Interventional Prospective Studies on Xerostomia in Patients Undergoing Palliative and End-of-Life Care: A Scoping Review.

Patients undergoing palliative care often develop debilitating oral conditions, including xerostomia. These conditions may significantly impact patients' quality of life. Despite the high prevalence and adverse impact of xerostomia, effective management strategies remain unclear. This scoping review was performed to elucidate effective interventions for xerostomia in patients undergoing palliative and end-of-life care. A comprehensive search strategy was employed to identify relevant studies up to August 2023. Full-text primary articles focusing on xerostomia in patients receiving palliative care were included in the review. Eleven articles were selected for analysis, and data were extracted by six reviewers. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Among the 11 studies, interventions ranged from oral care to saliva substitutes and methods to stimulate saliva secretion. The primary method of assessing xerostomia was the performance of subjective evaluations using visual analog scale scores or numerical rating scale scores. Various interventions including oral care regimens, topical treatments, and mixed efficacy outcomes were reported. Notably, only one study directly measured the saliva volume, highlighting a reliance on subjective endpoints in most studies. Although no definitive conclusions can be drawn regarding the most effective intervention, oral care was a preferred option for managing xerostomia in patients undergoing palliative care. Additionally, adjunctive treatments such as ice cubes, saline, and moisturizers showed promise but require further investigation. Objective measures should be incorporated into future intervention trials to complement subjective assessments and provide a comprehensive evaluation of xerostomia management strategies in this patient population.

Oral candida lesions and Candida tropicalis: Potential prognostic markers in end-of-life cancer patients.

AIMS: Oral candidosis is common in patients with end-of-life cancer; however, its prognosis is unclear. We aimed to assess oral candidosis and Candida species as prognostic indicators in palliative care for these patients. METHODS: We consecutively included palliative care patients, assessed for candidosis via microbiological techniques, and classified into three groups by the extent of oral lesions. The association between oral candidosis and overall survival was assessed using a Cox proportional hazards model adjusted by performance status (PS). RESULTS: We studied 142 patients (median age 77; 52.8% women) with a 76.1% oral candidosis prevalence. Candida albicans (80.6%) was the most common species. Oral lesions were classified as none, grade 1 (28.7%), or ≥ grade 2 (14.8%). During follow-up, Cox models identified ≥grade 2 lesions (aHR = 2.04; 95% CI: 1.18-3.54; p = .011) and Candida tropicalis (aHR = 2.38; 95% CI: 1.03-5.55; p = .044) as predictors. CONCLUSION: The extent of oral candidosis lesions or the presence of C. tropicalis may serve as prognostic indicator in patients with end-of-life cancer. Therefore, solely concentrating on the prevalence and frequency of fungal species may be insufficient for predicting life prognosis; it is advisable to assess these parameters through both visual examination and culture.

Association between poor oral health and overall mortality in palliative care patients: An analysis using time-dependent receiver operating characteristic curves.

AIMS: To determine the Oral Health Assessment Tool (OHAT) critical score in palliative care patients and the optimal timing for predicting mortality using time-dependent receiver operating characteristic (ROC) curves. METHODS AND RESULTS: A retrospective observational study was conducted on 176 patients treated by the palliative care team of our medical center between April 2017 and March 2020. Oral health was assessed using the OHAT. Prediction accuracy was evaluated using the area under the curve (AUC) analysis, sensitivity, and specificity, using time-dependent ROC curves. Overall survival (OS) was compared using Kaplan-Meier curves with the log-rank test; hazard ratios (HRs) adjusted for covariates were calculated using a Cox proportional hazard model. A OHAT score of 6 was shown to best predict 21-day OS (AUC 0.681, sensitivity 42.2%, specificity 80.0%). The median OS was significantly shorter in patients with total OHAT scores ≥6 than in patients with scores < 6 (21 days vs. 43 days, p = .017). For individual OHAT items, the unhealthy status of the lips and tongue was associated with decreased OS (HR = 1.91; 95% confidence interval [CI], 1.19-3.05 and adjusted HR = 1.48; 95% CI, 1.00-2.20). CONCLUSION: Predicting disease prognosis based on patient oral health can enable clinicians to provide timely treatment.

Oral dryness and moisture degree at the lingual but not buccal mucosa predict prognosis in end-of-life cancer patients.

