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Introduction
According to the Worldwide Hospice Palliative Care Alliance (WHPCA), palliative care is a health policy priority. It is health care, coordinated and global. Its main objective is to promote the quality of life, the development of human well-being and maximize the dignity of care. They help the person with an advanced and incurable chronic illness to live and reduce suffering in extreme end-of-life circumstances. They promote person- and family-centred care. They are provided by multidisciplinary units and teams and in inpatient units or at home (WHO, 2014). It promotes the relief of pain and other disruptive symptoms, affirms life and views death as a natural process. Palliative care integrates the psychological and spiritual aspects of the person in the care process, helping the patient to live as actively as possible until death. They use a multidisciplinary approach to meet the needs of the person and family, including follow-up in bereavement. They encourage quality of life and positively impact the course of the disease, with an early intervention and a systematic assessment of the person in a palliative situation. That combines treatments that aim to prolong life, and when needed, exams to better understand and treat the person's problems (WHPCA, 2020). The strict control of the various symptoms that the person in a palliative situation presents is one of the supporting pillars of palliative care. This is ensured by the rigorous assessment of the symptoms’ triggering effects (Twycross, 2020). Xerostomia is the subjective sensation of dry mouth reported by patients. It is considered a symptom of various pathologies, and may also be a consequence of treatments and changes in salivary gland function (De Luca & Roselló, 2014). Xerostomia, is illustrated in the literature as a triggering factor of changes and transformations at various levels (Mercadante et al., 2015). The impact of this problem on the person in a palliative situation interferes with the physical, psychological, emotional and social capacities, conditioning quality of life and even dignity (Fischer et al., 2014). The prevalence of xerostomia ranges from 78% to 88%, being one of the most frequent patients reported symptoms (Lourenço, 2017). Xerostomia is the third most frequent symptom in palliative care, when excluding pain (Al-Shahri et al., 2012). It has a multifactorial aetiology and sometimes it is a very complex symptom to resolve. Identifying it makes it important to assess the oral cavity, use appropriate diagnostic tools and apply effective therapeutic approaches (Al-Shahri et al., 2012). Aetiological factors can be divided into four major groups: iatrogenic, organic diseases, functional causes and psychogenic causes. The iatrogenic causes include head and neck radiotherapy, the use of cytostatics, bone marrow transplantation, smoking, alcohol consumption and the use of drugs (Plemons et al., 2014). With regard to the causes of organic origin, there are also multiple situations that are conducive to the existence of xerostomia, among which rheumatoid arthritis, systemic lupus erythematosus, scleroderma type 1 and 2 diabetes mellitus, sarcoidosis, HIV, primary biliary cirrhosis, hepatitis C, thyroid diseases, amyloidosis, iron accumulation diseases (thalassaemia), infectious diseases (parotitis), cystic fibrosis, among others (Montgomery-Cranny et al., 2014; Mortazavi et al., 2014). Functional causes are also relevant, such as dehydration or inadequate fluid intake, diarrhoea and persistent vomiting, protein deficiencies, cardiac disorders, oedema and malnutrition (De Luca, & Roselló, 2014). The aetiology of xerostomia should also include other physiological causes, mouth breathing, and psychological causes, such as anxiety, stress and depression, which are also triggering factors of this symptom (Montgomery-Cranny et al., 2014). The decrease in the quantity and quality of saliva predisposes to the appearance of lesions of varying severity in the mouth. Due to their difficulty in speaking, halitosis and pain due to dry mucous membranes, patients often avoid social contacts and many of them isolate themselves, which negatively interferes with their quality of life. The mouth is an important and complex organ of the body, with physiological and psychological significance, which allows people to interact between their inner and outer worlds. It is through the mouth that we can perform some of the most important functions of our entire existence, such as eating or verbal communication. Caring for the patient’s mouth is a basic intervention of health professionals, especially nurses. They are responsible for managing the aspects related to the provision of this type of care, either directly by providing oral care, or indirectly through the teaching provided to patients and families, or the promotion of self-care. Caring for the mouth of the person in a palliative situation requires various skills which include assessing the condition of the mouth, early recognition of changes, and planning and implementing interventions aimed at solving and/or minimising these problems. This care goes beyond the physical dimension. It can be considered a global care that seeks, together with all other interventions, to promote the dignity of the person in need of palliative care through unconditional respect. Nevertheless, evidence shows that although nurses, for example, recognize the importance of the person's oral cavity care in a palliative situation, they attribute little relevance to it, underlying the lack of knowledge about the subject (Lourenço, 2017). This scoping review was guided by the methodology proposed by the Joanna Briggs Institute (JBI) for scoping review assessments (Peters, et al., 2020). In this respect, and as recommended by the JBI, preliminary research on MEDLINE, CINAHL and the JBI Database of Systematic Reviews and Implementation Reports, was conducted, allowing to verify that there was no scoping review record on the subject. The main objective was to systematically examine and map the research conducted on the interventions used to control xerostomia in palliative care. The reason is that xerostomia is described as a symptom, which is uncomfortable and implies various changes in the quality of life of patients, and because of that, it is imperative to map the existing evidences on the subject, thus giving the possibility of knowledge and understanding to health professionals who want to make a difference in intervening effectively in symptomatology relief. This mapping also allows us to identify relevant questions that help advance the evidence-based health system, increase knowledge, identify gaps, and inform systematic reviews.
