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Palliative cancer care - oral problems - Management
View full scenario
What different types of mouth ulcers are there?
- Table 1 shows the types of mouth ulcers that may be evident.
What assessment do I need to make?
- 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
How should I manage mouth ulcers?
- 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).
In depth
How should I treat aphthous ulcers?
- 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.
- Triamcinolone in an adhesive paste (Adcortyl in Orabase®) has been discontinued.
- For severe recurrent aphthous ulcers doxycycline mouthwash can be used (which can be made up by stirring the contents of a doxycycline 100 mg capsule into a small amount water and rinsing around in the mouth for 2 to 3 minutes, four times a day).
- 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.
In depth
How should I treat oral herpes simplex infection?
- 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 immunocompromised people commence oral aciclovir urgently wherever the herpes simplex infection is located.
- Admit people with severe infection or people who are severely immunocompromised.
In depth
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.
In depth
How should I manage neutropenic ulcers?
- Seek urgent specialist advice if neutropenia is suspected from the appearance of the ulcer (see Examination) or if confirmed by a blood test.
In depth
What follow-up is recommended?
- Follow-up depends on the underlying cause.
When is referral indicated?
- Refer or seek specialist advice if there is doubt about diagnosis or management of any oral problem. Refer if:
- Oral problems are causing a decrease in oral intake or there are concerns about nutrition.
- Mucositis is uncontrolled or problematic.
- Oral ulcers are bleeding.
- Taste disturbance is likely to be prolonged. Refer to a dietitian.
- Pain is difficult to manage.
- There is severe candida infection.
- There are communication problems. Consider referral to a speech and language therapist.
Prescriptions
Aphthous ulcers prodromal phase: Corticosteroid product
Age from 16 years onwards
Hydrocortisone 2.5mg oromucosal tablets:use four times a day
Hydrocortisone 2.5mg oromucosal tablets
Place one tablet over the affected area and allow it to dissolve slowly, four times a day.
Supply 20 oromucosal tablets.
Severe or extensive aphthous ulcers: Corticosteroid products
Age from 16 years onwards
Betamethasone 500mcg soluble tablets: use twice a day
Betamethasone 500microgram soluble tablets sugar free
Dissolve one tablet in 20ml water and rinse around the mouth four times a day.
Supply 56 tablets.
Beclometasone 50mcg inhaler: use 2 to 4 times a day
Beclometasone 50micrograms/actuation inhaler
Spray one puff into the mouth onto the affected area(s) 2 to 4 times a day.
Supply 1 200 dose inhaler.
Aphthous ulcers: Chlorhexidine mouthwash
Age from 16 years onwards
Chlorhexidine mouthwash: rinse with 10ml twice a day
Chlorhexidine gluconate 0.2% mouthwash
Rinse the mouth with 10ml for about 1 minute twice a day. Continue use for 48 hours after symptoms have resolved.
Supply 300 ml.
Herpes simplex: Topical antivirals
Age from 16 years onwards
Aciclovir 5% cream: apply five times a day for 5 days
Aciclovir 5% cream
Apply to cold sore five times a day for 5 days.
Supply 2 grams.
Penciclovir 1% cream: apply every 2 hours for 4 days
Penciclovir 1% cream
Apply to cold sore every 2 hours (during waking hours) for 4 days.
Supply 2 grams.
Herpes simplex: Aciclovir tablets
Age from 16 years onwards
Immunocompetent: aciclovir 200mg five times a day for 5 days
Aciclovir 200mg tablets
Take one tablet five times a day for 5 days.
Supply 25 tablets.
Immunocompromised:aciclovir 400mg 5 times a day for 5 days
Aciclovir 400mg tablets
Take one tablet five times a day for 5 days.
Supply 25 tablets.
Localized oral pain
Age from 16 years onwards
Choline salicylate gel: use up to 6 times a day
Choline salicylate 8.7% oromucosal gel sugar free
Gently massage 1/2 inch of gel onto the affected area when required for pain relief. Maximum of 6 applications in 24 hours.
Supply 15 grams.
Benzydamine spray: use 4 to 8 sprays every 3 hours
Benzydamine 0.15% oromucosal spray
Spray 4 to 8 times onto the affected area every 3 hours when required for pain relief. Increase to every one and a half hours if required.
Supply 30 ml.
Lidocaine 5% ointment: use when required
Lidocaine 5% ointment
Apply a small amount of ointment to the affected area when required for pain relief.
Supply 15 grams.
Lidocaine 10% spray: use when required
Lidocaine 10% spray sugar free
Spray one puff into the mouth when required for pain relief.
Supply 1 50ml spray.
Mechanical protection: carmellose paste
Orabase paste
Apply a thin layer to the affected area after meals.
Supply 30 grams.
Diffuse oral pain
Age from 16 years onwards
Benzydamine 0.15% mouthwash: rinse with 15ml every 3 hours
Benzydamine 0.15% mouthwash
Rinse the mouth with 15ml every 3 hours when required for pain relief. Increase to every one and a half hours if required.
Supply 300 ml.
Diclofenac 50mg soluble tablets: use as a mouthwash
Diclofenac 50mg dispersible tablets
Dissolve one tablet in water and rinse around the mouth for a few minutes before swallowing.
Supply 42 tablets.
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