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Palliative cancer care - oral problems - Management
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What are the risk factors for oral candidiasis?
- Local factors:
- Poor oral hygiene.
- Wearing dentures.
- Dry mouth.
- Alteration of saliva composition (e.g. when levels of salivary glucose are high owing to diabetes).
- Damage to the oral mucosa from radiotherapy, chemotherapy, surgery, or cancer.
- Alterations in mouth flora (e.g. levels of competitive bacteria in the mouth are reduced after treatment with antibiotics).
- Reduced mechanical debridement (e.g. comatose, enterally or parenterally fed people, trismus).
- Systemic factors:
- Diabetes.
- Immunosuppression.
- Drugs (e.g. corticosteroids).
- Malnutrition.
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
What is the first-line treatment for oral candidiasis?
- In immunocompetent people, use topical nystatin, or miconazole for first-line treatment.
- In immunocompromised people, high-dose oral fluconazole is generally preferred for first-line treatment.
- Predisposing local and systemic risk factors for oral candida should be managed in conjunction with anticandidal treatment.
- Chlorhexidine should be used to clean dentures and may be used as an adjunct to topical or oral treatment.
- Note: the choice of anticandidal drug treatment may be dictated by local policy or based on advice from a local microbiologist.
How should I manage treatment failure of oral candidiasis?
- Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
- Fluconazole is the preferred oral antifungal drug, except when fluconazole-resistant infections are present.
What other advice should I give?
- Encourage regular oral hygiene. See Self care.
What follow-up is recommended?
- Review if the person does not respond to first-line topical antifungal treatment within 7 days.
- Oral fluconazole is recommended for persistent candidiasis that does not respond to topical treatment.
- If there is evidence of persistent oral candidiasis after initial topical treatment, consider prescribing oral fluconazole.
- If oral candidiasis persists, seek specialist advice.
When is referral indicated?
- If oral candidiasis:
- Persists, despite specialist advice.
- Is interfering with oral intake and nutrition.
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