Perform a full history and examination. Assess concurrent symptoms, psychological state, social needs, and spiritual needs. See the CKS topic on Palliative cancer care - general issues.

Refer or seek specialist advice if in doubt about the diagnosis or management of any oral problem, especially severe or recurrent symptoms.

Stress the importance of regular self care to prevent the development of general oral problems and complications after chemotherapy and radiotherapy.

The following oral problems may present and should be treated:

• Dry mouth
• Oral candida
• Oral pain
• Mouth ulcers
• Excessive salivation
• Alteration in taste
• Halitosis

Manage symptoms in the terminal phase being sensitive to the needs of the person and their carers.

• Perform a full history and examination. Assess concurrent symptoms, psychological state, social needs, and spiritual needs. See the CKS topic on Palliative cancer care - general issues.
• Assess the person's:
• Understanding of the diagnosis and their current problems.
• Coping ability, and how their family/carer is coping.
• Nutritional status and whether their fluid intake is adequate.
• Level of oral hygiene and whether they can carry out routine oral care.
• Estimate the likely prognosis, if possible. For further information, see Prognostic Indicator Guidance (pdf), which is part of the Gold Standards Framework.

• Attempt to estimate the prognosis, as this helps in the planning of appropriate treatment and care. For further information, see Prognostic Indicator Guidance (pdf), which is part of the Gold Standards Framework [Gold Standards Framework, 2006a].

• These recommendations are based on national guidance from the National Institute for Health and Clinical Excellence (NICE) and expert opinion [NICE, 2004; Regnard and Hockley, 2004].
• As symptoms are often multiple and interrelated, a systematic approach to assessment and management is necessary.
• Assessment and discussion of the person's needs for physical, psychological, social, spiritual, and financial support should be undertaken at key points (such as at diagnosis; at commencement of, during, and at the end of treatment; at relapse; and when death is approaching).
• Terminal illness may affect the relationship between the person and their family. It is important to recognize this and to offer appropriate support and advice when needed.
• Always carry out assessments and make decisions in partnership with the person and their carers.

[NICE, 2004]

• Refer or seek specialist advice if in doubt about the diagnosis or management of any oral problem.
• Refer if any of the following are present:
• Oral problems that are causing a decrease in oral intake or concerns about nutrition.
• Severe oral herpes simplex infection. Intravenous administration of aciclovir may be needed if pain limits the person's ability to take oral medication.
• Severe mucositis. It can be extremely painful and may limit the person's ability to tolerate chemotherapy or radiotherapy.
• Suspected neutropenic ulcers and neutropenia. Urgent medical advice should be sought because recovery of the neutrophil count is needed for healing.
• Severe or persistent Candida infection.
• Oral ulcers that are bleeding.
• Taste disturbance that is likely to be prolonged. Refer to a dietitian where appropriate.
• Pain that is difficult to manage.
• Communication problems. Refer to a speech and language therapist where appropriate.

• These recommendations are based on standard clinical practice.

• 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.

• 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.

• 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].

• 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.

• 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].

• 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].

• Elicit the causes of the symptoms. Symptoms commonly have more than one cause. Each cause should be considered for treatment.
• Set goals for treatment with the person and their carers and negotiate a treatment plan. Explain the rationale for this plan especially if it is different to their usual oral care regime.
• Communicate with the other members of the multidisciplinary team involved.

• Always perform assessments and make decisions in partnership with the person and their carer(s).
• Be aware that many people wish to be enabled to die in the place of their choice, often their own home. They need to be assured that their families and carers will receive support during their illness and after bereavement.
• Each multidisciplinary team or service should implement processes to ensure effective inter-professional communication within teams and between them and other service providers with whom the person has contact. Mechanisms should be developed to promote continuity of care, which might include the nomination of someone to take on the role of 'key worker' for an individual person.

[NICE, 2004]

• The recommendation is based on good clinical practice recommended by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2004].

