There are a number of simple interventions, which are outlined below, that can help improve the comfort of the mouth.
Where interventions involve using water ensure that this is from an appropriate source. Check with the cancer team providing care if you aren’t sure.
1. Oral Hygiene
Patients should be encouraged to brush their teeth at least twice a day. It is the physical act of tooth-brushing that removes dental plaque and this cannot be achieved through the use of mouthwashes alone. Typical adult toothpastes include detergents and flavouring agents that can exacerbate pain associated with oral ulceration. Toothpastes without detergents (SLS-free) or prepared specifically for the ‘sore mouth’ are widely available. An alternative option is to use a children’s toothpaste. Toothpastes used by adults should include 1450ppm fluoride.
Dentures should be brushed twice daily to remove plaque and other debris. They should be left out of the mouth at night-time. Soaking dentures in commercially prepared hypochlorite solutions (e.g. Dentural® – available over the counter) according to the manufacturer’s instructions should be encouraged, although there is the potential for discolouration of a metal denture framework.
2. Mucosal Coating Agents
Mucosal coating agents are used to physically cover ulcerated areas to reduce unpleasant symptoms associated with activities such as speaking, smiling, swallowing or yawning.
Carmellose sodium paste (Orabase® ). This should be applied sparingly to appropriate sites (e.g. buccal or labial mucosa), ideally to dry mucosa, when required. Application to some parts of the mouth (e.g. very mobile structures such as the tongue) is very difficult.
Gelclair® 15ml sachet – prescription only. Gelclair® is a liquid gel and can be used up to 3 times daily as a mouthwash or neat solution. The mouthwash involves dilution of the contents of a sachet in 3 tablespoons of water and rinsed around the mouth for at least 1 minute, to coat the oral mucosa. Alternatively, undiluted Gelclair® can be applied directly to specific parts of the mouth with a clean finger or swab.
3. Anti-Microbial Agents
These help to control pain by reducing secondary infection associated with mucosal ulceration.
Chlorhexidine has a broad anti-microbial spectrum.
Chlorhexidine mouthwash. Rinse 10ml of solution around the mouth for 1 minute twice daily and then spit out. The solution can be diluted with 10ml of water (1:1 dilution) if the patient is unable to tolerate the concentrated solution. The mouthwash can be continued until the lesions have resolved.
Some preparations contain alcohol which can be irritant to the oral mucosa. Others are alcohol free (e.g. Corsodyl® Alcohol Free – over the counter, Curasept® – non prescription and Periogard® – prescription only). Chlorhexidine spray (Corsodyl® – prescription only) may be prescribed for patients who wish to carry the preparation with them. Up to 12 applications (approximately 140 microlitres per actuation) should be used twice daily. This preparation contains 7% alcohol which may cause oral discomfort in some patients.
Chlorhexidine gel formulations are also available and can be applied directly to the ulcers or brushed on the teeth once or twice daily. Preparations available without prescription include Corsodyl gel® (Chlorhexidine gluconate 1%, contains alcohol 4%) and Curasept Gel® (Chlorhexidine gluconate 0.5%, alcohol free).
The effectiveness of chlorhexidine is reduced by constituents of toothpaste. An interval of at least 30 minutes should be left between using chlorhexidine preparations and toothpaste.
4. Topical analgesia for oral ulceration
0.15% benzydamine hydrochloride is both a topical anaesthetic and anti-inflammatory. It is available as mouthwash and spray ( e.g. Difflam® – without prescription). The mouthwash potentially allows more parts of the mouth to be reached than the spray, but is less portable. The patient should be instructed to rinse or gargle with 15ml of the mouthwash every 1½ to 3 hours as needed and then spit it out. The preparation contains 10% alcohol and some patients report stinging when used with a sore mouth. Dilution with an equal volume of water can help. For the spray preparation, 4 to 8 sprays should be directed onto the affected area every 1½ to 3 hours as needed. The spray contains 8.6% alcohol.
5. Warm salty mouthwashes
A simple salt water mouthwash made from approximately 10ml (equivalent to a cup) of warm water and 2 teaspoons of table salt can be held in the mouth for around two minutes. Spit the mouthwash out and do not swallow. It is best to avoid eating or drinking for 1 hour afterwards, if possible.