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Oral disease in terminally ill cancer patients with xerostomia
ORAL ONCOLOGY Oral Oncology 34 (1998) 123 126
PERGAMON
Oral disease in terminally ill cancer patients with xerostomia M. P. Sweeney a, J. Bagg b*, W. P. Baxter c, T. C. Aitchison d aRenfrewshire Healthcare NHS Trust, Dykebar Hospital, Grahamston Road. Paisley PA2 7DE, U.K. bGlasgow Dental Hospital & School, 378 Sauchiehall Street, Glasgow G2 3JZ, U.K. cACCORD Hospice, Hawkhead Road, Paisley PA2 7BL, U.K. dUniversity of Glasgow Statistics Department, 15 University Gardens, Glasgow G12 8QQ, U.K. Received 20 July 1997; received in revised form 14 September 1997; accepted 6 October 1997
Abstract
Xerostomia is common among patients with advanced cancer and is likely to contribute to oral disease. This study determined the prevalence of oral signs and symptoms among a group of 70 terminally ill cancer patients [25 male, 45 female; age range 42-88 (mean 66) years] complaining of oral dryness, and examined the associated oral microflora. Imprint cultures for yeasts, coliforms and staphylococci were collected from the tongue and, in denture wearers, from the palate and denture fitting surface. A swab was collected for culture of herpes simplex virus. 68 patients (97%) complained of oral dryness during the day and 59 patients (84%) complained of oral dryness at night. Oral soreness was reported by 22 patients (31%). 46 patients (66%) had difficulty talking and 36 (51%) reported difficulty eating. Of the 56 denture wearers, 40% complained of denture problems. On examination, 63 (90%) of the patients had clinically dry mouths. Oral mucosal abnormalities were detected in 45 patients (65%), most commonly erythema (20%), coated tongue (20%), atrophic glossitis (17%), angular cheilitis (11%) and pseudomembranous candidosis (9%). 47 (67%) of the patients carried yeasts, 18 (26%) were carriers of Staphylococcus aureus and 13 (19%) carried coliforms. Herpes simplex virus was isolated from 5 patients, of whom 2 had herpetic stomatitis. Oral complications and abnormalities of the oral microflora can be detected among significant numbers of terminally ill cancer patients with xerostomia. © 1998 Elsevier Science Ltd. All rights reserved. Keywords." Cancer; Hospice; Oral health; Palliative treatment; Xerostomia
1. Introduction
2. Patients and methods
Patients suffering from terminal cancer m a y experience a range of oral symptoms [1,2], m a n y of which are due to infection and are a consequence of changes in the oral microflora. The c o m m o n e s t oral s y m p t o m is oral dryness [1,2], which is often drug-related. Saliva plays a major role in the maintenance of health of both the hard and soft tissues of the m o u t h and xerostomia can lead to rapid deterioration in oral health. In cancer patients, this problem is c o m p o u n d e d by other factors, for example their relative immunosuppression, which predisposes to oral infections such as candidosis. The present study describes the oral signs and symptoms displayed by a group of terminally ill cancer patients, all with a complaint of xerostomia, who were subsequently offered treatment with a salivary substitute spray.
Ethical approval for the study was obtained from the Ethics Panel of the Royal Alexandra Hospital N H S Trust, Paisley, U.K.
