Mouth care during chemotherapy

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1 Some people having chemotherapy treatment find that their mouth gets sore. This information gives some tips about how you can look after your mouth before and during your chemotherapy treatment. In this information: How chemotherapy affects the mouth Looking after your mouth Eating and drinking Coping with mouth problems References and thanks How chemotherapy affects the mouth Chemotherapy drugs kill cancer cells, but they also harm healthy cells, including cells in the mouth. This can cause side effects such as a sore or dry mouth, mouth ulcers, taste changes and mouth infections. If mouth problems are more severe they may affect eating and speaking. Effects on your mouth depend on which chemotherapy drugs you have and how your body reacts to them. Your cancer doctor or nurse can tell you how your mouth may be affected. If you have any mouth problems during treatment always tell your cancer doctor or nurse. They can prescribe treatments and give you helpful advice. Any effects of chemotherapy in the mouth are temporary and get better when treatment finishes. Before your treatment begins a nurse or doctor may examine your mouth and ask about your usual mouth care routine. This is called an oral assessment. It s done to identify any additional care you need to keep your mouth healthy. They may also give you advice about how to help prevent or reduce mouth problems during treatment. Looking after your mouth It s important to see a dentist as soon as possible before you start your treatment. Make an appointment for a dental check up and tell your dentist you are going to have chemotherapy. They will help you get your teeth and gums into the healthiest possible condition before your treatment begins. 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 risk of infection and will bleed more easily. This means the timing of any dental work needs to be planned very carefully. Page 1 of 6

2 Keeping your mouth as clean as possible during your treatment will help to prevent or reduce side effects in your mouth. Check inside your mouth once a day for any signs of redness, swelling, ulcers, white patches or bleeding. Your nurse at the hospital can show you how to do this. Clean your teeth morning and evening and after meals. Replace your toothbrush every three months, sooner if the bristles are spread out of shape. A toothbrush with soft bristles, or a toothbrush for babies or young children, is gentler on your gums if your mouth is sore. Use fluoride toothpaste. If your usual brand irritates your mouth, or if your mouth is sore, choose a mild-flavoured, non-foaming toothpaste. You can ask your nurse if there is one they recommend. Non-foaming brands include: Biotene fluoride, Sensodyne Pronamel Daily protection, Corsodyl daily and Sensodyne Daily Care. You can buy them in larger chemists or online. Check with your nurse or doctor if it s alright for you to use dental floss or tape once a day to clean between your teeth. Avoid toothpicks, as they can damage your gums. There may be times when it s best not to floss, because flossing can make your gums bleed if your platelets are low (platelets are tiny blood cells that help stop bleeding). If you wear dentures clean them with a separate toothbrush and a denture cleaning cream. Clean and rinse them morning, night and after eating. Before you go to bed, soak your dentures in a denture cleaning solution, then leave them in a container of water overnight. This will give your mouth a rest and reduce the chance of mouth infections. Avoid mouthwashes that contain alcohol as they can irritate your mouth. If your doctor or nurse prescribes a mouthwash for you, use it regularly as prescribed. Otherwise rinse your mouth with a saline (salty water) or bicarbonate of soda mouthwash four times a day. To make a saline mouthwash, add 1 teaspoon of salt to 1 pint of cold or warm water. To make a bicarbonate of soda mouthwash, add 1 teaspoon of bicarbonate of soda to cold or warm water. Make a fresh solution of mouthwash each day. After using the mouthwash, rinse your mouth with water. Keep your lips moist by using Vaseline, or a lip balm. If you re having radiotherapy to your head or neck, check with your radiotherapy team or specialist nurse before using any products on your lips. Eating and drinking Try to eat a well-balanced diet during your treatment. This will help your mouth to recover from any effects of chemotherapy. Be careful with rough or crunchy foods as they can damage the lining of your mouth. Hot spices, garlic, onion, vinegar and salty foods may irritate your mouth. Acidic drinks, such as Page 2 of 6

3 orange or grapefruit juice, can also do this. Avoid these if your mouth is sore or more sensitive than usual. Aim to drink at least 1.5 litres (3 pints) of fluid a day. This can include water, tea, herbal teas, coffee, and soft drinks. It s better to let hot drinks cool a little so they are warm but don t scald your mouth. Tobacco and alcohol Smoking irritates your mouth and slows healing. If you do smoke, try to stop or cut down. Your family doctor can help you with this. Alcohol also irritates the mouth. Avoid it if your mouth is sore or if your nurse or doctor has told you that you re at high risk of mouth problems during chemotherapy. Coping with mouth problems Here are some tips to help you cope with common mouth problems during chemotherapy. But, always tell your nurse or doctor if you develop mouth problems. They can give you specific advice and may prescribe treatments to help. Dry mouth If your mouth is dry, take sips of water often. Moisten foods with sauces and gravies. Some people are prescribed saliva replacement products. You re most likely to need these if you are having radiotherapy to the head and neck as well as chemotherapy. They come as gels, sprays and tablets and are designed to have a similar consistency to saliva. Our booklet Understanding head and neck cancer has more information on coping with a dry mouth. Taste changes Chemotherapy can affect your taste buds, making food and drinks taste different to you. When treatment is over your taste will gradually return to normal. If your taste is affected, try different foods and drinks to see what tastes best to you. We have more information on coping with taste changes in our booklet Eating problems and cancer. Sore mouth Tell your nurse or doctor if your mouth is sore. They will check for problems such as infection or ulcers and may prescribe mouthwashes, painkillers or other treatments to help. Regularly rinsing your mouth with a saline mouthwash or one prescribed by your nurse or doctor can help to ease soreness. If it s too sore to brush your teeth your nurse may suggest gently cleaning around teeth and gums with a swab soaked in saline mouthwash. Page 3 of 6

