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Palliative cancer care - oral problems - Management
How should symptoms of a dry mouth be relieved?
- Try simple saliva stimulatory measures first, as these will often relieve symptoms of dry mouth (even if rehydration is not undertaken):
- Cold unsweetened drinks.
- Frequent sips or sprays of cold water.
- Ice cubes/crushed ice/ice lollies.
- Mints.
- Rubbing petroleum jelly (e.g. Vaseline®) on the lips. However, if a person is on oxygen apply a water-soluble lubricant (e.g. K-Y Jelly®).
- Sugar-free chewing gum, boiled sweets, or pastilles.
- If symptom relief is not adequate, consider using:
- A topical saliva stimulant.
- A topical artificial saliva substitute.
- Pilocarpine tablets.
- In people with their own teeth, the use of acidic foods (e.g. pineapple) or acidic artificial saliva products (e.g. Glandosane® aerosol spray) should generally be avoided.
- Note: patient preference is likely to influence product acceptability and compliance.
Clarification / Additional information
- Products can hasten tooth decay in a dry mouth if they contain sugar (e.g. fruit juices) or are acidic (e.g. topical artificial saliva or saliva stimulant products Glandsone® spray, Salivix® pastilles, and SST® tablets) [Regnard and Hockley, 2004; WeMeReC, 2006]. Alternative products may be appropriate in people who still have their own teeth and are not in the terminal phase of life.
- Avoid using glycerin, which dehydrates the mucosa further, and lemon juice, which rapidly exhausts salivary secretion; the combination acts to dry the mouth [Krishnasamy, 1995; Doyle et al, 2004].
- Topical artificial saliva and saliva stimulant products are not licensed medicines, as they do not contain active drug ingredients. Therefore, manufacturers are not bound by the same requirements to produce trial evidence, statutory monitoring, or good manufacturing requirements as for licensed medicines. Of the products available in the UK:
- Salinum® and SST® Saliva Stimulating Tablets are classified as appliances.
- The remaining seven products have been classified as borderline substances by the Advisory Committee on Borderline Substances (ACBS). This means that they can be prescribed as drugs for the treatment of dry mouth caused by having (or having had) radiotherapy (or sicca syndrome), but the prescriber must endorse prescriptions 'ACBS'.
- Note: some products contain mucin from pigs (e.g. AS Saliva Orthana®) which may be unacceptable to certain groups of people, such as vegetarians, and people of Jewish or Muslim faith.
- Some experts may recommend the use of bethanechol tablets as an alternative to pilocarpine tablets. Note: bethanechol is not licensed for this indication.
Basis for recommendation
- These recommendations are from palliative care textbooks and local guidelines written by experts on the basis of experience of clinical practice [Doyle et al, 2004; Fife Area Drug & Therapeutics Committee, 2004; Lothian Palliative Care Guidelines Group, 2004; Regnard and Hockley, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005; WeMeReC, 2006].
- A review of the literature found that no good-quality trial evidence exists for simple saliva stimulatory measures [Krishnasamy, 1995; Miller and Kearney, 2001].
- CKS found limited evidence that artificial saliva substitutes are clinically effective (or that they are any more effective than simple saliva stimulant measures), although some people report gaining relief from their use.
- Mucin-containing artificial saliva was found to be of benefit in one small study [Vissink et al, 1983], but another small study found no significant difference in effect between mucin-containing saliva spray and a placebo spray containing identical ingredients but no mucin [Sweeney et al, 1997].
- It has been suggested that lactoperoxidase-containing sprays may be preferred, but evidence to support their use in preference to alternative options is limited. Biotene Oralbalance® and BioXtra® both contain lactoperoxidase.
- The available evidence indicates that pilocarpine provides a beneficial response in most people (depending on the cause of the dry mouth), but adverse effects are commonly reported.
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