* Corresponding author. 1368-8375/98/$19.00 © 1998 Elsevier Science Ltd. All rights reserved PII: S 1368-8 375(97)00076-6
2.1. Patients
70 terminally ill patients (25 male and 45 female) were studied. Their ages ranged from 42 to 88 years (mean age 66 years). 37 (53%) were in-patients at the Bedded Unit of the A C C O R D Hospice, Paisley, U.K., 25 (36%) were attending the D a y Unit of the same hospice and 8 (11%) were visited at home but were also receiving intermittent care at the hospice. All patients attending this hospice are routinely asked on admission, by the medical and nursing staff, whether their mouths feel dry. Over the period of the study, consecutive patients with a positive response were invi-
124
M. P. Sweeney et al./Oral Oncology 34 (1998) 12~126
ted by the receiving physician to participate and were then referred to the main investigator (MPS), a dental surgeon. The majority of the primary tumours were carcinomas (62/70), with lung and breast the commonest sites. Two patients had oral carcinoma. 41 of the patients had received surgical treatment for their malignant disease, 39 had been treated with radiotherapy and 20 had undergone chemotherapy, many having received multiple forms of treatment. All of the patients examined were on complex, customised palliative care drug regimens and each was taking at least one form of medication known to induce xerostomia. 2.2. Clinical assessment
Demographic details, underlying diagnosis and details of previous and current treatments were obtained by direct patient questioning and from the medical records. Oral symptoms were recorded on visual analogue scales graded from 0 (no problem) to 6 (severe problem). The symptoms assessed were: dry mouth during the day; dry mouth at night; soreness of the mouth; bad or altered taste; difficulty talking and difficulty eating. Patients were asked an open question on whether they encountered problems with their dentures. The mouth was examined by incandescent torch light illumination. A subjective assessment of the degree of oral dryness was made by the clinician, based on the presence or absence of a salivary pool and the clinical appearance of the oral mucosa. This was scored on a visual analogue scale from 0 (absent) to 3 (severe). For dentate patients, teeth were charted and visible caries recorded. Oral hygiene was assessed by a modification of the D6bris Index [3], in which plaque deposits were subjectively scored on the buccal surfaces of all remaining natural teeth, where 0 = n o visible plaque, 1 = minimal plaque, 2 - m o d e r a t e plaque and 3 = severe plaque. Each tooth was scored and the mean determined. The types of dentures owned and worn were recorded. Details of denture fit and cleanliness were categorised as good, acceptable, poor or very poor. The oral mucosa was examined for pathological changes, particularly erythema, plaques, atrophic glossitis, thrush, denture stomatitis and angular cheilitis. 2.3. Specimen collection
Imprint cultures [4] were collected from the tongue and, when appropriate, from the palate and fitting surface of the denture. Briefly, a sterile foam pad (1 cm× 1 cm) was applied to the sample site for 5 s. The pad was then used to inoculate sequentially individual plates of Sabouraud's agar and Pagano Levin agar [5]
for yeast culture, mannitol salt agar for Staphylococcus aureus and MacConkey agar for coliforms. The plates were transported to the laboratory within 3 h for incubation and processed according to standard methods. The floor of the mouth was sampled with a dry swab which was broken off into 2 ml of virus transport medium. The specimen was relayed to the laboratory within 3 h and cultured in tubes containing a human embryonic lung fibroblast cell line (HEL 299; ECACC No. 87042207) for detection of herpes simplex virus. All tubes were examined daily for cytopathic effect and growth of virus confirmed by immunofluorescence (HSV1 and HSV2 Direct Specimen Reagent, Syva Microtrak). Finally, the insert from a sterile Salivette ® (Sarstedt Ltd, Leicester, U.K.) was placed beneath the tongue for 30 s. It was then removed, replaced in the inner tube of the Salivette e and the unit sealed. On arrival at the laboratory the Salivette @ was centrifuged at 4000 rpm in a bench top centrifuge (Centaur 1, Fisons, Crawley, Sussex, U.K.) and the volume of saliva which collected in the outer tube was measured by means of a microsyringe. Salivette ® specimens were also collected from a group of matched control subjects for purposes of comparison.
