• Patients who are receiving or have recently received chemotherapy or radiotherapy need careful monitoring both pre- and post-treatment.
• Medication history is important as numerous medications can affect the oral environment:
  • opioids, diuretics and anticholinergics increase dry mouth
  • steroids increase the risk of candidiasis
  • bisphosphonates increase the risk of osteonecrosis of the jaw. Ill-fitting dentures and surgical intervention including tooth extraction increase this risk, highlighting the need for preventative oral hygiene therapy.
• For patients who are dying, ensure that active routine assessment is carried out.
• Ensure comfort and minimise pain when carrying out an assessment by lubricating cracked lips with a water-based product.
• Petroleum lip balms should be avoided due to flammability and aspiration risk.
• Previous applications of water-based lubricants should be gently removed before replacing.
• Remove dentures before examining the mouth or performing routine mouth care.
• Check the lining of the mouth is clean.
• Look for signs of dryness, coating, ulceration, infection or tooth decay. Assess for pain.
• Consider dental referral with the patient’s consent for persistent oral symptoms or if it has been more than one year since the patient has been examined by a dentist.

All patients

• Oral care is most effective when the patient can be in a semi-upright position to avoid choking or aspiration of bacteria or debris. When positioning is not possible, care should be taken to avoid collection of fluids in the oral cavity or aspiration.
• Looking after oral soft tissues is just as important as looking after the teeth.
• Keep mouth and lips clean, moist and intact by removal of plaque and debris (refer to section on dry/coated mouth care).
• Gentle tongue brushing should also be encouraged to reduce halitosis and prevent tongue coating.
• Encourage fluid intake with frequent, small drinks.
• Apply †water-based gel to dry lips after oral care.
• Where possible reduce intake of sugary foods and drinks between meals (refer to Anorexia/cachexia guideline). There may be additional oral care requirements as frequency of intake increases.
• Where there is concern about oral intake and nutrition, consider referral to a dietitian with consent.
• Encourage and support family members who wish to participate in carrying out mouth care.

Patients with natural teeth

• Clean natural teeth with fluoride toothpaste (1350 to 1500ppm fluoride) after every meal, but at least twice daily if tolerated.
• Mechanical brushing of teeth and gums to remove plaque and debris is as important as application of toothpaste or chlorhexidine digluconate 1%w/w dental gel.
• Encourage patients to spit out excess toothpaste after brushing.
• The mouth should not be rinsed with water after brushing.
• Remove partial dentures and clean separately.
• A dental hygienist or dentist can provide professional advice on oral hygiene for those with complex dental needs.
• Very soft toothbrushes (for example silk toothbrush or baby toothbrush) can be used to perform oral daily care for patients with a painful mouth.

Denture care

• Mark all dentures with the patient’s name.
• A denture fixative may provide relief from extensive movement of dentures.
• Brush dentures at least twice a day over a sink of water to guard against splashing and prevent them from breaking if they are dropped.
• Use of a personal toothbrush and running water are adequate for the physical cleaning of dentures. Denture cream or unperfumed soap may be used but not regular toothpaste.
• Rinse dentures thoroughly after meals and before replacing in the mouth.
• Remove dentures at night and soak in a suitable cleansing solution for
  20 minutes, then overnight in plain water. Recommended soaking solutions are:
  • dilute sodium hypochlorite solution for plastic dentures
  • chlorhexidine gluconate 0.2% solution for dentures with metal parts.
• Check dentures for cracks, sharp edges and missing teeth daily.

Mouth care if receiving chemotherapy/radiotherapy – key difference

• Refer to local cancer centre/cancer network guidelines.
• Patients may be advised to avoid anti-pyretic analgesics (paracetamol, aspirin) if at risk of neutropenia as this can mask fever due to sepsis.
• Patients receiving head and neck radiotherapy should avoid oil-based products.

