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Palliative cancer care - oral problems - Management
When should topical pain relief be used?

  • Treat the underlying cause of oral pain where possible. If this is not possible or not fully effective, treat pain symptomatically.
  • For mild to moderate oral pain, use topical non-opioid analgesia.
    • For localized pain:
      • Choline salicylate gel.
      • Benzydamine spray.
      • Lidocaine 5% ointment or 10% spray.
      • Carmellose paste.
    • For diffuse oral pain:
      • Benzydamine mouthwash.
      • Diclofenac dispersible tablets used as a mouthwash is an alternative option.
      • For moderate to severe pain relief consider combining use of topical and systemic analgesia.
  • For severe oral pain, consider the combined use of topical and systemic preparations. Topical opioids e.g. morphine may help and are recommended by some specialists, but usually systemic opioids are required for severe pain.
    • Seek specialist advice if pain is difficult to manage.
  • See the CKS topic on Palliative cancer care - pain for more information.
Clarification / Additional information
  • Erythematous candidiasis in the absence of white patches may be the cause and should be excluded [Regnard and Hockley, 2004].
  • The effect of choline salicylate gel is short-lived [BNF 52, 2006]. Excessive use should be avoided because it can lead to ulceration, particularly if the gel is trapped under dentures.
  • The duration of action of benzydamine is relatively short, and numbness and stinging are sometimes a problem. With benzydamine mouthwash, diluting the mouthwash in an equal volume of water before use reduces stinging.
  • The duration of action of topical local anaesthetics, such as lidocaine, is relatively short, and these agents will not provide continuous pain relief throughout the day [Doyle et al, 2004; BNF 52, 2006]:
    • Care should also be taken not to anaesthetize the pharynx before meals, as this might lead to aspiration or choking.
    • Ideally, use of topical local anaesthetics should be reserved for severe pain (e.g. chemotherapy- or radiotherapy-induced mucosal pain/mucositis).
  • Carmellose paste can be difficult to apply effectively to some parts of the mouth [BNF 52, 2006]. If used to manage ulcer pain, it hardens on contact with saliva to form a protective cover over the ulcer.
  • Morphine sulphate 10 mg/5 mL solution can be used as a mouthwash, but some preparations contain alcohol and may cause stinging [Twycross et al, 2002].
Basis for recommendation

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