3. Results 3.1. Oral symptoms
Since a sensation of oral dryness was one of the enrolment criteria, all of the patients complained of xerostomia either during the day or the night. The overall prevalence and severity of symptoms are summarised in Table 1.22 (40%) of the 56 denture wearers reported difficulties with their prostheses. 3.2. Dental status
21 of the patients had remaining natural teeth. The mean plaque score was 0.8 + 0.8 (range 0.0 3.0). Only 7 patients had clinically evident dental caries. 56 of the patients were denture wearers. Details of denture fit and cleanliness are given in Table 2. 3.3. Oral signs
On clinical examination, 63 patients (90%) had visual evidence of xerostomia. This visual impression was reinforced by the Salivette ~ volumes. The median Salivette e volume for the 70 patients was 25 I~1 and for 68 healthy controls was 250 ~1. 45 patients (65%) demonstrated abnormalities of the oral mucosa, the most frequent of which are summarised in Table 3.
M. P. Sweeney et al./Oral Oncology 34 (1998) 123-126 Table 1 Summary of symptoms reported by the 70 patients Symptom Dryness during day Dryness at night Difficulty talking Altered taste sensation Difficulty eating Soreness
No. (%) 68 59 46 40 36 22
(97) (84) (66) (57) (51) (31)
No. with moderate/severe symptom* (%) 51 (73) 58 (83) 32 (46) 28 (40) 22 (31) 13 (19)
Table 2 Summary of denture fit and denture hygiene for the 56 denture wearers*
Upper denture Good Acceptable Poor Very poor Lower denture Good Acceptable Poor Very poor
Fit
Cleanliness
24 23 4 1
27 22 3 0
10 21 7 1
22 14 3 0
*4 of the 56 patients were not wearing their dentures on the day of examination. Table 3 Summary of the most frequent oral mucosal abnormalities among the 70 patients Sign
No. (%)
Erythema Coated tongue Atrophic glossitis Angular cheilitis Pseudomembranous candidosis Total with mucosal abnormalities
14 (20) 14 (20) 12 (17) 8 (11) 6 (9) 45 (65)
Table 4 The species of oral yeasts isolated from the study group Species Candida albicans Candida glabrata Candida parapsilosis Candida tropicalis Candida krusei Saccharomyces cerevisiae
nised with more than one species. Candida albicans was the most common isolate as illustrated in Table 4. Herpes simplex virus was isolated from 5 patients, 2 of whom had clinically evident herpetic stomatitis.
4. Discussion
*Visual analogue score of 4-6.
Grading
125
No. of times isolated 23 13 2 1 1 1
3.4. Oral microbiology
The oral carriage rates of the organisms studied were 67% for yeasts, 26% for S. aureus and 19% for coliforms. In relation to the yeasts, 5 patients were colo-
Oral disease among the elderly and medically compromised is increasingly recognised as a common and important problem which is frequently overlooked in protocols for general patient care. We have recently reported a high prevalence of mouth problems among hospitalised patients in a geriatric unit [6] and described a form of mucositis in the elderly caused by S. aureus [7]. Terminally ill cancer patients represent another group with significant oral problems [1,2]. Xerostomia has been identified as one of the major complications [2] and the present study has examined, in detail, the oral health of a group of terminally ill cancer patients with dry mouth. The severity of the dryness, both during the day and at night, was reported as moderate to severe by a majority of the patients. This is a distressing problem for patients who are already seriously ill and study of its treatment should be a priority. The dryness contributes to other symptoms, such as difficulty with talking and eating, and can also affect denture retention, all of which were reported by patients in the present study. Denture retention is also compromised in many cases by the loss of bulk of the facial musculature that occurs in cachectic cancer patients. The oral and denture hygiene among this group of patients was generally good, considering their poor general state of health, reflecting the strong emphasis on mouth care at the hospice where the