Mouth care during chemotherapy
Some people having chemotherapy treatment find that their mouth gets very sore. This information gives some ideas about how you can look after your mouth before and during your chemotherapy treatment.
How chemotherapy affects the mouth
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Chemotherapy drugs interfere with the way that cells of the body divide and reproduce. Both healthy cells and cancer cells are affected by chemotherapy drugs. Healthy cells can generally repair the damage caused by the chemotherapy, but cancer cells can’t and so they eventually die. When the healthy cells in the lining of the mouth are affected, this can lead to a number of side effects.
Soreness and ulceration of the mouth
Chemotherapy can cause the lining of the mouth to become very sore, and small ulcers may form. Soreness and ulceration of the lining of the mouth are known as mucositis and can be very painful.
You may get an infection in the lining of your mouth if it becomes sore and ulcerated, or if the number of white blood cells in your blood is reduced. These cells are needed to fight infections. Chemotherapy can temporarily reduce the number of white blood cells in the blood, so for a while after chemotherapy your resistance to infection may also be reduced.
The most common mouth infection is a fungal infection called thrush, also known as candidiasis. Thrush usually appears as white patches, or a white coating, over the lining of the mouth and tongue. It's treated with anti-fungal medicines.
Chemotherapy sometimes leads to a dry mouth.
Occasionally some bleeding or ulceration of the gums may develop.
Damage to the cells lining the mouth is usually temporary, and most side effects will disappear once the chemotherapy has finished and the number of white blood cells has returned to normal. The likelihood of developing a sore mouth varies, and your doctors and nurses will be able to tell you how likely this is with your particular type of chemotherapy.
How to keep your mouth healthy
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There's a lot you can do to help keep your mouth healthy. It's important to inspect your mouth daily for any signs of redness, swelling, sores, white patches or bleeding. Your nurse at the hospital can show you how to do this.
Clean your teeth or dentures gently every morning and evening.
Use a soft-bristled or child's toothbrush. Toothbrush bristles can also be softened in hot water. An electric toothbrush can clean your teeth very effectively.
Replace your toothbrush frequently to prevent problems with infection.
If your toothpaste stings, you could try using a non-foaming toothpaste. Ask your specialist nurse to advise you on the best one to use.
If brushing your teeth makes you feel sick, use a saline (salty water) mouthwash four times a day. (Make it by adding 1 teaspoon of salt to 1 pint of cold or warm water.) After using the mouthwash, rinse your mouth with cold or warm water.
If you've been sick, rinse out your mouth before cleaning your teeth, as the acid in your vomit may damage your teeth.
If your doctor or nurse prescribes a mouthwash for you, use it regularly as prescribed.
You can gently use dental tape or floss daily, but check with your doctor or nurse first. Dental flossing should be avoided if the level of platelets in your blood is low (called thrombocytopenia), or if you’re having radiotherapy to the head or neck area. This is because a low platelet count can cause bleeding in the mouth, even with very gentle flossing. Toothpicks should not be used.
Keep your lips moist by using Vaseline®, or a lip balm if you prefer. If you’re having radiotherapy to your head or neck area, check with your radiotherapy team or specialist nurse before using these products on your lips.
Avoid alcohol, tobacco, hot spices, garlic, onion, vinegar and salty foods, as these may irritate your mouth.
Some crunchy foods may damage your gums and should be avoided when your white blood cell counts are low.
Keep your mouth and food moist. Add gravies and sauces to your food to help with swallowing.
If you’re finding it difficult to eat because your mouth is sore, ask your doctor, nurse or a dietitian for advice about taking food supplements. Some supplements can be prescribed by your doctor or nurse. Others, for example Build-Up® or Complan®, can be bought from your chemist and some supermarkets.
Try to drink at least 1.5 litres (3 pints) of fluid a day. This can include water, tea, weak coffee, and soft drinks such as apple juice.
Avoid acidic drinks, such as orange or grapefruit juice. Warm herbal teas may be more soothing.
Let your doctor or nurse know if you have mouth ulcers, as you may need medicines to help heal the ulcers and clear infection.
How your dentist can help you
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It's important to see a dentist a couple of weeks before you start your chemotherapy. Dentists can advise on any problems, and can help you get your teeth and gums into the healthiest possible condition before your treatment begins.
If your mouth becomes dry during your chemotherapy treatment, there will be less saliva to protect the teeth. Because of this, your dentist may recommend that you use fluoride toothpaste or a fluoride mouthwash during your chemotherapy to help protect your teeth.
If you need to have dental work done during your chemotherapy treatment, it's important to discuss this with your cancer specialist. There will be times during your chemotherapy when you will be at more risk of bleeding and infection, and the timing of any dental work needs to be planned very carefully.