4 Your doctor or nurse may prescribe a gel, spray or mouthwash that forms a protective coating over sore areas in the mouth. You apply gels such as Orabase, and sprays like Episil, directly to sore areas in your mouth. Your nurse may advise you to use a mouthwash such as (Caphosol, Gelclair, MuGard ) several times a day and before eating. Or they may prescribe a benzydamine mouthwash (Difflam ). It contains a local anaesthetic to numb the mouth making it easier to eat and drink. Painkillers can help relieve mouth soreness. It s important to take painkillers regularly as prescribed. This keeps a constant level of painkiller in your blood so that it works more effectively for you. There are liquid and soluble painkillers if you find swallowing pills difficult. If mild painkillers like paracetamol don t control the pain, let your doctor know. They may prescribe something stronger such as codeine combined with paracetamol (co-codamol). For severe mouth pain doctors may prescribe strong painkillers such as morphine. Painkillers containing codeine and morphine can make you constipated, and you ll usually be prescribed a laxative to take while you re taking them. You may have to adjust the amount of laxative you take to manage your constipation. For a few people mouth pain can make it difficult even to drink liquids. This is more likely in people having high-dose chemotherapy. If this happens you may have to be admitted to hospital to be given fluids and painkillers by drip into a vein (intravenously). When your mouth is sore, soft, bland foods are usually easier to eat. If you have problems eating, tell your doctor or nurse. They may refer you to a dietitian for additional support and advice. Food supplements such as Build-Up or Complan can help you to get extra energy and nutrients. You can buy them from chemists and some supermarkets, or your doctor, nurse or dietitian may prescribe food supplements. If you are having high dose chemotherapy or radiotherapy to the head and neck combined with chemotherapy, you may need additional support to get the nutrition you need. This may involve being fed through a tube, called a nasogastric tube, that goes up the nose and down into the stomach. Or, some people are given specially prepared nutrition directly into a vein (intravenously). Mouth infections During chemotherapy, you are more likely to get an infection in your mouth. This is why it s important to keep your mouth as clean as possible. Infection can happen because chemotherapy temporarily thins the lining inside your mouth making it less good at keeping bugs like bacteria, viruses or fungi out. Chemotherapy also reduces the number of white blood cells in your blood. These cells fight infections, so when they are low your body isn t as good at fighting infection. The most common mouth infection is called thrush. Thrush usually appears as white patches, or a white coating, over the lining of the mouth and tongue. It can also cause bad breath. It s treated with anti-fungal drugs. These can be tablets (fluconazole) or a liquid you put on your tongue (nystatin). Doctors sometimes prescribe these treatments to prevent thrush in people having chemotherapy. Page 4 of 6

5 Rarely, an infection in your mouth can enter your bloodstream and make you very unwell. Your specialist doctor or nurse may ask you to check your temperature regularly and to contact the hospital if you feel unwell or if your temperature is high (a high temperature may be over 37.5 C (99.5F) or over 38 C (100.4F), depending on the advice given by your chemotherapy team. Having mouth problems can sometimes be difficult to cope with. But they will gradually improve and eventually go away after your treatment is over. You can contact our cancer support specialists on our freephone for more information and support. References and thanks The information in this section has been produced in accordance with the following sources and guidelines: Mouth care guidance and support in cancer and palliative care UK Oral Mucositis in Cancer Group The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and / or Bone Marrow Transplantation Clinical Guidelines 2012 The Royal College of Surgeons of England / The British Society for Disability and Oral Health If you d like further information on the sources we use, please feel free to contact us. Thanks With thanks to Ms Kathleen Mais, Nurse Clinician Head and Neck Oncology, who reviewed this information. Thank you to all of the people affected by cancer who reviewed what you re reading and have helped our information to grow. You could help us too when you join our Cancer Voices Network - find out more. Content last reviewed: 1 August 2014 Next planned review: 2016 We make every effort to ensure that the information we provide is accurate and up-to-date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication or third party information or websites included or referred to in it. Page 5 of 6

6 Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). A company limited by guarantee, registered in England and Wales company number Isle of Man company number 4694F. Registered office: 89 Albert Embankment, London SE1 7UQ. For cancer support every step of the way, call Macmillan free on (Mon-Fri, 9am-8pm) or visit macmillan.org.uk Page 6 of 6