• 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.

• 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.

• 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.

• Treat any of the following underlying causes of dry mouth if appropriate:
• Adverse effect of a drug being taken. Reduce the dose or change the drug if possible.
• Dehydration. This should be reversed (except in the terminal phase then simple coping measures should be considered).
• Anxiety. This becomes increasingly common towards the end of life and should be managed appropriately.
• Candida infection. See Oral Candida infection.
• If on oxygen, consider humidification of this.

• Where possible, treatment is directed at the underlying cause of dry mouth. If this is not possible or is only partially successful, symptoms are treated. Possible causes of a dry mouth include dehydration (due to fluid loss or poor oral intake) or a lack of saliva production (due to salivary gland damage after radiotherapy, or adverse effects of some drugs).
• In practice, it is often very difficult to discontinue, or substitute drugs causing dry mouth. Many of these drugs are necessary for symptom control and salivary gland dysfunction is usually a drug-class adverse effect [Davies and Finlay, 2005].

• The basis for recommendation is expert opinion [Regnard and Hockley, 2004; Davies and Finlay, 2005; Pan-Glasgow Palliative Care Algorithm Group, 2005].
• Much anxiety can be eased with clear communication and treatment of symptoms. Specialist help is needed for persistent severe anxiety [Regnard and Hockley, 2004].

• Manage predisposing local and systemic risk factors for oral Candida infection in conjunction with anticandidal treatment.
• In immunocompetent people:
• Topical nystatin, or miconazole is recommended as first-line treatment.
• Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
• In immunocompromised people, high-dose oral fluconazole is generally preferred for first-line treatment.
• Chlorhexidine should be used to clean dentures, and it may be used as an adjunct to topical or oral treatment.

• The choice of anticandidal drug treatment may be dictated by local policy or based on advice from a local microbiologist.
• People should be advised to keep the drug formulation in contact with the oral mucosal surface for as long as possible by:
• Holding the formulation in the mouth for as long as possible before swallowing.
• Avoiding eating or drinking for 30 minutes after each dose [Regnard and Hockley, 2004].
• When using topical preparations, removing dentures before each administration [Twycross and Wilcock, 2001].
• Oral antifungals are reserved for widespread (e.g. evidence of oesophageal candidiasis) or severe infection, or when topical anticandidals are not tolerated or are ineffective:
• Ketoconazole is less commonly used, following the Committee on Safety of Medicines (CSM) advice that it should not be used for superficial fungal infections because of rare reports of liver damage [CSM, 1983; CSM, 1984].
• Itraconazole is an alternative, but it is less suitable for people at high risk of heart failure. Reports of heart failure have been rare, but the risk seems to be higher in elderly people, people with cardiac disease, people taking negative inotropic drugs (e.g. calcium-channel blockers), and people taking high doses or receiving longer treatment courses [CSM, 2001].
• Dentures should be removed at least once a day and the underside cleaned to remove any adherent infected debris [Twycross and Wilcock, 2001]. For maximum patient comfort, dentures should be rinsed under running water after every meal and the lining of the mouth should be checked for food debris, and dentures left out overnight [Davies and Finlay, 2005].
• Nystatin and chlorhexidine mouthwash should not be used at the same time, as they will inactivate each other. They should be used 1 hour apart.
• Thirty minutes must also be left between the use of toothpaste and chlorhexidine mouthwash [Kinley, Personal Communication, 2007].