Mouth care in the last days of life

• Include mouth care in the patient’s care plan.
• Encourage family members who may wish to participate in mouth care activities with guidance and support from the team looking after the patient.
• Consider changing or stopping medicines that are causing a dry mouth.
• Carry out mouth care as often as necessary to maintain a clean mouth.
• In people who are conscious, the mouth can be moistened every 30 minutes with water from a water spray or dropper or ice chips can be placed in the mouth.
• In unconscious people, moisten the mouth frequently, when possible, with water from a water spray, dropper, or sponge stick or ice chips placed in the mouth.
• To prevent cracking of the lips, a water-soluble lubricant should be applied.
• When the weather is dry and hot, if possible, use a room humidifier or air conditioning.
• Ensure help is offered to clean teeth or dentures.
• Manage oral pain symptomatically, using analgesics via a suitable route.
• Stop treatment of the underlying cause of oral pain when the burden of treatment outweighs the benefits.

• Oral care should be offered at least four times daily or as tolerated. Some patients may need more frequent care.
• Where possible, identify and manage the underlying cause, for example review medication, manage anxiety, treat intraoral infection, humidify oxygen and if appropriate encourage hydration.
• Gently remove coatings, debris and plaque from soft tissues, lips and mucosa.
• Failing to remove dried secretions, debris and plaque gently can cause pain, ulceration, bleeding and predispose to infection.
• Use damp non-fraying gauze (which has been thoroughly wetted in clean, running water) wrapped round a gloved finger to gently soak coated areas, provided it is safe to do so.
• Damp gauze (as above) or a moistened soft toothbrush can then be used to gently remove coatings and debris. The gauze should be changed when required and several pieces of gauze used to clean the mouth.
• If sponge sticks are used, they should only be used to moisten the mouth or clean the soft tissues not to remove plaque from tooth surfaces. Always check to ensure the sponge head is secure prior to use. Sponge sticks should be discarded after single use and must never be left to soak as this increases the risk of detachment and subsequent choking.
• If the patient is likely to bite down on the sponge stick, use a small headed toothbrush with soft bristles or a product with a fixed cleaning head such as “MoutheZe”.
• Encourage hydration. Cold, unsweetened drinks (such as sips of water) should be taken frequently throughout the day if possible. Sucking crushed ice or frozen tonic water may provide relief.
• Saline mouthwashes may help to clean the mouth. Patients in hospital may use 0.9% sodium chloride from a vial to be followed by rinsing with cold or warm water. For patients at home, 1 teaspoon of salt may be added to a pint of cold or warm water. A fresh supply should be made daily.
• Saline nebulisers may help with thick or crusty secretions.
• Saliva stimulation (for example sugar-free chewing gum, sugar-free boiled sweets, pastilles, mints) should be considered if the patient is able to comply.
• Saliva substitutes (for example oral gel, spray or mouth rinse) may be used if other measures are insufficient. Refer to local formulary and Chapter 12 of the British National Formulary (BNF).
• There is no strong evidence that topical therapy is effective for relieving xerostomia but many patients find them useful.
• The ideal product should be acceptable to the patient, be of neutral pH and contain electrolytes (including fluoride) to correspond approximately to the composition of saliva.
• Some preparations for dry mouth are derived from animal products and may be unsuitable for vegetarians and people from certain religious groups. AS Saliva Orthana products contain mucin of porcine origin.
• Some preparations with an acidic pH (for example Glandosane^®) should be avoided in dentate patients as long term use of an acidic product may demineralise tooth enamel.
• If a preparation without fluoride is used, a fluoride mouthwash should also be used daily in dentate patients.
• Fluoride mouthwash (0.05%) can be used at a different time from brushing.
• Topical artificial saliva and saliva stimulant products should be used as frequently as needed, including before and during meals.
• Enough artificial saliva should be used to cover the whole mouth. Applying the artificial saliva under the tongue can help to spread the artificial saliva around the whole mouth.
• Attention should also be paid to the lips. Applying a water-based product will help to prevent or treat cracked lips.
• A dry mouth can contribute to tooth decay. Where appropriate, patients should be encouraged to attend their dentist regularly for assessment and necessary treatment.