study was undertaken. The hospice has a strict denture hygiene policy, whereas less attention is often paid to mouth care for cancer patients being nursed in acute hospitals or in the community [8]. The clinical importance of immaculate denture hygiene in this group of patients, with such a marked predisposition to oral candidosis [9], cannot be over-stated. Significantly, 40% of the denture wearers complained of denture problems and simple procedures, such as bed-side re-lining of dentures, can be extremely effective in the last few weeks of life. These are areas, therefore, in which the dental profession can play a significant educational and therapeutic role. The prevalence of oral mucosal abnormalities (65%), although high, was lower than the 82% described in a previous study [2]. This may again reflect the level of oral care provided. Much of the mucosal disease noted was fungal in nature and yeasts were isolated from the mouths of 67% of the patients. Oral candidosis is a well-recognised complication among cancer patients [9],
126
M. P. Sweeney et al./Oral Oncology 34 (1998) 123 126
in whom it can present in many forms, including plaques, areas of erythema, or angular cheilitis. With the availability and increasing use of systemic triazole antifungal drugs, accurate diagnosis and monitoring of treatment of oral candidosis is important among groups such as cancer patients. The detection of S. aureus in the mouths of 26% of the patients was in keeping with figures from a previous study [10]. It has recently been suggested that S. aureus may be responsible for a type of oral mucositis among elderly dehydrated patients receiving intravenous fluids and parenteral nutrition [7]. Its role in mediating oral mucosal disease among other groups of patients, including those with cancer, is the subject of continuing study. The fact that the mouth is a potential reservoir of S. aureus, particularly among the seriously ill, should not be forgotten and is relevant to the carriage of methicillin resistant S. aureus. The carriage rate of coliforms (19%) was much lower than that described in another study of hospice patients [10]. It is well recognised that both chronic and acute underlying disease can promote the acquisition and subsequent oral carriage of aerobic Gram-negative bacilli [11]. Whilst endotoxin release from coliforms has been suggested as an aetiological factor in mucositis induced by radiotherapy or chemotherapy [12], there is no recognised causal link with other forms of oral mucosal disease. Oral shedding of herpes simplex virus was studied because of recent evidence that such shedding is more frequent among the immunocompromised [13]. In addition, intra-oral reactivation lesions are more common in such patients and are often clinically atypical. The number of individuals who were shedding the virus was relatively low and it would be of interest to repeat this part of the study using more sensitive molecular techniques to detect the virus. However, the culture results were very helpful in establishing the diagnosis for the 2 patients with herpetic stomatitis. In recent months, we have seen and treated several cancer patients with unusual forms of oral ulceration which have proved on culture to be caused by herpes simplex virus. This diagnosis should always be considered in immunocompromised patients with painful, clinically atypical oral ulceration [13]. With the current expansion in palliative medicine, dentists are increasingly likely to be asked to provide advice and treatment for patients with advanced cancer. This study has indicated some of the common oral problems that are encountered and a recent paper has pro-
vided practical advice on the provision of oral care for hospice patients [14]. Relief of oral discomfort is an important element of cancer care and active involvement of the dental profession is an essential part of the multidisciplinary approach required in effective palliative medicine.
Acknowledgement This study was supported by Nycomed (U.K).
