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Palliative cancer care - oral problems - Management
How should I manage malodorous malignant oral ulcers?

  • Ensure effective wound cleansing through regular mouth care.
  • If anaerobic organisms are present (as indicated by a foul smell), metronidazole is recommended. Discuss the dose and length of treatment with a specialist. Long-term use of metronidazole may be appropriate in some people.
  • For bleeding ulcers, seek the advice of a specialist.
Clarification / Additional information
  • Using sucralfate suspension 1 g (5 mL) diluted with 5 mL water as a mouthwash may be an option for use with bleeding ulcers, but this unlicensed use is recommended by few experts [Regnard and Hockley, 2004].
Basis for recommendation
  • We recommend discussing management with a specialist as expert opinion is divided on the dose and duration of metronidazole treatment [O'Neill and Fallon, 1997; Twycross and Wilcock, 2001; Doyle et al, 2004; Regnard and Hockley, 2004].
  • Metronidazole is active against anaerobic organisms. Although there are no studies of its use in malignant ulcers in the oral cavity, some small studies in cutaneous malignant ulcers found a marked reduction in odour [Sparrow et al, 1980; Ashford et al, 1984].
  • Treatment may need to be continued over the long term, as the odour usually returns when treatment is stopped. There is no evidence that the effectiveness of metronidazole decreases with prolonged or repeated use. Resistance to metronidazole by the odour-producing anaerobes is unlikely to develop [UKMI, 2002].

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