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Palliative cancer care - oral problems - Management
Choice of mouthwash

  • Water or sodium chloride 0.9% solution is recommended.
  • Chlorhexidine can be used in people who have, or are at risk of, secondary bacterial infection, including people that do not have their own teeth.
  • Note: chlorhexidine is the most commonly used mouthwash. Other mouthwashes are available and selection is often based on personal preference.
Clarification / Additional information
  • Water and sodium chloride solution are soothing, nontraumatic, and safe to use as frequently as required. Water can be given warm or cool, depending on individual preference [Milligan et al, 2001].
  • Chlorhexidine should not be used more than twice a day. It contains alcohol, which may cause stinging, particularly in people with inflamed mucosa (e.g. people with mucositis). It also commonly alters taste initially, which may not be desirable [Milligan et al, 2001].
Basis for recommendation
  • Water, sodium chloride, and chlorhexidine are the most common mouthwash options referred to by experts [Regnard et al, 1997; Twycross and Wilcock, 2001; Doyle et al, 2004; Regnard and Hockley, 2004]. However, there is little evidence to guide the best choice of mouthwash.
  • 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]. However, there is no evidence to support its use.
  • Other mouthwashes are used in some centres, but are less suitable for long-term use:
    • Povidone-iodine mouthwash should generally be avoided because high doses of iodine can be absorbed [BNF 52, 2006].
    • Effervescent ascorbic acid solution is widely used, but citric acid can damage tooth enamel, and high sugar levels can promote fungal growth [Milligan et al, 2001]. These preparations should therefore be avoided in people who have their own teeth.
    • Sodium bicarbonate 1% mouthwash is used by some, but it has an unpleasant taste, and higher concentrations can irritate the oral mucosa [Milligan et al, 2001].
    • Hydrogen peroxide 1.5% mouthwash is also used because its foaming action helps to remove debris. However, many people find the foaming sensation and taste unpleasant. Higher concentrations may cause burns, and regular use may promote fungal overgrowth because of its antimicrobial effects [Milligan et al, 2001].
    • Glycerine and lemon mouthwashes should be avoided. They often increase the sensation of dry mouth, probably because of a direct dehydrating effect of glycerine and overstimulation and exhaustion of the salivary glands by lemon juice [Krishnasamy, 1995; Twycross and Wilcock, 2001].

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