Other common oral problems DR ANDREW DAVIES FRCP CONSULTANT IN PALLIATIVE MEDICINE ROYAL SURREY COUNTY HOSPITAL, GUILDFORD, UK

Outline Epidemiology OASis study Poor oral hygiene Halitosis Taste disturbance

Epidemiology

Statistics While the individual man is an insoluble puzzle, in the aggregate he becomes a mathematical certainty. You can, for example, never foretell what any one man will be up to, but you can say with precision what an average number will be up to. Individuals vary, but percentages remain constant. So says the statistician. Arthur Conan Doyle

Statistics The average human has one breast and one testicle. Des McHale

Statistics

Assessment tools No validated generic oral assessment tool [Some symptom specific / disease specific assessment tools] Validated general symptom assessment tools contain variable number oral symptoms

Assessment tools Edmonton Symptom Assessment Scale (ESAS) - none Palliative Outcome Scale (POS) - none Memorial Symptom Assessment Scale (MSAS) - xerostomia, dysgeusia, mouth sores

Assessment tools Thirty-three symptoms commonly associated with cancer were selected following review of the literature pertaining to symptom assessment and control.

Assessment tools 10 Study Population Xerostomia Dysgeusia Mouth sores Portenoy et al, 1994 Harrison et al, 1997 Mixed cancer (n = 218) Ca tongue - post RT (n = 29) Davies, 2000 Advanced cancer (n = 120) Tranmer et al, 2003 Advanced cancer (n = 66) 55.5% 37% 13% 100% 34% 7% 78% 44% 14% 82% 50% n/s

Assessment tools Symptom Slight Moderate Severe Very severe Xerostomia 14% 37% 33% 16% Dysgeusia 30% 45% 19% 6% Mouth sores 59% 35% 6% 0% Davies, 2000

Assessment tools Symptom Not at all A little bit Somewhat Quite a bit Very much Xerostomia 16% 21% 23% 26% 14% Dysgeusia 17% 32% 23% 21% 7% Mouth sores 18% 35% 18% 29% 0% Davies, 2000

OASis study

OASis study Observational study Patients with advanced cancer Oral Symptom Assessment Scale (cf MSAS)

OASis study Symptom Frequency (%) Dry mouth 83.5% Taste disturbance 55.5% Coating tongue 47.0% Lip discomfort 38.5% Dirty mouth 35.0% Difficulty swallowing 34.5% Lip cracking 34.0% Mouth discomfort 30.5% Difficulty speaking 27.0% Difficulty chewing 22.5%

OASis study Symptom Frequency (%) Mouth corner cracking 22.5% Sensitive teeth 21.0% Mouth ulcers 17.0% Bad breath 16.5% Jagged teeth 16.5% Altered sensation 11.0% Denture fitting problems 10.5% Toothache 10.0% Burning sensation 9.5% Bleeding mouth 7.5%

Poor oral hygiene (coated tongue, dirty mouth )

Poor oral hygiene

Poor oral hygiene Maintenance of normal oral hygiene measures Management of contributing factors (e.g. fatigue, depression) Management of salivary gland dysfunction

Poor oral hygiene 20 Toothbrushing twice daily Interdental cleaning once daily Denture cleaning once daily (night) Oral mucosa cleaning after each meal (Tongue scraping) (Chlorhexidine difficulties with mechanical control of dental plaque)

Poor oral hygiene

Black / brown hairy tongue

Black / brown hairy tongue Common Hypertrophy / elongation filiform papillae; over-growth of chromogenic bacteria or pigments derived from eating / smoking Idiopathic; smoking; poor oral hygiene; salivary gland dysfunction; antibiotic use; ferrous sulfate use

Black / brown hairy tongue Asymptomatic; (oral discomfort / dysgeusia) Oral hygiene measures; tongue cleaning; reassurance

Halitosis

Halitosis Definition: Offensive odours from the mouth or hollow cavities such as the nose, sinuses, and pharynx.

Halitosis Classification: A. Genuine halitosis Physiological halitosis Pathological halitosis - intra-oral causes - extra-oral causes B. Pseudohalitosis C. Halitophobia

Halitosis 30 Pathophysiology (physiological): Putrefaction of amino acids / polypeptides / proteins in food debris, epithelial cells, blood cells and saliva. Production of volatile sulphur compounds (e.g. hydrogen sulphide) and volatile non-sulphur compounds (e.g. diamines).

Halitosis Clinical features: Malodour mouth > malodour nose oral cause Malodour nose > malodour mouth upper RS tract (nose / sinuses) Malodour mouth = malodour nose lower RS tract / GI tract / metabolic cause

Halitosis Management (physiological): 1. Dietary modification 2. Smoking cessation 3. Measures to reduce bacterial substrates (e.g. oral hygiene measures, tongue cleaning) 4. Measures to reduce bacterial numbers (e.g. chlorhexidine, essential oils)

Halitosis

Halitosis Management (physiological): 5. Measures to convert VSCs (e.g. zinc salts, baking soda) 6. Use of masking agents (e.g. mints) 7. Use of natural products (e.g. herbs) 8. [Management of salivary gland dysfunction]

Taste disturbance

Taste disturbance We were to celebrate my birthday and I had helped to prepare salmon and looked forward to have dinner with the family. The taste alteration was incredible, the food tasted of absolutely nothing or possibly of wheat flower; I was disappointed and depressed and felt sorry for myself, I couldn t feel or share happiness with my family during that occasion.

Taste disturbance Treatment of underlying cause (e.g. salivary gland dysfunction) Dietary interventions - utilisation of foods that taste good - avoidance of foods that taste bad - enhancing the taste of the food (using salt, sugar, and other flavourings) - addressing the presentation, smell, consistency and temperature of the food

Taste disturbance

Taste disturbance Zinc supplements [Other treatments]

Conclusion