carers/nursing staff with advice from a physiotherapist where necessary.
  • Referral with consent to a speech and language therapist should be considered for advice on swallowing techniques.
  • Consider a trial of an antimuscarinic agent for treatment for sialorrhoea:
    • glycopyrronium bromide – oral dose (as oral solution) 200 micrograms every 8 hours, titrated according to response and tolerability to 1mg every 8 hours. May be given via enteral feeding tube.
    • hyoscine hydrobromide 1mg/72 hour transdermal patch. If necessary, use 2 patches concurrently. Oral dose (tablets) 300micrograms up to three times daily.
    • amitripyline 10mg to 25mg at night.
    • atropine 1% eye drops may also be used, 4 drops on the tongue or sublingually, every 4 hours as required.
  • Glycopyrronium should be used as first-line treatment in patients who have cognitive impairment, because it has fewer central nervous system side effects.
  • For subcutaneous administration, glycopyrronium or hysocine (as hysocine butylbromide) are preferred because of the lower incidence of central nervous system effects.
  • Medication to manage sialorrhoea may exacerbate dry mouth causing thickened secretions which may be more difficult to clear.
  • Where there is thick, tenacious saliva:
    • review all current medicines, especially any treatment for sialorrheoea
    • consider treatment with humidification, sodium chloride 0.9% nebulisers and carbocisteine
  • If treatment for sialorrhoea is not effective or not tolerated, consider referral to a palliative care specialist or the specialist team looking after the patient.

Bleeding in the mouth

Refer to Bleeding guideline.

Taste change

Maintenance of nutritional intake is essential and referral to a dietitian with consent should be considered.

  • Diet should be adapted and patients encouraged to try new foods and drinks which are enjoyable and look good.
  • If minerals are lacking, supplements may be required.
  • If patients are prescribed food supplements and/or having frequent small food intake over the day, basic oral hygiene measures may need to be carried out more frequently.

Resources

References

Bensinger W, Schubert M, Ang KK, Brizel D, Brown E, Eilers JG, et al. NCCN Task Force Report. prevention and management of mucositis in cancer care. J Natl Compr Canc Netw. 2008;6 Suppl 1:S1-21; quiz S2-4.

Clarkson JE, Worthington HV, Eden TOB. Interventions for preventing oral candidiasis for patients with cancer receiving treatment. 2007 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003807.pub3/epdf/standard.

Clarkson JE, Worthington HV, Furness S, McCabe M, Khalid T, Meyer S. Interventions for treating oral mucositis for patients with cancer receiving treatment. 2010 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001973.pub4/epdf/standard.

Davies A, Finlay I. Oral care in advanced disease. Oxford: Oxford University Press; 2005.

Davies A, Hall S. Salivary gland dysfunction (dry mouth) in patients with advanced cancer. Int J Palliat Nurs. 2011;17(10):477-82.

De Conno F, Martini C, Sbabotto A, Ripamonti C, V V. Mouth care. In: Hanks G, Cherny NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK, editors. Int J Palliat Nurs. 4th ed. Oxford: Oxford University Press; 2010.

Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. 2011 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008934.pub2/epdf/standard.

Glenny A, Fernandez Mauleffinch LM, Pavitt S, Walsh T. Interventions for the prevention and treatment of herpes simplex virus in patients being treated for cancer. 2009 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006706.pub2/epdf/standard.

Harris DJ, Eilers J, Harriman A, Cashavelly BJ, Maxwell C. Putting evidence into practice: evidence-based interventions for the management of oral mucositis. Clin J Oncol Nurs. 2008;12(1):141-52.

Jensen SB, Pedersen AM, Vissink A, Andersen E, Brown CG, Davies AN, et al. A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact. Support Care Cancer. 2010;18(8):1061-79.

Lalla RV, Latortue MC, Hong CH, Ariyawardana A, D'Amato-Palumbo S, Fischer DJ, et al. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer. 2010;18(8):985-92.

Medicines and Healthcare products Regulatory Agency (MHRA). Oral swabs with a foam head - heads may detach during use. 2014 [cited 01 Nov 2024]; Available from: https://www.gov.uk/drug-device-alerts/medical-device-alert-oral-swabs-with-a-foam-head-heads-may-detach-during-use

NHS Health Scotland. Caring for smiles. Guide for care homes. 2013 [cited 2018 Oct 03]; Available from: http://www.knowledge.scot.nhs.uk/media/7460397/caringforsmilescarehomes2013.pdf.

National Institute for Health and Clinical Exellence (NICE). Motor neurone disease: assessment and management NG42. 2016 [cited 2018 Oct 03]; Available from: https://www.nice.org.uk/guidance/ng42.

Oral Health Improvement – Scottish Dental (nhs.scot)

Oralieve dry mouth relief [cited 28 Nov 24]; Available from: 360⁰ Tooth & mouth brush | Oralieve

Pienaar ED, Young T, Holmes H. Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children. 2010 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003940.pub3/epdf/standard.

Quinn B. Efficacy of a supersaturated calcium phosphate oral rinse for the prevention and treatment of oral mucositis in patients receiving high-dose cancer therapy: a review of current data. Eur J Cancer Care (Engl). 2013;22(5):564-79.

Royal College of Nursing, Mouth Care Matters in End-of-Life Care. 2021 [cited 25 Nov 2024]. Available from: Mouth Care Matters in End-of-Life Care | Publications | Royal College of Nursing

Scottish Dental Clinical Effectiveness Programme (SDCEP). Oral health assessment and review. 2011 [cited 2018 Oct 03]; Available from: http://www.sdcep.org.uk/published-guidance/oral-health-assessment/.

Scottish Dental Clinical Effectiveness Programme (SDCEP). Drug prescribing for dentistry. 2016 [cited 2018 Oct 03]; Available from: http://www.sdcep.org.uk/published-guidance/drug-prescribing/.

Scottish Dental Clinical Effectiveness Programme (SDCEP). Oral health management of patients at risk of medication-related osteonecrosis of the jaw. 2017 [cited 2018 Oct 03]; Available from: http://www.sdcep.org.uk/published-guidance/medication-related-osteonecrosis-of-the-jaw/.

Special Pharmacy Service (SPS) What should be considered when choosing or prescribing saliva substitutes? 2020 [cited 28 Nov 24]; Available from: https://www.sps.nhs.uk/articles/what-should-be-considered-when-choosing-or-prescribing-saliva-substitutes/

UK Medicines Information (UKMI) Q&As: What should be considered when choosing or prescribing salvia substitutes? 2019 [cited 28 Mov 24]; Available from: QA_Saliva-Subsitutes_update_June-2019-1.pdf

UK Oral Mucositis in Cancer Group. Mouth care guidance and support in cancer and palliative care. 2015 [cited 2018 Oct 03]; Available from:http://www.ukomic.co.uk/guidance.html

Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny A, Littlewood A, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. 2011 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000978.pub5/epdf/standard.

Worthington HV, Clarkson JE, Khalid T, Meyer S, McCabe M. Interventions for treating oral candidiasis for patients with cancer receiving treatment. 2010 [cited 2018 Oct 03]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001972.pub4/epdf/standard.