Ask patients with advanced illness about mouth symptoms and examine their mouths. Oral symptoms have a significant effect on quality of life.
Both medical and dental conditions can cause oral pain.
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 (both very common if on steroids)
- Many medications dry up saliva (the main barrier to mouth infection) and make eating difficult. Opioids, tricyclics, diuretics and all anti-cholinergics can dry saliva - can doses be reduced or stopped?
An initial approach to treatment
- Treat any infection - see table below
- Pain control - NICE suggests topical agents for localised pain e.g. benzydamine spray/mouthwash (Difflam), lidocaine ointment/spray (Anbesol) and systemic analgesia for severe pain
- Mouth care is key to keep mouths moist and comfortable. Do share our patients and carers mouth care guide
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 (e.g. Biotene) or artificial saliva sprays (e.g. Glandosane) |
| Dental problems |
Consider any specific teeth related problems Poorly fitting dentures can cause intense pain and ulceration (often after weight loss) |
|
Ulceration and mucositis (generalised sore lining of mouth) Herpes simplex, aphthous ulcers or chemotherapy related mucositis |
Topical steroids e.g. beclometasone spray for local ulceration or lidocaine 5% ointment Analgesic mouthwash e.g. aspirin (soluble 300mg in 15ml warm water) or Oramorph mouth wash (5ml Oramorph plus 10ml warm water) Bonjela (choline salicylate) or Anbesol gel (contains local anaesthetic) may help Systemic or topical antiviral - acyclovir for Herpes simplex Consider systemic opioids if it is too painful to eat Consider checking FBC for neutropaenia and thrombocytopaenia |
|
Candidiasis (thrush) |
Miconazole oral gel (10mls after food) or topical Nystatin (1ml q.d.s) - hold in mouth for as long as possible If topical treatments not effective use oral fluconazole 200mg on day 1 and 100mg for 7 days (then review) |
|
Rarer problems e.g. oral tumours, bleeding and difficulty swallowing |
Seek advice from your local palliative care team |
Top Tips
- Saline mouthwash works well (½ a teaspoon of salt to a cup of warm water)
- Chewing gum stimulates saliva
- Chlorhexidine often hurts with painful mouths
- Avoid acidic or spicy food and alcoholic spirits
- Use a soft toothbrush (children's)
- Some mouth pain may be referred neuropathic pain from a head and neck tumour