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Painful mouth care

 

  • 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.