References [l] Aldred MJ, Addy M, Bagg J, Finlay I. Oral health in the terminally ill: a cross-sectional pilot survey. Special Care in Dentistry 1991;11:59~2. [2] Jobbins J, Bagg J, Finlay IG, Addy M, Newcombe RG. Oral and dental disease in terminally ill cancer patients. British Medical Journal 1992;304:1612. [3] Greene JC, Vermillion JR. The oral hygiene index: a method of classifying oral hygiene status. Journal of American Dental Association 1960;61:172 179. [4] Arendorf TM, Walker DM. Oral candidal populations in health and disease. British Dental Journal 1979;147:267 272. [5] Samaranayake LP, MacFarlane TW, Williamson MI. Comparison of Sabouraud dextrose and Pagano Levin agar media for detection and isolation of yeasts from oral samples. Journal of Clinical Microbiology 1987;25:16~164. [6] Sweeney MP, Shaw A, Yip B, Bagg J. Oral health of elderly institutionalised patients. British Journal of Nursing 1995;4:1204-1208. [7] Bagg J, Sweeney MP, Harvey Wood K, Wiggins A. Possible role of Staphylococcus aureus in severe oral mucositis among elderly dehydrated patients. Microbial Ecology in Health and Disease 1995;8:51-56. [8] Sweeney MP, Bagg J, Doig P, McGill M, Milligan S, Malarkey C. Provision of mouth care by nursing staff for Scottish cancer patients: current status and the role of training. Nursing Times Research 1996;1:389 395. [9] Finlay I. Oral fungal infections. European Journal of Palliative Care 1995;2(Suppl. 1):4-7. [10] Jobbins J, Bagg J, Parsons K, Finlay I, Addy M, Newcombe RG. Oral carriage of yeasts, coliforms and staphylococi in patients with advanced malignant disease. Journal of Oral Pathology and Medicine 1992;21:305 308. [11] Bagg J. Can the colonisation resistance of the oral microflora be reduced? Microbial Ecology in Health and Disease 1990; 3: v viii. [12] Spijkervet FKL, van Saene HKF, van Saene JJM, et al. Effect of selective elimination of the oral flora on mucositis in irradiated head and neck cancer patients. Journal of Surgical Oncology 1991;46:167 173. [13] Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Current Opinions in Dentistry 1988; 1:384-397. [14] Sweeney MP, Bagg J. Oral care for hospice patients with advanced cancer. Dental Update 1995;22:424-427.
PERGAMON
Oral disease in terminally ill cancer patients with xerostomia M. P. Sweeney a, J. Bagg b*, W. P. Baxter c, T. C. Aitchison d aRenfrewshire Healthcare NHS Trust, Dykebar Hospital, Grahamston Road. Paisley PA2 7DE, U.K. bGlasgow Dental Hospital & School, 378 Sauchiehall Street, Glasgow G2 3JZ, U.K. cACCORD Hospice, Hawkhead Road, Paisley PA2 7BL, U.K. dUniversity of Glasgow Statistics Department, 15 University Gardens, Glasgow G12 8QQ, U.K. Received 20 July 1997; received in revised form 14 September 1997; accepted 6 October 1997
Abstract
Xerostomia is common among patients with advanced cancer and is likely to contribute to oral disease. This study determined the prevalence of oral signs and symptoms among a group of 70 terminally ill cancer patients [25 male, 45 female; age range 42-88 (mean 66) years] complaining of oral dryness, and examined the associated oral microflora. Imprint cultures for yeasts, coliforms and staphylococci were collected from the tongue and, in denture wearers, from the palate and denture fitting surface. A swab was collected for culture of herpes simplex virus. 68 patients (97%) complained of oral dryness during the day and 59 patients (84%) complained of oral dryness at night. Oral soreness was reported by 22 patients (31%). 46 patients (66%) had difficulty talking and 36 (51%) reported difficulty eating. Of the 56 denture wearers, 40% complained of denture problems. On examination, 63 (90%) of the patients had clinically dry mouths. Oral mucosal abnormalities were detected in 45 patients (65%), most commonly erythema (20%), coated tongue (20%), atrophic glossitis (17%), angular cheilitis (11%) and pseudomembranous candidosis (9%). 47 (67%) of the patients carried yeasts, 18 (26%) were carriers of Staphylococcus aureus and 13 (19%) carried coliforms. Herpes simplex virus was isolated from 5 patients, of whom 2 had herpetic stomatitis. Oral complications and abnormalities of the oral microflora can be detected among significant numbers of terminally ill cancer patients with xerostomia. © 1998 Elsevier Science Ltd. All rights reserved. Keywords." Cancer; Hospice; Oral health; Palliative treatment; Xerostomia
1. Introduction
2. Patients and methods
Patients suffering from terminal cancer m a y experience a range of oral symptoms [1,2], m a n y of which are due to infection and are a consequence of changes in the oral microflora. The c o m m o n e s t oral s y m p t o m is oral dryness [1,2], which is often drug-related. Saliva plays a major role in the maintenance of health of both the hard and soft tissues of the m o u t h and xerostomia can lead to rapid deterioration in oral health. In cancer patients, this problem is c o m p o u n d e d by other factors, for example their relative immunosuppression, which predisposes to oral infections such as candidosis. The present study describes the oral signs and symptoms displayed by a group of terminally ill cancer patients, all with a complaint of xerostomia, who were subsequently offered treatment with a salivary substitute spray.