1. Methods
The research is orientated by the methodology proposed by the JBI for the Scoping Revision (Peters, et al., 2020It was written, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Systematic Review Protocols- Scoping Reviews Extension (PRISMA-ScR) (Tricco et al., 2018). A research protocol was developed with inclusion and exclusion criteria, related to the review and revision issue, and the research limiters.
Review question/objectives: More specifically, the revision was guided by the following questions:
i-What are the used interventions in the xerostomia control of the patient in a palliative situation?
ii-What are the characteristics (intervention and duration type) of those interventions?
iii-What is the specific health professional area that performs those interventions?
1.1 Inclusion criteria
As for the participants, this scoping review considered studies focused on patients with advanced and irreversible disease and in palliative situations aged 18 years or older. A person in a palliative situation, due to incurability and disease progression, is subject to physical, psychological and social suffering as well as spiritual (WHPCA, 2020).
Concept: This scoping review considered the studies that address the implemented interventions on controlling xerostomia, dry mouth and salivary gland dysfunction. It was considered non-pharmacological and pharmacological interventions.
1.2 Context
This review considered the studies that address the interventions for the xerostomia control in the context of advanced chronic disease and/or palliative and end-of-life care.
Sources: This scoping review considered quantitative studies and systematic reviews. Included quantitative studies are experimental (including controlled randomized trials or quasi-experimental studies) as well as observational designs (cohort and cross-sectional studies).
1.3 Research strategy
A three-stage search strategy was used. An initial search limited to MEDLINE Complete®; CINALH Complete®, PUBMED, SCOPUS. This is followed by an analysis of subject words contained in the title, in the abstract and, in index terms used to describe the articles. In the second stage, the search was replicated, using keywords and subject descriptors identified. In the third stage were examined the bibliographic references of the eligible articles so that it was possible to identify the additional studies. Included in this review were published studies in English and Portuguese regardless of the year of publication. The Mendeley software was used to manage the bibliographic references. The search was made through a Boolean language and by Boolean operators as AND (conjunction) and OR (disjunction) for the descriptors combination. According to the same language and, following mathematical logic, it was also used parentheses (to indicate which part of the research should be carried out first) and inverted commas (to indicate compound terms). The search was conducted in 26 February 2021. The Boolean sentences used on the research were: TI (((MH "Hospice and Palliative Nursing")) OR (MH "Palliative Care") OR (MH" Terminally Ill Patients") OR "end-of-life care" OR "Palliative Medicine" OR ((MH "Hospice and Palliative Nurses Association")) OR (MH "Hospice Care") OR (MH "Terminal Care") OR "Palliative" OR "end of life" OR (MH "Hospices")) OR AB (((MH "Hospice and Palliative Nursing")) OR (MH "Palliative Care") OR (MH "Terminally Ill Patients") OR "end-of-life care" OR "Palliative Medicine" OR ((MH "Hospice and Palliative Nurses Association")) OR (MH "Hospice Care") OR (MH "Terminal Care") OR "Palliative" OR "end of life" OR (MH "Hospices"))) AND (TI ((MH "Xerostomia") OR "dry mouth" OR "Salivary Flow" OR "Oral dryness") OR AB ((MH "Xerostomia") OR "dry mouth" OR "Salivary Flow" OR "Oral dryness"));
1.4 Study selection and data extraction
The study selection and data extraction were carried out by two independent authors and the possible differences between them were solved by consensus by a third author with the aim of confirming the eligibility of publications. To facilitate the process, the Rayyan QCRI® (Web Systematic Reviews) platform was used in the first stages of publication selection.