• These recommendations represent the general consensus from palliative care resources and local guidelines written by experts on the basis of experience of clinical practice [Twycross and Wilcock, 2001; Twycross et al, 2002; Doyle et al, 2004; Fife Area Drug & Therapeutics Committee, 2004; Lothian Palliative Care Guidelines Group, 2004; Regnard and Hockley, 2004; Davies and Finlay, 2005; Pan-Glasgow Palliative Care Algorithm Group, 2005; DynaMed, 2006; WeMeReC, 2006].
• From an evidence-based perspective:
• Few trials have compared the use of topical anticandidal treatments in people with cancer in palliative care [Pankhurst, 2005].
• A Cochrane review investigated treatment of oral candidiasis in people with cancer receiving treatment and found that evidence about the clinical effects of oral antifungals was insufficient to make strong recommendations for patient care [Clarkson et al, 2004].
• Resistance to nystatin is uncommon although resistance to miconazole is becoming increasingly common, especially in people who are immunocompromised [Davies and Finlay, 2005].
• Mouthwashes are licensed for treatment of oral candidiasis:
• However, apart from their use in disinfecting dentures, evidence is insufficient to recommend their sole use for treating oral candidiasis.
• The adjunctive use of chlorhexidine in oral candidiasis produces varying degree of success [Ellepola and Samaranayake, 2001]. The available evidence about the clinical effects of oral antifungals is insufficient to make strong recommendations for patient care [Clarkson et al, 2004].

• 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.

• 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].

• These recommendations for pain relief are based on expert opinion [O'Neill and Fallon, 1997; Twycross et al, 2002; Doyle et al, 2004; Regnard and Hockley, 2004; Davies and Finlay, 2005].

• Treat the underlying cause of oral pain where possible. If this is not possible or not fully effective, treat pain symptomatically.
• Use systemic analgesia if the person prefers this option or as an alternative/addition to topical analgesia in cases where oral pain is extensive and not controlled by topical analgesia.
• The choice of systemic analgesia depends on the severity of pain and the benefits compared with risks for the individual person.
• Mild pain: nonsteroidal anti-inflammatory drug (NSAID) or paracetamol.
• Mild to moderate pain: full-dose weak opioid plus paracetamol or NSAID.
• Moderate to severe pain: strong opioid (e.g. morphine) plus paracetamol or NSAID.
• Seek specialist advice if pain is difficult to manage.
• See the CKS topic on Palliative cancer care - pain for more information.

• Topical treatment is preferred to systemic treatment because of the lower incidence of significant adverse effects. Some drugs have both topical and systemic actions (e.g. dispersible diclofenac).
• Systemic analgesics are used when topical therapies are inadequate at controlling pain.
• Oral analgesia is preferred where possible, but if the person cannot eat or drink (e.g. mucositis), consider using a 24-hour continuous subcutaneous infusion of an opioid (e.g. diamorphine). See the CKS topic on Palliative cancer care - pain for further information on starting and titrating oral morphine.

• The basis of these recommendations is the World Health Organization (WHO) stepped guide to pain management [WHO, 1996; WHO, 2003].

• Aim to:
• Treat the cause of the ulcer.
• Prevent secondary infection with regular mouth care. Twice-daily chlorhexidine mouthwashes can also be used in the short term but may not be suitable for all people, as the alcohol content can sting. See Choice of mouthwash for more information.
• Treat the pain of the ulcer (see Managing oral pain for further information).

• The basis of this recommendation is standard clinical care.

• Correct any underlying iron, folate, or vitamin B₁₂ deficiency if the prognosis allows.
• Topical corticosteroids:
• Hydrocortisone lozenges are best used in the prodromal period, before the ulcer develops.
• Beclometasone spray or betamethasone soluble tablets are more potent and are generally reserved for use when ulceration is extensive, or is at a difficult-to-reach site.
• Use doxycycline mouthwash for severe recurrent aphthous ulceration.
• Chlorhexidine mouthwash can be used to prevent secondary bacterial infection.
• For management of pain associated with aphthous ulcers, see Managing oral pain.
• For severe persistent ulceration, seek specialist advice.