It can often be a good idea to see a dentist once you have finished your chemotherapy treatment. Your teeth are more prone to decay during treatment, and it can be helpful to get a dental check-up.
How your doctor or nurse can help you
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Many hospitals have developed their own mouth care guidelines. You may have an oral (mouth) assessment at your hospital:
to check your usual mouth care routine
to identify the care needed to keep your mouth healthy.
An oral assessment can be useful for all patients who have mouth problems, or who are at a high risk of developing them. An oral assessment can help decide which treatment should be prescribed if your mouth becomes sore. Don't worry if you're not offered an oral assessment at your hospital.
It's important to tell your doctor and nurses if you have a sore mouth, so they can assess your mouth and recommend what needs to be done.
Inflammation and ulceration can often be eased by regularly using a mouthwash. Saline (salty water) mouthwashes are often recommended, and should be used at least four times a day. Benzydamine mouthwash (Difflam®) can be helpful as a local anaesthetic, and can ease the discomfort caused by an inflamed mouth lining. Your doctor or specialist nurse will give you advice about which mouthwashes to use.
Protective gels and mouthwashes
Using gels, sprays and mouthwashes to form a protective coating can sometimes help ease the pain and discomfort of mouth ulcers. Gels such as Orabase®, and sprays like Episil®, can be applied directly to the sore areas in the mouth. Mouthwashes (Caphosol®, Gelclair®, MuGard®) can be rinsed around the mouth before eating.
There are many pain-relieving medicines. If it's hard for you to swallow pills, you can be prescribed liquid or soluble painkillers.
Mild painkillers include paracetamol. Stronger painkillers include codeine combined with paracetamol (co-codamol), and morphine. It’s important to take your painkillers as prescribed, even if this means getting up during the night to take them. This will help keep a constant level of painkiller in your blood and make it more effective for you. Don’t exceed the maximum recommended dose of your painkillers. If your pain isn’t controlled, let your doctor or specialist nurse know.
Painkillers containing codeine and morphine can make you constipated, and you’ll usually be prescribed a laxative to take while you’re taking them. Everyone is different and you may have to adjust the amount of laxatives you take to manage your constipation.
Occasionally, if the pain is severe and drinking is difficult, you may have to be admitted to hospital to be given fluids and painkillers by drip into a vein (intravenously). This is more likely to occur in people who are having high-dose chemotherapy. Taking painkillers for mouth pain may be necessary for a while, but the sores will heal as the number of white blood cells in your blood increases and your immunity improves. You’ll then be able to stop taking the painkillers.
If you have oral thrush (white patches in your mouth), this can be treated with anti-fungal drugs. There are different types of drugs available. Sometimes they are given to prevent thrush in people having chemotherapy. Oral thrush is sometimes treated with a liquid applied inside the mouth (nystatin). But if you're having chemotherapy, taking medicines that are absorbed by the body, such as fluconazole, works better.
Sucralfate is a drug that may help control mucositis during chemotherapy. It creates a protective layer over the sores to prevent the acid in saliva from coming into contact with them. It can cause side effects, such as constipation, diarrhoea, a dry mouth and dizziness.
Some medicines, such as Maalox® or Asilone®, may help neutralise the acid in the mouth, which may help your mouth feel less sore. Your doctor can give you more information.
Some hospitals prescribe mucilages to help ease soreness. These are unmedicated, jelly-like substances (lubricants).
With some chemotherapy drugs, sucking ice chips (or an ice lolly) for 5–10 minutes before the drug is given, and for half an hour afterwards, can also help prevent further mucositis and ulceration. Some people find that the cold can be very uncomfortable, but ask your nurses and doctors if this might be helpful with the drugs you are going to have.
Generally, any soreness of your mouth will begin to improve when your white blood cell count returns to normal.
Many people have a loss of appetite and taste because of chemotherapy. If you notice these problems, it may be helpful to discuss them with a dietitian at the hospital. They should be able to help you with any eating difficulties and suggest ways to make food more palatable.
This section has been compiled using information from a number of reliable sources including:
British National Formulary. 63rd edition. March 2012. British Medical Association and Royal Pharmaceutical Society of Great Britain.
Mouth care guidance and support in cancer and palliative care. 2012. UK Oral Mucositis in Cancer Group. www.ukomic.co.uk (accessed August 2012).
Perry, MC. The Chemotherapy Source Book. 5th edition. 2012. Lippincott Williams and Wilkins.
With thanks to Ms Kathleen Mais, Nurse Clinician – Head and Neck Oncology.
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