Ethical approval for the study was obtained from the Ethics Panel of the Royal Alexandra Hospital N H S Trust, Paisley, U.K.
* Corresponding author. 1368-8375/98/$19.00 © 1998 Elsevier Science Ltd. All rights reserved PII: S 1368-8 375(97)00076-6
2.1. Patients
70 terminally ill patients (25 male and 45 female) were studied. Their ages ranged from 42 to 88 years (mean age 66 years). 37 (53%) were in-patients at the Bedded Unit of the A C C O R D Hospice, Paisley, U.K., 25 (36%) were attending the D a y Unit of the same hospice and 8 (11%) were visited at home but were also receiving intermittent care at the hospice. All patients attending this hospice are routinely asked on admission, by the medical and nursing staff, whether their mouths feel dry. Over the period of the study, consecutive patients with a positive response were invi-
124
M. P. Sweeney et al./Oral Oncology 34 (1998) 12~126
ted by the receiving physician to participate and were then referred to the main investigator (MPS), a dental surgeon. The majority of the primary tumours were carcinomas (62/70), with lung and breast the commonest sites. Two patients had oral carcinoma. 41 of the patients had received surgical treatment for their malignant disease, 39 had been treated with radiotherapy and 20 had undergone chemotherapy, many having received multiple forms of treatment. All of the patients examined were on complex, customised palliative care drug regimens and each was taking at least one form of medication known to induce xerostomia. 2.2. Clinical assessment
Demographic details, underlying diagnosis and details of previous and current treatments were obtained by direct patient questioning and from the medical records. Oral symptoms were recorded on visual analogue scales graded from 0 (no problem) to 6 (severe problem). The symptoms assessed were: dry mouth during the day; dry mouth at night; soreness of the mouth; bad or altered taste; difficulty talking and difficulty eating. Patients were asked an open question on whether they encountered problems with their dentures. The mouth was examined by incandescent torch light illumination. A subjective assessment of the degree of oral dryness was made by the clinician, based on the presence or absence of a salivary pool and the clinical appearance of the oral mucosa. This was scored on a visual analogue scale from 0 (absent) to 3 (severe). For dentate patients, teeth were charted and visible caries recorded. Oral hygiene was assessed by a modification of the D6bris Index [3], in which plaque deposits were subjectively scored on the buccal surfaces of all remaining natural teeth, where 0 = n o visible plaque, 1 = minimal plaque, 2 - m o d e r a t e plaque and 3 = severe plaque. Each tooth was scored and the mean determined. The types of dentures owned and worn were recorded. Details of denture fit and cleanliness were categorised as good, acceptable, poor or very poor. The oral mucosa was examined for pathological changes, particularly erythema, plaques, atrophic glossitis, thrush, denture stomatitis and angular cheilitis. 2.3. Specimen collection
Imprint cultures [4] were collected from the tongue and, when appropriate, from the palate and fitting surface of the denture. Briefly, a sterile foam pad (1 cm× 1 cm) was applied to the sample site for 5 s. The pad was then used to inoculate sequentially individual plates of Sabouraud's agar and Pagano Levin agar [5]
for yeast culture, mannitol salt agar for Staphylococcus aureus and MacConkey agar for coliforms. The plates were transported to the laboratory within 3 h for incubation and processed according to standard methods. The floor of the mouth was sampled with a dry swab which was broken off into 2 ml of virus transport medium. The specimen was relayed to the laboratory within 3 h and cultured in tubes containing a human embryonic lung fibroblast cell line (HEL 299; ECACC No. 87042207) for detection of herpes simplex virus. All tubes were examined daily for cytopathic effect and growth of virus confirmed by immunofluorescence (HSV1 and HSV2 Direct Specimen Reagent, Syva Microtrak). Finally, the insert from a sterile Salivette ® (Sarstedt Ltd, Leicester, U.K.) was placed beneath the tongue for 30 s. It was then removed, replaced in the inner tube of the Salivette e and the unit sealed. On arrival at the laboratory the Salivette @ was centrifuged at 4000 rpm in a bench top centrifuge (Centaur 1, Fisons, Crawley, Sussex, U.K.) and the volume of saliva which collected in the outer tube was measured by means of a microsyringe. Salivette ® specimens were also collected from a group of matched control subjects for purposes of comparison.