• Treatment choices should be guided by disease severity (pain), the frequency of flare-ups, and the tolerability of medication.
• When using topical corticosteroids, a short course should be given. Beclometasone inhaler or betamethasone soluble tablets are more potent, but the risk of systemic adverse effects and oral candidiasis is increased. They are generally reserved for use when ulceration is extensive or is at a difficult-to-reach site.
• Doxycycline mouthwash can be made up by dispersing the contents of a doxycycline 100 mg capsule in water and rinsing the solution around in the mouth for 2 to 3 minutes, four times a day [BNF 52, 2006]. It may cause oral candidiasis and a burning sensation of the pharynx [Porter et al, 2000].
• Chlorhexidine gluconate 0.2% mouthwash is used for aphthous ulcers (particularly if it is too painful to brush teeth). It should not be used at the same time as nystatin because it reduces the activity of nystatin [Milligan et al, 2001].
• Persistent and severe ulcers may respond to thalidomide (unlicensed use), but this can only be prescribed under specialist supervision.

• The recommendations are based on those in the CKS topic on Aphthous ulcer.
• Topical corticosteroids: there are few studies to support their use, but some evidence indicates that they reduce the duration of ulcers and hasten pain relief without causing notable local or systemic adverse reactions [Porter and Scully, 2006]. Triamcinolone in an adhesive paste (Adcortyl in Orabase^®) has been discontinued.
• Chlorhexidine mouthwash: some evidence indicates that it reduces the duration and severity of aphthous ulcers [Porter and Scully, 2006]. It can stain the plaque on teeth brown.
• Tetracycline used to be recommended, but because tetracycline capsules are no longer available in the UK, doxycycline capsules are generally used.

• Advise bed rest, maintenance of adequate fluid intake and use of antipyretics where necessary.
• In immunocompetent people who are in the early stages of an uncomplicated herpes simplex infection in the locality of the lips, commence topical aciclovir or penciclovir.
• In immunocompetent people who are in the early stages of an intraoral herpes infection, commence oral aciclovir.
• In all immunocompromised people commence oral aciclovir urgently whether herpes simplex infection is in the locality of the lips, or in the mouth.
• Admit people with severe infection or people who are severely immunocompromised.

• In people with advanced cancer, the oral and topical routes are best used [Doyle et al, 2004].
• Topical antiviral dosage:
• Aciclovir 5% cream, apply to cold sore every four hours, five times aday for 5 days.
• Penciclovir 1% cream, apply to cold sore every 2 hours (during waking hours) for 4 days.
• Systemic aciclovir dosages:
• Aciclovir 200 mg tablets five times a day for 5 days in people who are immunocompetent.
• Aciclovir 400 mg tablets five times a day for 5 days in people who are immunocompromised.

• The basis for this recommendation is expert opinion [Doyle et al, 2004; Regnard and Hockley, 2004; Davies and Finlay, 2005].
• The recommended doses reflect the manufacturer's licence [ABPI Medicines Compendium, 2006b; ABPI Medicines Compendium, 2007].
• Aciclovir or penciclovir should be applied as early as possible in the development of a cold sore, preferably at the prodrome to increase the chance of shortening the course of the infection and reducing the severity of symptoms.

• 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.

• 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].

• 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].

• Seek urgent specialist advice if neutropenia is suspected from the appearance of the ulcer (see Examination) or if confirmed by a blood test.

• The basis for this recommendation is pragmatic advice.
• Recovery of the neutrophil count is needed for healing [Doyle et al, 2004].

• Correct the underlying cause if possible. Modification of dentures may help.
• Head positioning with or without suction may help.
• Local palliative care guidelines on excessive salivation should be followed. If these are not available, specialist advice should be sought regarding off-licence drug management of excessive salivation.
• If swallowing problems are present refer to a specialist (usually a speech and language therapist).

• There are few data to guide drug and dosage recommendations.
• Some experts suggest trying hyoscine hydrobromide 75–150 micrograms sublingually every 8–12 hours or applying hyoscine hydrobromide 1 mg/72 hour patches [Regnard and Hockley, 2004].
• Alternative options are to use drugs with antimuscarinic adverse effects such as amitriptyline or hyoscine hydrobromide [Regnard, Personal Communication, 2007].

