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Referral and warning signs
When to refer
Severe mucositis. Oral pain unresponsive to standard measures. Suspicion of oral malignancy. Need for specialist dental review. Consideration for systemic steroids or pilocarpine.
Red flags
- Suspected oral malignancy (persistent ulcer, lump, red/white patch).
- Signs of severe systemic infection originating from oral source.
- Inability to maintain hydration/nutrition due to oral symptoms.
- Severe pain preventing oral hygiene.
Signs and symptoms
- Subjective feeling of dry mouth.
- Difficulty swallowing dry food.
- Difficulty speaking.
- Altered taste.
- Burning sensation in mouth.
- Oral pain.
- Cracked lips.
- Visible signs: Lack of saliva pooling, thick/stringy saliva, dry/fissured tongue, oral thrush (white patches), ulcers, gingivitis, mucositis (red, inflamed mucosa).
Risk factors
- Medications (anticholinergics, opioids, diuretics, antidepressants like amitriptyline).
- Dehydration.
- Radiotherapy to head/neck.
- Chemotherapy.
- Mouth breathing.
- Oxygen therapy.
- Infections (Candidiasis, Herpes Simplex).
- Systemic diseases (Sjogren's syndrome, uncontrolled diabetes).
- HIV infection.
- Poor oral hygiene.
Diagnosis
Clinical assessment
Patient report of symptoms. Oral examination: Inspect mucosa, tongue, teeth, lips. Look for dryness, redness, ulcers, white patches (thrush), inflammation, hygiene status.
Investigations
- Oral swab for fungal smear/culture if thrush suspected and diagnosis uncertain.
- Viral swab if herpes suspected.
Diagnostic criteria
Clinical assessment based on symptoms and oral examination findings.
Management
Non-pharmacological management
- Good Oral Hygiene:
- - Gentle tooth brushing (soft brush) and tongue cleaning at least 3 times/day.
- - Regular mouth rinsing with salted water (1 tsp salt in 1 pint/500ml cooled boiled water) - hourly if needed.
- Moisture:
- - Frequent sips of water.
- - Sucking on ice chips or sugar-free candies/lozenges.
- - Using saliva substitutes or stimulants (less available).
- - Applying lip balm (e.g., Vaseline) to cracked lips.
- Diet:
- - Eat soft, moist foods.
- - Avoid sugary foods/drinks, alcohol, tobacco, very hot/spicy foods.
- Other:
- - Review medications for potential causative agents.
- - Treat underlying dehydration.
- - Fresh cold pineapple cubes (sucked) may help stimulate saliva/cleanse mouth (UCG suggestion).
Pharmacological treatment
- Treat Specific Causes:
- - Candidiasis (Thrush): Fluconazole 200mg PO OD for 7 days (adjust for renal impairment). Alternatives: Nystatin suspension, Miconazole oral gel.
- - Herpes Simplex: Acyclovir 200mg PO 5 times/day for 5-10 days.
- - Anaerobic Gingivitis/Halitosis: Metronidazole mouthwash (Dilute 50ml IV Metronidazole in 450ml water + 50ml juice for taste - UCG suggestion). OR Systemic Metronidazole.
- Pain/Ulcers:
- - Topical Analgesic Gels (e.g., Benzydamine, Lidocaine viscous - Bonjela/Oracure mentioned in UCG). Apply before meals.
- - Systemic Analgesia: Paracetamol/NSAIDs. For severe pain, consider opioids (see PAL001). Liquid morphine held in mouth before swallowing can provide topical effect.
- - Severe Mucositis/Aphthous Ulcers: Consider short course of steroids (Dexamethasone 8mg OD for 5 days - specialist advice).
- Saliva Stimulation (Limited use): Pilocarpine (specialist use, side effects).
Monitoring
Monitor oral symptoms (dryness, pain). Inspect mouth regularly for improvement/worsening/new issues. Monitor effectiveness and side effects of treatments (e.g., Fluconazole LFTs).
Complications
- Oral infections (candidiasis, bacterial).
- Dental caries.
- Difficulty eating/drinking leading to poor nutrition/hydration.
- Pain and discomfort.
- Difficulty speaking.
- Reduced quality of life.
Prevention
- Maintain good oral hygiene.
- Ensure adequate hydration.
- Review medications regularly.
- Prophylactic antifungals in high-risk situations (e.g., during head/neck radiotherapy - specialist).
- Avoid irritants (tobacco, alcohol).
Patient education
- Importance of regular, gentle oral hygiene.
- How to perform mouth care (brushing, rinsing).
- Strategies to keep mouth moist (water sips, ice chips).
- Dietary advice (soft foods, avoid irritants).
- How to use prescribed medications (mouthwashes, gels, systemic drugs).
- When to report problems.
Uganda-specific notes
Oral thrush is very common, especially in HIV/AIDS and cancer patients; Fluconazole is widely available. Emphasis on simple, low-cost measures like salt water rinses and basic hygiene is crucial. Access to topical analgesic gels and saliva substitutes is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 13, Section 13.2.7