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Palliative cancer care - oral problems - Management
What self care is recommended?

  • Brush the teeth twice a day with a soft toothbrush and fluoride-containing toothpaste, and rinse with water, or a fluoride or antiseptic mouthwash. Note: a 'sore mouth' toothpaste or a child's toothpaste with fluoride is often better tolerated.
  • Rinse the mouth after each meal and at night with warm water or 0.9% sodium chloride solution (ready made or made up).
  • If the tongue is heavily furred (especially if causing distress), brush with a soft toothbrush twice a day and use an antiseptic mouthwash, such as chlorhexidine.
  • Use chlorhexidine mouthwash if gum disease is diagnosed.
  • Take adequate fluids.
  • Clean debris from the teeth. Dental floss, chewing pineapple, fresh or unsweetened, may help to remove debris.
  • The frequency of mouth care should be increased to:
    • Every 2 hours if there is a high risk of oral problems (any persons with advanced disease or neurological impairment, and/or those undergoing advanced treatment).
    • Every hour in people at high risk or who have severe problems (e.g. oral infections, coma, severe mucositis, dehydration, immunosuppressed, diabetes, or needing oxygen therapy).
  • Dentures should be removed at night and cleaned with a soft toothbrush and unperfumed soap or denture toothpaste. Seek the advice of a dentist regarding how to soak dentures overnight.
Clarification / Additional information
  • Irrigation with warm water or sodium chloride 0.9% helps to remove oral debris and is soothing and nontraumatic. Sodium chloride solution can be made for each rinse by dissolving half a 5 mL teaspoon of salt in 225 mL water [Wade, 1980; BNF 52, 2006].
  • Chewing pineapple may also help to clean the mouth. Pineapple contains ananase, which is a cleansing enzyme [WeMeReC, 2006].
  • Some experts believe that a mouthwash of cider and soda water (mixed in equal parts) is more pleasant than most mouthwashes [Regnard et al, 1997; Twycross and Wilcock, 2001].
  • For more information about mouthwashes, see Choice of mouthwash.
  • Different strategies are used to soak dentures overnight, some experts recommend the following options [Davies and Finlay, 2005]:
    • Plastic dentures should be soaked overnight in a denture solution containing sodium hypochlorite (1 part Milton® 1 per cent to 80 parts of water).
    • Dentures with metal parts should be soaked overnight in chlorhexidine solution (as sodium hypochlorite causes metal discolouration).
    • Dentures should be rinsed well under running water before being returned to the mouth.
Basis for recommendation
  • These recommendations are pragmatic and are based on expert opinion.
  • A healthy mouth is clean, moist, and pain free. Regular mouth care will prevent or reduce the risk of many oral problems, such as infections and mucositis. Maintaining oral hygiene is very important [Regnard and Hockley, 2004]. The incidence of ulceration or infection of the oral mucosa also increases with dry mouth.
  • Regular mouth care to prevent oral problems is standard nursing practice [Xavier, 2000] and is based on expert opinion [Milligan et al, 2001; Regnard and Hockley, 2004] and local guidelines [Fife Area Drug & Therapeutics Committee, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005]:
    • A small prospective study (n = 42) of children 6 to 17 years of age with haematological cancers or solid tumours compared an oral care protocol intervention (tooth brushing, 0.2% chlorhexidine mouth rinse, 0.9% saline rinse) (n = 21) with no intervention (n = 21) [Cheng et al, 2001]. Compared with the control group, the protocol intervention group had:
      • A reduction in the incidence of ulcerative mucositis (p = 0.01).
      • A reduction in the severity of oral mucositis (p = 0.000002).
      • A reduction in related pain (p = 0.0001).
      • The authors concluded that these results support regular oral care.
  • Overviews of the literature found that although several studies on mouth care (e.g. use of foam sticks or toothbrushes or the frequency of oral care) have been published, they were small or methodologically flawed [Krishnasamy, 1995; Evans, 2001; Miller and Kearney, 2001].
  • Some evidence suggests that chlorhexidine mouthwash reduces the incidence of oral complications [Rutkauskas and Davis, 1993]. Chlorhexidine helps with plaque control, but its value in reducing the symptoms of mucositis is unclear [Spijkervet et al, 1989; Wahlin, 1989].

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