Patients with serious illness are vulnerable to oral complications, with symptoms that may impact their quality of life. An attentive oral history and examination can advance diagnosis and symptom control.
Screening questions for lucid patients
- Is there pain or discomfort in the mouth. What is its location? Character? Does it worsen with hot or cold foods/liquids?
- Do you have dentures? Oral bleeding? Dryness? Sense of taste? Odor? Difficulties chewing/swallowing?
Assessment of patients not able to express their symptoms (e.g., those with dementia, aphasia)
Assess generalized pain (with i.e., the Pain Assessment in Advanced Dementia [PAINAD] scale) and thus focus on pains that could benefit from an oral evaluation.
Gauze, a penlight, wooden tongue-depressor, and pair of gloves will suffice for the initial evaluation for most patients. Delay the exam of agitated/delirious patients until they are more calm, do not use excessive force or metal devices to force the mouth open, to avoid injury do not insert the finger.
If unable to complete the oral examination, referring the patient a dentist or otolaryngologist may be necessary.
The Brief Oral Health Status Examination (BOHSE) is a validated tool for oral examination that can be applied reliably in about 2-3 minutes; it evaluates 10 oral anatomical structures and rates them on a 3-point scale: 0 normal, 1 little structural disease status, 2 great structural disease status.
• Odor, dryness, oral hygiene, presence of prosthesis, food particles, and any active bleeding or dried blood.
• Lymph nodes (tonsillar, submandibular and submental nodes) for symmetry, enlargement, consistency, and tenderness. Small, moveable, soft, mildly tender, and symmetrical enlargement is more indicative of a viral illness whereas hard, indurated lymph nodes may denote malignancy.
• Lips: Check visually for dryness, chapping, redness at corners, bleeding, patches, or ulcers.
• Dentures: Remove and check for cleanliness and fit (poor fitting can impact oral intake).
• Tongue: Check for fissuring, redness, red or white patches, ulceration, and saliva production.
• Cheek, floor/roof of mouth for dryness, swelling, induration, masses, and aphthous ulcers. White confluent plaques that do not scrape off with a tongue depressor easily often denote thrush.
• Gums for bleeding, friability, swelling, tenderness, sores, and white patches.
• Teeth for chipped, missing, or broken teeth, decays, fillings, or sharp edges.
• Uvula, tonsils, and posterior pharyngeal wall: Check for swelling, redness, mucositis, or abscess.
Management of common causes of oral discomfort
• Thrush (candida albicans), can elicit dysgeusia and oral dryness. A 7-14-day course of fluconazole
O (initial dose 200 mg, subsequent 100 mg/day). Clotrimazole
troches or topical nystatin
4-5 times/day for 7-14 days. Advise patients to soak dentures in nystatin solution for 24 hours at least twice to prevent recurrence.
• Mucositis from chemoradiation. Mouthwash mixture of lidocaine
, and/or magnesium hydroxide
(a swish and spit for oral pain or a swish and swallow for pharyngeal or esophageal mucositis). Once daily doxepin
rinses have shown analgesic benefit. Topical opioids, anti-inflammatories, cryotherapy, sucralfate
, growth factors, and photobiomodulation have also been described.
• Oral dryness. Regular use of a non-alcohol-based mouthwash and/or oral lozenges may alleviate oral dryness. Oral saliva supplements for patients who underproduce saliva (e.g., salivary gland damage from radiation/chemotherapy).
• Aphthous ulcers: Triamcinolone
0.1% in orabase; dexamethasone
elixir swish and spit; viscous lidocaine
; and amlexanox
5% paste reduce pain in the short term.
• Swallowing problems/tongue paralysis: Referral to a speech therapist.
Oral conditions that need referral to a dentist or otolaryngologist
• Intractable oral bleeding from a dental cause
• Gingival necrosis from a recent radiation treatment
• Infection of bilateral submandibular space (Ludwig’s angina)
• Acutely painful tonsillar and retropharyngeal abscess
• Tooth extraction prior to chemo-radiation initiation
• Temporomandibular joint issues
• Ill-fitting dentures
See reference for more information
Adapted from Habib MH et al. Oral care: focused history and examination in patients with serious illness. Palliative Care Network of Wisconsin. Fast facts and concepts #430. Internet. Available at https://www.mypcnow.org/fast-fact/oral-care-focused-history-and-examination-in-patients-with-serious-illness/