• The basis for this recommendation is expert opinion [Twycross and Wilcock, 2001; Regnard and Hockley, 2004].
• Correction of the underlying cause is usually not possible in advanced cancer [Twycross and Wilcock, 2001].
• Secondary care irradiation of the salivary glands corrects the problem [Twycross and Wilcock, 2001].

• Stress the importance of good oral hygiene. See Self care.
• Treat dry mouth if present.
• Treat oral candidiasis. See Oral Candida infection.
• Withdraw treatment with drugs that may induce or increase symptoms (Table 1).
• Refer to a dietitian where appropriate. Give general advice whilst awaiting an appointment.
• If loss of taste follows radiotherapy, reassure the person that taste acuity is partially restored 20 to 60 days after radiotherapy and is usually fully restored within 2 to 4 months.
• Some experts recommend a trial of an oral zinc salt.

• Give general advice whilst the person is waiting to see the dietitian. The following may be tried [Twycross and Wilcock, 2001]:
• Encourage eating tart foods (e.g. lemon juice, pickles, vinegar), if stomatitis or mouth ulcers are not present.
• Recommend food that leaves its own taste (e.g. fresh fruit, hard sweets).
• Add or reduce sugar as appropriate.
• Reduce the urea content of the diet by eating white meats, eggs, and dairy products.
• Mask the bitter taste of food containing urea:
• Add wine or beer to soups and sauces.
• Marinate chicken, meat, and fish.
• Use more and stronger seasonings.
• Eat food cold or at room temperature.
• Drink more liquids.
• Hot food with a strong smell may be helpful [Doyle et al, 2004].
• With the advice of a specialist, a trial of an oral zinc salt e.g. zinc sulphate, may be used.

• The basis of this recommendation is expert advice [Twycross and Wilcock, 2001; Doyle et al, 2004].
• The authors of a standard textbook on oral care in palliative disease recommend that it is appropriate to offer people with taste disturbance a trial of an oral zinc salt [Davies and Finlay, 2005]. However:
• There is is limited and conflicting evidence from small trials of 30 or less people with radiotherapy-related taste problems that use of an oral zinc salt may be effective, but this may not be generalizable to people with other cancer-related taste problems.
• No zinc salt is licensed for this use in the UK and the optimum dose of a zinc salt is unknown as the zinc regimen varied in the different trials.

• Encourage:
• Regular oral hygiene, including tongue cleaning.
• Good care of dentures.
• Fluid intake.
• Modification of diet (e.g. exclude garlic and onions).
• Smoking cessation.
• Regular use of a gargle or mouthwash containing an antimicrobial agent (e.g. chlorhexidine) may reduce breath odour.
• Consider artificial saliva if the mouth is very dry.
• Treat any underlying cause. See:
• Oral Candida infection.
• Malodorous malignant oral ulcers.

• Oral hygiene should include tooth brushing, tongue scraping, and dental flossing.
• The tongue is the main source of malodour and can be cleaned with an ordinary toothbrush, a paediatric toothbrush, a tongue brush or a 'tongue scraper' [Davies and Finlay, 2005].
• The aim of the cleaning is to remove the coating on the tongue without damaging the mucosa of the tongue.
• Clean as far back as possible as the putrefaction occurs mainly on the posterior part of the tongue.
• Discontinue cleaning once the coating has been removed or becomes difficult to remove.
• A gargle or mouthwash should be used daily on waking and after meals and at bedtime.
• Using cider and soda water in equal parts has also been suggested as a gargle/mouthwash [Regnard et al, 1997].

• The basis for recommendation is expert opinion [Twycross and Wilcock, 2001; Doyle et al, 2004; Davies and Finlay, 2005].
• There is some evidence that the use of a mouthwash containing an antimicrobial agent may reduce breath odour compared with placebo [Scully and Porter, 2006].
• There is no evidence for the use of the other pragmatic measures recommended.

