Topical treatment options for painful mouth

11 June, 2019

Pain in the mouth is a distressing problem and affects so many essential activities. It can have many causes and good mouthcare is of enormous benefit to all patients, particularly towards the end of life. NICE guidelines (NG48) and quality standards (QS151) are in place for oral health for adults in care homes and are in development for people in hospital. Our standard references, the Palliative Adult Network Guidelines and the Palliative Care Formulary contain chapters on oral problems. Some of the common problems, such as dry mouth and infections, have the potential to be improved or reversed but there are times when pain in the mouth is due to an irreversible cause. These may include stomatitis, ulceration and mucositis, which is usually reserved for that inflammation caused by cancer treatments and the options may be limited to managing the discomfort.

Of the options available for the treatment of pain in the mouth, most use the local analgesic effect provided by a variety of mechanisms. The benefits of these are sometimes limited by their short duration of action. Other products work by forming a protective layer in the mouth, thus reducing pain, whilst some preparations combine both actions. Systemic analgesia should also be considered for patients with oral pain.

As ever, first check whether there are any reversible causes. As mentioned, dry mouth and infection can cause pain and some drugs are associated with oral ulceration. Each case should be assessed individually and the most appropriate treatment chosen. This includes not only the choice of product but also the most acceptable formulation for the patient (e.g. a very weak patient may be unable to use a mouthwash effectively).

The approximate cost for those, where cost is relevant, is given in italics.

Sodium chloride

negligible cost

Warm saline mouthwash can be soothing
Add 1 x 5ml spoonful of salt to 250ml boiled and cooled water
May be used as required (not swallowed)

Anti-inflammatories

Benzydamine (Difflam) mouthwash 300ml

A non-steroidal anti-inflammatory and mild local anaesthetic agent available as a mouthwash (or spray)
It can sting, so may be diluted with an equal volume of water before use, if required
May be used as required, up to hourly (not swallowed)

Choline salicylate (Bonjela) inexpensive

A gel formulation of an aspirin derivative
1–2cm can be applied every 3 hours, up to 6 times a day
Excessive use can cause irritation, especially if confined under a denture

Aspirin (as a mouthwash)
low cost for aspirin tablets

A mouthwash made by dissolving a 300mg aspirin tablet in about 30ml warm water can be used every 3–4 hours – not swallowed
If the aspirin is dissolved in a minimal amount of water, it can be mixed with a flavoured mucilage (a similar consistency to Calpol, which coats the mouth for a longer period. This may be available from a hospital pharmacy or made by a specials manufacturer but this increases the cost considerably

Local anaesthetics

When patients are using these for mouth pain, they must be advised to avoid eating or drinking (especially hot food/drinks) soon after application.

Lidocaine gel inexpensive

2% gel (Instillagel) may be used before meals and when required
5% ointment is also available for individual patients on order

Lidocaine spray inexpensive

The spray in normally used for anaesthetising prior to laryngoscopy and may be useful as it has a directional spray which can be used to target specific areas in the mouth
10mg spray (Xylocaine)

Oxetacaine and antacid mixture expensive

A ‘specials’ product made to replace Mucaine, which was discontinued
5-10ml can be used as a mouthwash and swallowed if pain radiates further down into the throat and oesophagus
The product has a very short shelf life (3 weeks) and there is likely to be a delay when ordering from the specials provider

Cocaine mouthwash 2% expensive

Not available commercially, dispensed to order (Requires CD regulations)
10ml may be used every 4 hours if required (not swallowed)
Available from Guy’s and St Thomas’ NHS Trust hospital manufacturing unit
Additional information sheet available on request from Ashtons

Other analgesics

Morphine solution

Standard oral liquid morphine contains alcohol and should not be used but an aqueous solution can be prepared specially or 5mg from an ampoule diluted with water or made into a gel could be used. It needs to be held in the mouth for some minutes to be effective
Neither of these options are easy to obtain but are included as they have been reported to be effective anecdotally

Doxepin rinse expensive

Doxepin – a tricyclic antidepressant with antihistaminic activity has been reported to be helpful
It can be used up to 6 times per day and not swallowed
Not commercially available in the UK but could potentially be ordered as a special

Caphosol mouth rinse