2. Results
The full text articles were read and analysed by three independent researchers. About 19 articles met the inclusion criteria. The study selection process is according to the PRISMA diagram and is represented in Fig.1 (available at http://prismastatement.org/prismastatement/flowdiagram.aspx)
The extracted data from the 19 included studies for this revision were organized in two charts according to JBI (2020). The included study information was summarized, regarding the authors, year of publication, originating country, subject study, study design/method, and number of participants on table 1. In table 2 it is possible to see the intervention type used, professional group that used the intervention, duration time, and main results. To facilitate the presentation and results analysis, the studies were coded from E1 to E19. Of nineteen studies included in this review, seven are primary studies (S4, S5, S7, S10, S14, S17, S18) and twelve are literature reviews (S1, S2, S3, S6, S8, S9, S11, S12, S13, S15, S16, S19). The publication year of the studies included in this review range from 1997 to 2020. Most included studies were from the United States (S5, S8, S11, S13, S15, S16, S18) and the United Kingdom (S1, S2, S6, S9, S10, S19). The other articles are from the north of Europe: The Netherlands (3), Sweden (4), Norway (7). Finally, it included an article from Brunei (southeast of Asia, E12).
On table 2 the summary about the data extracted from the analysed studies is continued. The main results and the details were stressed out as well as the main discoveries related to the revision matters.
I -The interventions used to control xerostomia in palliative patients
The interventions used for xerostomia control in palliative patients, the studies point out for the following non-pharmacological interventions: acupuncture (E1, E2, E3, E4, E5, E6, E9, E11, E12, E19), saliva substitutes as artificial saliva and glycerine (E2, E10, E11, E12, E15, E19), saliva stimulants as: chewing gum, ascorbic acid, citric acid and malic acid (E2, E3, E6, E7, E9, E10, E11, E13, E14, E15, E18, E19). Still under the non-pharmacological intervention scope are: the food regimen changes, avoiding alcohol beverages and sugar rich foods (E3, E6, E13, E16, E19), the importance of oral hygiene educational programmes (E6, E9, E12, E15) and electrostimulation (E6). The pharmacological interventions were also highlighted as an important treatment in xerostomia control like the parasympathomimetic medicine: pilocarpine (E2, E3, E6, E11, E16, E17, E19) and bethanechol chloride (E2, E6, E16, E19).
ii- Characteristics (intervention and duration type) of those interventions
In what concerns the intervention characteristics, the studies point out to the non-pharmacological interventions frequency that depends on the type of treatment used. Acupuncture was used for 5 weeks, two times per week (E4) in a total of 4 or 6 treatments (E5). The saliva stimulants were used for three to five days (E7, E10) and citric acid before meals were used for six weeks (E18). Saliva substitutes were used between 7 to 14 days (E14). Pharmacological interventions were based on the use of pilocarpine three times a day for a week (E17).
iii- Specific health professional area that performs those interventions
The xerostomia control interventions were used mainly by: dentists (E3, E7, E8, E12, E13, E14), nurses (E2, E9, E12, E18), nurses with acupuncture training (E4), doctors (E2, E19), acupuncturists (E5) and health professionals in oncology, palliative care and odontology (E6, E17). Diagnosis tests with yes or no questions were used to assess some of the interventions as the salivary function and the saliva substitutes effect. (E13). Clinical assessment of the client's oral cavity, upon admission to the health service and its reassessment at regular intervals, was the strategy used to understand the effectiveness of educational programmes on the relevance of oral hygiene. (E9). The use of acupuncture to control xerostomia was evaluated in one of the studies used in this review, through a visual analogue scale, and by measuring saliva production before and after treatment (E4).
