Contributory factors:

• Poor fluid intake and/or poor nutritional state
• Medication which dries secretions e.g. amitriptyline, hyoscine
• Hypercalcaemia – potentially reversible
• Radiotherapy to facial area
• Mouth breathing
• Use of non-humidified oxygen

Management

• Encourage frequent sips of water and offer to suck ice cubes
• Diet of soft, moist foods with extra gravy, sauces and/or butter (on veg)
• Artificial saliva - see section 12.3.5 Treatment of dry mouth
• Pineapple juice/unsweetened fruit chunks – avoid if lesions/ulcers, Please note that some patients develop a sore mouth because of proteolytic enzymes in pineapple natural juices therefore discontinue use of mouth becomes sore
• Pilocarpine 5mg 3 times daily – If had head and neck radiotherapy. Can cause abdominal pain and diarrhoea, so only rarely indicated.
• Pink sponges with water if patient unconscious – as required. Families can be shown how to use these to support comfort. Never leave the sponges soaking in water - there have been a small number of choking incidents. See MHRA alert
• Soft, small children's toothbrushes can be useful.
• Lip moisturiser. Do not use petroleum based products (e.g. Vaseline) in those on oxygen. Reports of 'sparking' and burns in the literature. Aloe Vera gel can be used

Oral candidiasis

Thrush is common in advanced illness and can cause great distress. If thrush is recurrent, look critically at: oral or inhaled steroids, treatment with antibiotics and oral hygiene care. Check a random blood sugar, especially for those patients on oral steroids.

Pharmacological management:

Miconazole gel

• See section 12.3.2 Oropharyngeal anti-infective drugs

Nystatin oral suspension

• See section 12.3.2 Oropharyngeal anti-infective drugs

Fluconazole

• Use if nystatin not effective or a systemic antifungal is required
• 50-100mg once daily for 7 days
• Reduce dose of fluconazole by 50% if creatinine clearance is less than 50mL/minute
• Be aware of potential drug interactions as a result of inhibition of various cytochrome P450 enzymes by azole antifungals
• Higher doses and longer courses may be needed in immunosuppressed patients, and patients with more severe infections
• See section 5.2.1 Triazole antifungals
• In resistant cases – seek specialist advice

Mouth ulcers

Herpetic ulceration

• Aciclovir [unlicensed] (see section 5.3.2 Herpes virus infections)
• Seek specialist advice for further information

Bacterial infection and recurrent aphthous ulcers

• Seek specialist advice - doxycycline rinsed in the mouth may be of value

Pain

Consider a range of options for symptomatic relief:

• Regular chlorhexidine mouthwash. Avoid if this stings. (see section 12.3.4 Mouthwashes, gargles, and dentifrices)
• Topical corticosteroids and local anaesthetic agents such as benzydamine mouthwash
• Antacid and oxetacaine unlicensed suspension, prescribed by secondary care
• Sucralfate may be of value, prescribed and dispensed by secondary care
• Opioids may be required if pain is severe
• Topical oral salicylates e.g. Bonjela are available to purchase OTC and may provide symptomatic relief