• Self care of the mouth before, during, and after treatment with chemotherapy or radiotherapy reduces the severity of mucositis and helps prevent secondary infection.
• Seek urgent specialist advice if mucositis is severe.
• Seek urgent specialist advice if spontaneous gingival bleeding occurs.
• Prevention of secondary infection, oral hygiene, and supportive therapy are very important.
• Use ice chips to soothe the affected area.
• Treat any infection (such as candida infection).
• Avoid spicy and acidic foods (including pineapple chunks and fruit-flavoured ice cubes), sweets, alcohol, tobacco, and hot or fizzy drinks. Advise consumption of soft foods with a low salt content.
• Ensure frequent oral care and use of sterile saline mouth rinsing.
• Avoid acidic mouthwashes.
• Morphine may be required for pain.

• Many non-prescription oral preparations are acidic (e.g. Listerine^®, hydrogen peroxide, Plax^®, glycerine and lemon swabs, lemon/raspberry mousselage, Glandosane^® aerosol spray) and should not be used, as they are likely to increase oral discomfort.
• Seek specialist advice if mucositis is severe, as it may limit the person's ability to tolerate chemotherapy or radiotherapy.
• With severe mucositis, hourly sterile saline mouth rinsing may be needed [Kinley, Personal Communication, 2007].

• The basis for this recommendation is expert opinion [Doyle et al, 2004] and national guidance [Royal College of Surgeons of England, 2004].
• Some weak evidence from a Cochrane review indicates that allopurinol mouthwash, immunoglobulin, and placental extract may be beneficial in improving or curing mucositis. The current evidence does not justify the use of any of these measures.
• There is no specific treatment for oral mucositis, although many strategies have been tried [Kostler et al, 2001].
• Mucositis occurs about 5 to 7 days after chemotherapy, often a few days before the person's haematological lowest point is reached. The mucosal disruption therefore provides a portal of entry for micro-organisms at the time of maximal myelosuppression [Doyle et al, 2004].
• Spontaneous gingival bleeding is likely to occur when the platelet count falls below 10 x 10⁹ cells/L (10,000 cells/mm³) [Doyle et al, 2004].
• Mucositis due to radiotherapy is self-limited and heals within 2 to 3 weeks of the end of radiation treatment [Doyle et al, 2004].

• Advise regular oral care to reduce the risk of oral problems. See Self care.

• Regular mouth care to prevent oral problems is standard nursing practice [Xavier, 2000] and is based on expert opinion [Regnard and Hockley, 2004] and local guidelines [Fife Area Drug & Therapeutics Committee, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005].

• Start preventative measures before and during early cancer treatment to reduce the number of oral complications that follow chemotherapy and radiotherapy.
• Stress the importance of regular oral care. See Self care.
• Check that the person has had a pretreatment oral assessment and that any active dental work required is done.
• Explain that smoking and drinking alcohol can aggravate oral mucositis.
• Advise avoidance of abrasive foods likely to traumatise soft tissue and consider referral to a dietician for dietary advice as necessary.

• A pretreatment oral assessment will usually be arranged by the oncology unit.
• Any necessary dental treatment should be done urgently to avoid any delay in treatment.
• Dental extractions should have a healing time of 10 days before commencement of chemotherapy or radiotherapy.

• The basis for this recommendation is national guidance from the Royal College of Surgeons [Joshi, 2002; Royal College of Surgeons of England, 2004; Davies and Finlay, 2005].
• Little good-quality evidence is available to guide the prevention of complications of radiotherapy and chemotherapy. However, two Cochrane protocols aim to investigate prevention of dry mouth with drug treatment [Davies et al, 2002a; Tavender et al, 2004].

• Seek specialist advice to discuss the prophylactic prescribing of an antifungal drug.
• Choose an antifungal drug that is partially (e.g. topical miconazole) or fully (e.g. systemic fluconazole) absorbed from the gastrointestinal tract.

