• Scenario: Self care: covers self-care strategies to help prevent and relieve palliative oral problems.
• Scenario: Dry mouth: covers the management of patients with dry mouth.
• Scenario: Oral Candida infection: covers the management of patients with Candida infection of the mouth (oral thrush).
• Scenario: Mouth ulcers: covers the management of patients with aphthous ulcers, oral herpes simplex infection, chemotherapy- or radiotherapy-induced mucositis, neutropenic ulcers, and malodour from malignant tumours in the oral cavity.
• Scenario: Halitosis, excessive salivation and altered taste: covers the management of people with halitosis, excessive salivation and altered taste.

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

In depth

• 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.

In depth

• Water or sodium chloride 0.9% solution are 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.

In depth

• Dehydration due to fluid loss.
• Reduction in the production of saliva.
• Mouth breathing.
• For further information, see Dry mouth.

• 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

• 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.
• 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.

In depth

• 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 or ice cubes/crushed ice/ice lollies.
• 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, pastilles, mints.
• 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.

In depth

• 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 as intravenous administration of aciclovir may be needed.
• Severe mucositis. It can be extremely painful and may limit future chemotherapy or radiotherapy.
• Suspected neutropenic ulcers and neutropenia. Seek urgent medical advice.
• 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.

In depth

• 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.

• 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

• 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.

• 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.

• Encourage regular oral hygiene. See Self care.

• 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.

• If oral candidiasis:
• Persists, despite specialist advice.
• Is interfering with oral intake and nutrition.

• Table 1 shows the types of mouth ulcers that may be evident.

• 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

• 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

• 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

• 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

• 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

• 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

• Follow-up depends on the underlying cause.

• 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.

• 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.