Oral problems: information for clinicians

This information is sourced from NICE and Marie Curie

Oral symptoms have a significant effect on quality of life and it is important to ask patients with advanced illness about mouth symptoms and to examine their mouths. 

Many medical conditions can cause oral pain along with dental problems (e.g. dental abscess, denture problems).

Key clinical features to assess in the community
  • Remember that sore mouths affect eating, drinking, hydration, nutrition and well-being
  • Look for any treatable infections such as Candida and Herpes Simplex
  • Review medications to see if any can be changed. Many medications dry up saliva (the main barrier to mouth infection) and make eating difficult. Opioids, antidepressants (SSRIs and TCAs), diuretics and all anti-cholinergics can dry saliva - can doses be reviewed or changed?
An initial approach to treatment
  • Treat any identified infection - see table below
  • Pain control - NICE suggests topical agents for localised pain e.g. benzydamine spray/mouthwash (difflam), lidocaine ointment/spray and systemic analgesia for severe pain
  • Oral hygiene and mouth care are key, particularly to keep mouths moist and comfortable. Do share our patients and carers mouth care guide
Top tips
  • Saline mouthwash works well
  • Chewing gum stimulates saliva
  • Chlorhexidine often hurts with painful mouths
  • Avoid acidic or spicy food and alcoholic spirits 
  • Dental hygiene and mouthcare are key

Specific treatments according to cause:

Cause

Initial approach to treatment

Dry mouth

Medication review - commonly prescribed drugs that can reduce saliva

Mouth care with soft toothbrush plus hydration with water spray, ice chips etc

Try gels (eg Biotene) or artificial saliva sprays (eg Glandosane)

Ulceration and mucositis (generalised sore lining of mouth often due to chemo)

Herpes simplex, aphthous ulcers or chemo related mucositis

Topical steroids eg beclometasone spray for local ulceration or lidocaine 5% ointment

Analgesic mouthwash eg aspirin (soluble 300mg in 15ml warm water) or Oramorph mouth wash (5ml Oramorph plus 10ml warm water)

Bonjela (choline salicylate) gel may help. An Indian preparation (Orasore gel) combining Bonjela with Lidocaine can be very helpful - and can be purchased via Amazon

Systemic or topical antiviral - acyclovir for Herpes simplex

Consider systemic opioids if it is too painful to eat

Consider checking FBC for neutropaenia

Candidiasis

Miconazole oral gel (10mls after food) or topical nystatin (1ml q.d.s) - hold in mouth for as long as possible

Oral fluconazole 50mg for 7 days if topical treatments not helping

Rarer problems

e.g. chronic facial pain, oral tumours, bleeding and difficulty swallowing

 Seek advice from your local palliative care team

 

Sources

NICE CKS Palliative care - oral

Published 1st March 2021

Marie Curie - Mouth care in palliative care

Published 29th January 2021

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