• Causes of mouth pain include trauma (from sharp teeth), haematinic deficiency, viral infection (herpes simplex), aphthous ulceration, oral malignancy and mucositis.
• Oral pain may be relieved by benzydamine 0.15% oral mouthwash or benzydamine 0.15% oromucosal spray. The mouthwash may be diluted 1:1 with water if stinging occurs.
• Other agents include choline salicylate (Bonjela^®) or a variety of proprietary preparations for use in the mouth containing the local anaesthetic, lidocaine. †Lidocaine ointment (5%) or †spray (10%) may be used but may increase the risk of choking if used before meals due to anaesthesia of the pharynx.
• Consider oral mucositis as a possible cause, particularly in patients receiving chemotherapy or radiotherapy. Oral mucositis is a condition characterised by pain and inflammation of the mucous membrane which may present as painful mouth ulceration affecting any or all intra-oral surfaces. Refer to local cancer centre guidelines or the current version of the UKOMIC (United Kingdom Oral Mucositis in Cancer Group) guidelines for recommended treatment based on the WHO assessment tool and grading scale.
• Soluble paracetamol and/or aspirin used as a mouthwash provides no topical effect. Do not advise patients to use this as a mouthwash. If topical analgesia on its own is not effective, systemic analgesia may be required, refer to Pain management guideline.
• Corticosteroids are not advised for the management of oral mucositis.
• Salt water mouthwashes are effective in maintaining oral hygiene and are advised for the prevention and management of mucositis. They should be used at least four times in 24 hours to clean the mouth and remove debris.
• Patients in hospital may use 0.9% sodium chloride from a vial to be followed by rinsing with cold or warm water. For patients at home, 1 teaspoon of salt may be added to a pint of cold or warm water. A fresh supply should be made daily.
• Gelclair® is a viscous gel specially formulated to aid in the management of lesions of the oral mucosa. It forms a protective film that, by coating and sticking to the lining of the mouth and throat, offers rapid and effective pain management. The contents of one sachet should be diluted with 40ml of water and used as a mouthwash. Repeat three times a day, 1 hour before eating or drinking.
• Carmellose paste (†Orabase^®) is a mucoadhesive paste that will adhere to lesions forming a protective barrier.
• Coating agents will not relieve persistent inflammatory pain but may reduce contact pain, for example from eating or drinking. The coating/barrier may prevent penetration of orally applied medicines, for example nystatin, which will need to be given prior to applying the coating agent.
• Chlorhexidine gluconate 0.2% mouthwash can be considered to treat secondary infections or when pain limits other mouth care methods; 10ml used twice daily may be useful to inhibit plaque formation in patients unable to tolerate other mouth care measures. Dilute 1:1 with water if it stings. Alcohol-free preparations are available.
• If the patient is unable to rinse and expectorate or there is an aspiration risk, soak gauze in chlorhexidine gluconate 0.2% mouthwash and gently wipe over coated surfaces, teeth and gums.
• Consider referral to a palliative care specialist or dentist with consent if there is refractory oral pain or severe mucositis.

Fungal infections

The most common types are candidiasis, denture stomatitis and angular cheilitis (soreness, redness and fissures at corners of mouth). Risk factors include wearing dentures, concomitant antibiotic or steroid use and xerostomia.

• Maintain oral hygiene.
• Systemic treatments are likely to be more effective than topical treatments. In many cases, a systemic antifungal such as fluconazole (capsules or suspension) 50mg daily for 7 days will be indicated with review and extension as necessary. Higher doses may be necessary in immunocompromised patients. Doses may need to be reduced in renal impairment. Topical miconazole oral gel 2% may also be used. Apply 2.5ml topically four times daily, retained near lesions before swallowing. Continue use for at least a week after lesions have healed. Topical miconazole should be considered for treating angular cheilitis.
• In patients where this treatment is contra-indicated, or for mild oral candidiasis in non‑immunocompromised patients, nystatin oral suspension 100,000 units/ml can be considered. Prescribe 1ml four times daily after food, usually for 7 days. Rinse around mouth and hold in contact with affected areas as long as possible. Continue use for 48 hours after lesions have healed. Some patients may be unable to comply with the administration instructions for nystatin and require a systemic antifungal.
• Always check the BNF or seek advice from a pharmacist before prescription of antifungal medication as there is a risk of serious drug interactions. Fluconazole and miconazole (including topical route) should be avoided in patients prescribed warfarin and statins.
• Swab angles, tongue and nostrils to investigate possible Staphylococcal infection. If present, adjust treatment accordingly.
  • If a fungal infection is present, dentures must be cleaned thoroughly – soak in chlorhexidine 0.2% mouthwash (if dentures have metal components) or dilute sodium hypochlorite for 20 minutes twice a day. Toothbrushes should also be replaced.
  • If symptoms persist, consider referral to a dentist with consent or a palliative care specialist.