PURPOSE: The aim of this study is to investigate the association of oral dryness with overall survival and determine the threshold points of moisture degree for predicting 7-day survival in palliative care patients. METHODS: A total of 147 consecutive palliative care patients were included between January 2017 and November 2018. Oral dryness at the lingual and buccal mucosa was measured using an oral moisture-checking device. Overall survival was compared between patients with and without oral dryness using Kaplan-Meier curves with a log-rank test. Prediction accuracy was evaluated by the receiver operating characteristic (ROC) curve and the area under the curve (AUC). RESULTS: Median survival (95% confidence interval) in patients with oral dryness at the lingual mucosa was shorter than that in patients without oral dryness (17 [11-24] days vs. 28 [22-37] days, log-rank test, p <0.001), but not at the buccal mucosa. Time-dependent ROC revealed that the AUCs for 7-, 14-, 21-, and 28-day survival predictions were 0.72, 0.68, 0.61, and 0.59 with a cutoff value of 19.2%, respectively. The prevalence of performance status (PS) 4 and oxygen administration in the 7-day death group were higher than those in the non-7-day death group. A stratified analysis indicated that moisture degree <19.2% showed fair predictive performance with an AUC of 0.74 and 0.74, in the case of PS ≤3 or without oxygen administration. CONCLUSION: Oral dryness was associated with increased risk of mortality in palliative care patients. Moisture degree <19.2% at the lingual mucosa predicted less than 7-day survival.

Diagnostic accuracy of patient-reported dry mouth as a predictor for oral dryness in terminally ill cancer patients.

PURPOSE: The aim of the study was to determine the diagnostic accuracy of patient-reported dry mouth using an oral moisture-checking device in terminally ill cancer patients. METHODS: The study was conducted following the STARD guidelines, and the participants were recruited prospectively from the Palliative Care Unit, Kyoto Medical Center, Japan, between 1 January 2017 and 30 November 2018. Patients reporting dry mouth were asked to rate oral dryness on a 5-point rating scale. The outcome was oral dryness at the lingual mucosa, measured using an oral moisture-checking device. Receiver operating characteristic (ROC) curves were plotted, and the sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LR), and overall diagnostic accuracy were calculated. RESULTS: Of 103 participants, the prevalence of oral dryness was 65.0%. ROC analysis indicated that patient-reported dry mouth was a poor predictor of oral dryness, with an area under the curve of 0.616 (95% confidence interval: 0.508-0.723), a sensitivity of 46.3%, a specificity of 75.8%, a PPV of 55.9%, an NPV of 68.1, a positive LR of 1.9, a negative LR of 0.7, and an overall diagnostic accuracy of 64.1%, with a cut-off value of 3 points. CONCLUSION: In conclusion, patient-reported dry mouth is not a useful parameter for the assessment of oral dryness in terminally ill cancer patients.

Single-center analysis of antiresorptive agent-related osteonecrosis of the jaw in lung cancer patients.

BACKGROUND: Over the past two decades, antiresorptive agent-related osteonecrosis of the jaw (ARONJ) has become a growing concern. We examined the incidence of ARONJ and identified its risk factors in lung cancer patients in the real-world clinical setting. To our knowledge, we are the first to do so. PATIENTS AND METHODS: We retrospectively analyzed lung cancer patients with bone metastases who had received anti-resorptive agents (zoledronate or denosumab) at the National Hospital Organization Kyoto Medical Center from October 2012 to September 2018. All ARONJ cases were diagnosed by the dentists according to the established diagnostic criteria. RESULTS: A total of 171 patients were reviewed, 13 (7.6%) of whom experienced ARONJ. Among the 13 patients, six (46.2%), four (30.8%) and three (23.1%) had adenocarcinoma, squamous carcinoma and not otherwise specified, respectively. ARONJ was stage 2 in three (23.1%) patients and stage 3 in 10 (76.9%). More cycles of antiresorptive agents (odds ratio [OR] = 11.54; 95% confidence interval [CI], 2.47-53.99; P < 0.01), use of immune checkpoint inhibitors (ICIs; OR = 5.05; 95% CI, 1.56-16.37; P < 0.01) and longer survival duration (≥2 years; OR = 12.16; 95% CI, 3.17-46.65; P < 0.01) were independently associated with ARONJ in a multivariate analysis. CONCLUSIONS: The incidence of ARONJ was relatively high in lung cancer patients with bone metastases. When using antiresorptive agents, oncologists should closely monitor patients for ARONJ during the course of treatment and regularly consult with dentists, especially in patients receiving ICIs.