3. Discussion
The studies under review revealed that xerostomia is a common symptom in palliative and end-of-life patients. This symptom is usually associated with significant morbidity and a decrease in the quality of life of these patients. (Meidell & Hoiritz Rasmussen, 2009; Lopez et al., 2018; Sheehy, 2013, Reisfield et al., 2009). Fleming and collaborators (2020) While assessing the xerostomia impact in daily activities (from 135 patients with advanced and progressive disease) concluded that xerostomia had a major negative impact in speaking capability, eating and food tasting. This situation also interfered with nasal mucosa dryness, swallowing and sleep. Saliva produced by the parotid, submandibular and sublingual glands is estimated to be about 0.5 L/day to 1 L/day and flow rates can fluctuate up to 50% with diurnal rhythms in adults. Salivary dysfunction (translated by the decrease in these flows) can be induced by drug therapy; disease states, radiotherapy treatment; anxiety, depression or stress (Moore & Guggenheimer, 2008). Xerostomia is reported by end-of-life patients to be an uncomfortable and very distressing symptom. (Sheehy, 2013). As a consequence, pain in the oral cavity, accelerated dental morbidity, infections of the oral mucosa, fissures and ulcers, halitosis, alteration in the taste and appreciation of food, chewing and swallowing difficulties, nutritional impairment, difficulty in speaking perceptibly and related problems with the dental prosthesis can arise (Reisfield et al., 2009, Fleming et al., 2020). According to this review, it has become consensual that the etiology of xerostomia is multifactorial, and may be associated with the adverse effect of treatment with anticholinergic, antiadrenergic or cytotoxic drugs, which cannot be discontinued due to the refractory symptoms that people in palliative situations have. (Barford & D’Olimpio, 2008; Moore & Guggenheimer, 2008; Reisfield et al., 2009; Sheehy, 2013; Crogan, 2015). Xerostomia is associated to radiotherapy treatments (Nieuw Amerongen & Veerman, 2003; Kahn & Johnstone, 2005; Moore & Guggenheimer 2008; Reisfield et al., 2009; Mercadante et al., 2000), anxiety, depression and stress states (Moore & Guggenheimer 2008; Reisfield et al., 2009). The analysed studies allowed mapping interventions for the control of xerostomia in palliative care. The systematic evaluation of the oral cavity is presented as an intervention of great relevance (Sheehy, 2013; Lopez et al., 2018). The remaining interventions were grouped into three areas: preventive care, symptom relief and training of family caregivers. (Sheehy, 2013). In what concerns preventive care, it includes hydration, oral hygiene with a small brush for 2 minutes, odontology consultation and ambient humidification (Venkatasalu et al., 2020, Sheehy, 2013). Symptom relief involves the use of non-pharmacological measures as well as pharmacological measures, resorting to the treatment of the underlying cause and the use of polycarpine. (Mercadante et al., 2000). Under non pharmacological measures it is included saliva production stimulation resorting to the use of saliva stimulants instead of substitutes as well as diet adequacy (Davies et al., 2011; Crogan, 2015) and acupuncture (Meidell & Holritz Rasmussen, 2009; Lopez et al., 2018). The seven primary analysed studies allowed us to know that the evidence relating to the type of treatment for xerostomia needs a larger number of clinical trials with amplified samples. Acupuncture revealed to be efficient in the relief of oral cavity dryness (Meidell & Holritz Rasmussen, 2009; Lopez et al., 2018). The idea of the need to obtain more studies, with larger samples, about the use of acupuncture in the relief of xerostomia, in people in palliative and end-of-life situations, is unanimous. (Lopez et al., 2018). Randomized clinical trials support the use of pilocarpine and saliva stimulants, such as chewing gum and citric acid-rich stimulants, in the treatment of xerostomia (Davies, 2000; Mercadante et al., 2000; Crogan,2015; Kvalheim et al., 2019).
This revision allowed us to understand the importance of educating xerostomia patients and families about measures to take to prevent complications and get relief from symptoms (Sheehy, 2013). This revision is an opportunity to point out the oral care. Even though they are basic and essential care most of the time health professionals, by many reasons, end up omitting them, because they are considered as a non-priority care in relation to other care (Lourenço, 2017). Since this theme has interference with quality of life, especially for those with xerostomia, this scoping revision is of great value since it connects the aspects related to the need for systematic assessment of the oral cavity, preventive care, symptom relief and treatment of xerostomia. It guides as well quality clinical practices necessary for those in a palliative and end-of-life situation that suffers with or have tendency to develop this problem.
Conclusion
Xerostomia is a health condition that can cause halitosis, sleep disorders, speech deficits, chewing and swallowing disorders, which result in malnutrition. Consequently, it generates social embarrassment and chronic discomfort, causing suffering and a great impact on people's quality of life. Due to the prevalence of patients in palliative and end-of-life situations and the scarcity of an existing evidence base, more research is required to improve the quality of life, a reality for people who suffer from xerostomia. It is critical for health professionals to prioritize oral cavity assessment and preventive care interventions, focusing on hygiene care and oral hydration, and environmental humidification, without forgetting people with compromised conscience. The prevention and relief of symptoms, in people with the potential risk of developing xerostomia, associated with taking medication, treatments such as radiotherapy, and states of anxiety, depression, and stress, is also a priority. Grouping and synthesizing the available evidence, within this theme, can help health professionals to incorporate them into clinical practice, thus contributing to an increase in excellence in the provision of care. The limitations and weaknesses perceived, throughout and during this research, are related to the reduced scientific dissemination, updated on this topic, and the scarcity of studies focused on the systematic evaluation of the interventions implemented for the control of xerostomia.