Viral infections

Herpes simplex is the most common viral infection.

• Treat infections inside the mouth with oral aciclovir: 200mg five times a day for at least 5 days (or until healing is complete). Soluble preparations are available.
• The dose of aciclovir may be doubled or intravenous treatment considered if the patient is immunocompromised or if absorption is impaired. In this case seek advice. Doses may need to be reduced in renal impairment.
• The use of antimicrobial mouthwashes (either chlorhexidine 0.2% mouthwash or hydrogen peroxide mouthwash, 6%) controls plaque accumulation if toothbrushing is painful and also helps to control secondary infection in general.
• Immunocompetent patients in the early stages of an uncomplicated herpes simplex infection in the lips (cold sore) should receive a topical antiviral preparation, for example acyclovir 5% cream applied 5 times a day for 5 days.
• Provide supportive therapy: encourage fluid intake, keep mouth moist, apply water-based lubricant, antipyretic medication and analgesia.
• Viral infections are highly contagious. Strict adherence to infection control measures is essential.

Bacterial infections

• The mouth may become infected and malodorous particularly if there is an oral cancer infected with anaerobic organisms. Poor dental hygiene may also encourage infection. Oral metronidazole (400mg every 8 hours for 3 to 7 days or longer if necessary) is recommended to control anaerobic infection and the associated odour.

• Regular oral hygiene, fluid intake and modification of diet should be encouraged where possible.
• Regular use of a gargle or mouthwash containing an antimicrobial agent (for example chlorhexidine) may reduce breath odour.
• Consider artificial saliva if the mouth is very dry.
• Treat any underlying cause.

• Excessive drooling of saliva is common in neurodegenerative disorders such as motor neurone disease (MND), Parkinson’s disease and multiple sclerosis. The cause is usually impaired swallowing of saliva rather than excessive saliva production.
• Advice should be given on posture, diet and oral care.
• For bed-bound patients, consider regular positional changes by carers/nursing staff with advice from a physiotherapist where necessary.
• Referral with consent to a speech and language therapist should be considered for advice on swallowing techniques.
• Consider a trial of an antimuscarinic agent for treatment for sialorrhoea:
  • †glycopyrronium bromide – oral dose (as oral solution) 200 micrograms every 8 hours, titrated according to response and tolerability to 1mg every 8 hours. May be given via enteral feeding tube.
  • †hyoscine hydrobromide 1mg/72 hour transdermal patch. If necessary, use 2 patches concurrently. Oral dose (tablets) 300micrograms up to three times daily.
  • †amitripyline 10mg to 25mg at night.
  • †atropine 1% eye drops may also be used, 4 drops on the tongue or sublingually, every 4 hours as required.
• †Glycopyrronium should be used as first-line treatment in patients who have cognitive impairment, because it has fewer central nervous system side effects.
• For subcutaneous administration, glycopyrronium or hysocine (as hysocine butylbromide) are preferred because of the lower incidence of central nervous system effects.
• Medication to manage sialorrhoea may exacerbate dry mouth causing thickened secretions which may be more difficult to clear.
• Where there is thick, tenacious saliva:
  • review all current medicines, especially any treatment for sialorrheoea
  • consider treatment with humidification, sodium chloride 0.9% nebulisers and carbocisteine
• If treatment for sialorrhoea is not effective or not tolerated, consider referral to a palliative care specialist or the specialist team looking after the patient.

Refer to Bleeding guideline.

Maintenance of nutritional intake is essential and referral to a dietitian with consent should be considered.

• Diet should be adapted and patients encouraged to try new foods and drinks which are enjoyable and look good.
• If minerals are lacking, supplements may be required.
• If patients are prescribed food supplements and/or having frequent small food intake over the day, basic oral hygiene measures may need to be carried out more frequently.

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