Dear Sir,

We read with interest the article “Oral health is an important issue in end-of-life cancer care” in your December 2012 issue and would like to share our experience of investigating xerostomia and mouth care in Yorkshire in our palliative care population. We note that the authors conclude that xerostomia has a high prevalence and impact in the palliative care population which has been supported in other articles [1]. Some studies claim that up to 83 % of cancer patients are considered to be affected by salivary gland hypofunction in comparison with 26 % of the general population [2].

A consensus statement recommended regular assessment of our patients' oral state and individualised treatment plans, based on grades C and D evidence [2]. It remains an “orphan topic”, with no further evidence available since the consensus statement, as supported by this article, is despite the problem being acknowledged for greater than a decade.

As a research group in the Yorkshire Deanery, we were interested to ascertain our colleagues' perceptions of the problem. We devised a peer-reviewed survey, which we circulated through our regional learning group to palliative care specialist doctors, nurses and pharmacists from hospital, community and hospice backgrounds in September 2012. We asked about the treatment practices of dry mouth, assuming that all reversible causes had been effectively managed. We received 55 replies in total.

FormalPara Results

Seventy-four percent of the replies scored 4 or 5 out of 5 to the question “on a scale of 1–5 please rate how problematic dry mouth is for your patients” (with 5 being anchored as “very problematic”). We then asked them to rank their top three most effective options in treating dry mouth and score these options from 1 to 5 (1—not at all effective, 5—very effective).

From the results, we observed that a total of 19 different treatment options were offered. It was clear from many responders that “artificial saliva” was being used as a general term for a varied group of separate products in a range of formulations. Biotene oral balance gel was the most frequently used with a mean effectiveness score of 3.4, with lower effectiveness scores quoted for other artificial saliva preparations. Use of ice, water, pineapple and chewing gum were also prevalent, with equivalent effectiveness scores quoted. Despite the relatively high number of different preparations suggested by responders, most were considered to have similar effectiveness scores, with none considered highly effective on their own (see Table 1).

Table 1 Comparison of topical and non-topical preparations
Full size table
FormalPara Conclusions

All surveys have a degree of responder bias, but our results demonstrate that palliative care professionals in our region acknowledge that xerostomia is very problematic, in keeping with the Wilberg et al. article. Our survey found no differences between drug and non-drug interventions in terms of perceived effectiveness. No type of intervention was perceived to be either effective or very effective.

We intend to perform a systematic review and explore the use of proprietary interventions versus conservative measures in advanced cancer patients. Dry mouth is a common burdensome symptom that has many potential interventions but has no evidence-based consensus as to the most appropriate management strategies.

Yours faithfully,

Drs. Lucy Adkinson, Jamilla Hussain, Sunitha Daniel, and Dr Stephen Oxberry