• 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, and how they and their family/carer are 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).

In depth

• 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).

In depth

• 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 20–60 days after radiotherapy and is usually fully restored within 2–4 months.
• Some experts recommend a trial of an oral zinc salt.

In depth

• Encourage:
• Regular oral hygiene, including tongue cleaning and 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.
• For more information, see Oral Candida infection and Malodorous malignant oral ulcers.

In depth

• Refer or seek specialist advice if in doubt about 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.
• Mucositis. Discuss with the oncology team if it is uncontrolled or problematic.
• Neutropenic ulcers. Seek urgent specialist advice if neutropenia is suspected.
• Severe candida infection.
• Oral ulcers that are bleeding.
• Taste disturbance. Refer to a dietitian if likely to be prolonged.
• Pain that is difficult to manage.
• Communication problems. Consider referral to a speech and language therapist.

• The length of follow up depends on the underlying cause.