Oral problems: information for clinicians

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 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
  • 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 (e.g. Biotene) or artificial saliva sprays (e.g. Glandosane)

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

Herpes simplex, aphthous ulcers or chemotherapy related mucositis

Topical steroids eg 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) 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

 

Recommended Resources

Marie Curie - Mouth care in palliative care

Published 29th January 2021

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Related Services

Community Palliative Care Team - based at Meadow House Hospice
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Community Palliative Care Team - based at Meadow House Hospice

T. 020 8967 5179

W. http://meadowhouse.lnwh.nhs.uk/our-services/community-team/

The Community Specialist Palliative Care Nurse Team provides advice and visiting to palliative care patients in Ealing and Hounslow. The team are based at Meadow House Hospice.

The team will visit patients with progressive life limiting illness in their own homes. They provide specialist advice around pain and symptom control and support for patients, their families, and carers during the last stages of illness. They also support patients wishing to die at home through coordination with GPs and hospital teams.

The team is comprised of medical consultants, specialist nurses, physiotherapists, occupational therapists, social workers, a bereavement support officer and a patient and carer advocacy worker

The team can be contacted for referrals Monday to Friday 9.00am to 5.00pm.

Between Monday to Friday 5.00pm and 8.30am, the Out of Hours Telephone Advice line 020 8102 5000 takes calls. Weekends and Bank Holidays 5.00pm to 9.00am.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4.1 (DOCX)
Ealing Carers
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The Ealing Carers Service support carers who have caring responsibilities living within the borough of Ealing.

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