• Prophylactic prescribing of an antifungal is likely to be appropriate in people at high risk of oral candida infection and in those for whom it is important to prevent the disease.
• Oral candidiasis is a potential adverse effect of cancer treatment, and complications may result in a further deterioration of the physical state. Prevention of superficial infection is important because of its possible role in the development of systemic fungal infection. Systemic infection is difficult to diagnose early and consequently cure because it rapidly becomes advanced and disseminated, leading to considerable morbidity and mortality [Worthington et al, 2004a].
• Doses and frequencies of antifungals used in trials vary.
• Fluconazole 50 to 400 mg daily is licensed (in adults) for prevention of fungal infections in immunocompromised people.
• Fluconazole 400 mg daily is licensed if the risk of systemic infections is high e.g. following bone-marrow transplantation.
• Itraconazole is licensed (in adults) for prevention of deep fungal infections in special circumstances (see the Summary of Product Characteristics [SPC] for more information).
• Ketoconazole 200 mg daily is licensed (in adults) for prophylaxis in immunosuppressed people.
• Miconazole 20 mg/g, 5 to 10 mL four times a day is licensed for prevention of fungal infections.

• The basis for recommendation is a Cochrane review [Worthington et al, 2004a]:
• There is evidence that treatment with oral antifungal drugs that are completely or partially absorbed from the gastrointestinal tract are effective in preventing oral candidiasis.
• There is no evidence on the effect of prevention of oral candidiasis on general well-being or that effective prophylaxis is associated with a reduction in systemic disease. Little evidence is available on drug toxicity and development of microbial drug resistance, and further information is required.
• In people with immunosuppression after cancer treatment, non-absorbed antifungal drugs (nystatin, amphotericin B) may be no more effective than placebo at preventing candidiasis. There is insufficient evidence to recommend whether antifungal prophylaxis is effective in adults having radiotherapy.
• Evidence is insufficient to determine whether intermittent or continuous prophylaxis with antifungal agents is more likely to prevent antifungal resistance.

• Start preventative measures before and during early cancer treatment to reduce the number of oral complications that follow chemotherapy and radiotherapy.
• Stress the importance of regular oral care. See Self care.
• Seek specialist advice to discuss whether any treatment to prevent or reduce the severity of oral mucositis is appropriate.

• A Cochrane review found evidence that amifostine, antibiotic paste or pastilles, hydrolytic enzymes, or ice chips may be beneficial in preventing or reducing the severity of mucositis. However, the benefits may be specific to a certain cancer type or treatment, and because the quality of the evidence was limited, CKS recommends seeking specialist advice for each individual case. In addition, some of these interventions are not routinely available in the UK.

• Carry out mouth care as often as necessary to maintain a clean mouth. See Self care.
• In unconscious people, moisten the mouth at least once an hour with water from a water spray, dropper, or sponge stick or ice chips placed in the mouth.
• To prevent cracking of the lips, smear 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^®).
• When the weather is dry and hot, if possible, use a room humidifier or air conditioning.
• Manage pain symptomatically, using analgesics via a suitable route. Stop treatment of the underlying cause of pain when the burden of treatment outweighs the benefits.

• In people who are conscious, the mouth can be moistened every 30 minutes with water from a water spray or dropper, or ice chips can be placed in the mouth.
• Dry mouth and thirst are very common in people who are dying, regardless of whether they are dehydrated. Reversing dehydration improves symptoms in only a small number of people [Ellershaw et al, 1995].
• People in the last 24–48 hours of life often have difficulty taking food, fluid, or oral medication. Good symptom control may allow the dying person to eat, drink, and talk comfortably. Mouth care can easily be carried out by the family, giving them greater involvement in the care of their dying relative.

• The basis for these recommendations is expert opinion [Twycross and Wilcock, 2001].