3. Results 3.1. Oral symptoms
Since a sensation of oral dryness was one of the enrolment criteria, all of the patients complained of xerostomia either during the day or the night. The overall prevalence and severity of symptoms are summarised in Table 1.22 (40%) of the 56 denture wearers reported difficulties with their prostheses. 3.2. Dental status
21 of the patients had remaining natural teeth. The mean plaque score was 0.8 + 0.8 (range 0.0 3.0). Only 7 patients had clinically evident dental caries. 56 of the patients were denture wearers. Details of denture fit and cleanliness are given in Table 2. 3.3. Oral signs
On clinical examination, 63 patients (90%) had visual evidence of xerostomia. This visual impression was reinforced by the Salivette ~ volumes. The median Salivette e volume for the 70 patients was 25 I~1 and for 68 healthy controls was 250 ~1. 45 patients (65%) demonstrated abnormalities of the oral mucosa, the most frequent of which are summarised in Table 3.
M. P. Sweeney et al./Oral Oncology 34 (1998) 123-126 Table 1 Summary of symptoms reported by the 70 patients Symptom Dryness during day Dryness at night Difficulty talking Altered taste sensation Difficulty eating Soreness
No. (%) 68 59 46 40 36 22
(97) (84) (66) (57) (51) (31)
No. with moderate/severe symptom* (%) 51 (73) 58 (83) 32 (46) 28 (40) 22 (31) 13 (19)
Table 2 Summary of denture fit and denture hygiene for the 56 denture wearers*
Upper denture Good Acceptable Poor Very poor Lower denture Good Acceptable Poor Very poor
Fit
Cleanliness
24 23 4 1
27 22 3 0
10 21 7 1
22 14 3 0
*4 of the 56 patients were not wearing their dentures on the day of examination. Table 3 Summary of the most frequent oral mucosal abnormalities among the 70 patients Sign
No. (%)
Erythema Coated tongue Atrophic glossitis Angular cheilitis Pseudomembranous candidosis Total with mucosal abnormalities
14 (20) 14 (20) 12 (17) 8 (11) 6 (9) 45 (65)
Table 4 The species of oral yeasts isolated from the study group Species Candida albicans Candida glabrata Candida parapsilosis Candida tropicalis Candida krusei Saccharomyces cerevisiae
nised with more than one species. Candida albicans was the most common isolate as illustrated in Table 4. Herpes simplex virus was isolated from 5 patients, 2 of whom had clinically evident herpetic stomatitis.
4. Discussion
*Visual analogue score of 4-6.
Grading
125
No. of times isolated 23 13 2 1 1 1
3.4. Oral microbiology
The oral carriage rates of the organisms studied were 67% for yeasts, 26% for S. aureus and 19% for coliforms. In relation to the yeasts, 5 patients were colo-
Oral disease among the elderly and medically compromised is increasingly recognised as a common and important problem which is frequently overlooked in protocols for general patient care. We have recently reported a high prevalence of mouth problems among hospitalised patients in a geriatric unit [6] and described a form of mucositis in the elderly caused by S. aureus [7]. Terminally ill cancer patients represent another group with significant oral problems [1,2]. Xerostomia has been identified as one of the major complications [2] and the present study has examined, in detail, the oral health of a group of terminally ill cancer patients with dry mouth. The severity of the dryness, both during the day and at night, was reported as moderate to severe by a majority of the patients. This is a distressing problem for patients who are already seriously ill and study of its treatment should be a priority. The dryness contributes to other symptoms, such as difficulty with talking and eating, and can also affect denture retention, all of which were reported by patients in the present study. Denture retention is also compromised in many cases by the loss of bulk of the facial musculature that occurs in cachectic cancer patients. The oral and denture hygiene among this group of patients was generally good, considering their poor general state of health, reflecting the strong emphasis on mouth care at the hospice where the study was undertaken. The hospice has a strict denture hygiene policy, whereas less attention is often paid to mouth care for cancer patients being nursed in acute hospitals or in the community [8]. The clinical importance of immaculate denture hygiene in this group of patients, with such a marked predisposition to oral candidosis [9], cannot be over-stated. Significantly, 40% of the denture wearers complained of denture problems and simple procedures, such as bed-side re-lining of dentures, can be extremely effective in the last few weeks of life. These are areas, therefore, in which the dental profession can play a significant educational and therapeutic role. The prevalence of oral mucosal abnormalities (65%), although high, was lower than the 82% described in a previous study [2]. This may again reflect the level of oral care provided. Much of the mucosal disease noted was fungal in nature and yeasts were isolated from the mouths of 67% of the patients. Oral candidosis is a well-recognised complication among cancer patients [9],
126
M. P. Sweeney et al./Oral Oncology 34 (1998) 123 126
in whom it can present in many forms, including plaques, areas of erythema, or angular cheilitis. With the availability and increasing use of systemic triazole antifungal drugs, accurate diagnosis and monitoring of treatment of oral candidosis is important among groups such as cancer patients. The detection of S. aureus in the mouths of 26% of the patients was in keeping with figures from a previous study [10]. It has recently been suggested that S. aureus may be responsible for a type of oral mucositis among elderly dehydrated patients receiving intravenous fluids and parenteral nutrition [7]. Its role in mediating oral mucosal disease among other groups of patients, including those with cancer, is the subject of continuing study. The fact that the mouth is a potential reservoir of S. aureus, particularly among the seriously ill, should not be forgotten and is relevant to the carriage of methicillin resistant S. aureus. The carriage rate of coliforms (19%) was much lower than that described in another study of hospice patients [10]. It is well recognised that both chronic and acute underlying disease can promote the acquisition and subsequent oral carriage of aerobic Gram-negative bacilli [11]. Whilst endotoxin release from coliforms has been suggested as an aetiological factor in mucositis induced by radiotherapy or chemotherapy [12], there is no recognised causal link with other forms of oral mucosal disease. Oral shedding of herpes simplex virus was studied because of recent evidence that such shedding is more frequent among the immunocompromised [13]. In addition, intra-oral reactivation lesions are more common in such patients and are often clinically atypical. The number of individuals who were shedding the virus was relatively low and it would be of interest to repeat this part of the study using more sensitive molecular techniques to detect the virus. However, the culture results were very helpful in establishing the diagnosis for the 2 patients with herpetic stomatitis. In recent months, we have seen and treated several cancer patients with unusual forms of oral ulceration which have proved on culture to be caused by herpes simplex virus. This diagnosis should always be considered in immunocompromised patients with painful, clinically atypical oral ulceration [13]. With the current expansion in palliative medicine, dentists are increasingly likely to be asked to provide advice and treatment for patients with advanced cancer. This study has indicated some of the common oral problems that are encountered and a recent paper has pro-
vided practical advice on the provision of oral care for hospice patients [14]. Relief of oral discomfort is an important element of cancer care and active involvement of the dental profession is an essential part of the multidisciplinary approach required in effective palliative medicine.
Acknowledgement This study was supported by Nycomed (U.K).
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