12.3 Oropharynx

12.3.1 Treatment of dry mouth

See BNF for conditions that allow saliva substitutes to be prescribed

See UKMI – Saliva substitutes: Choosing and prescribing the right product

Artificial saliva products 

Artificial saliva spray (Oralieve^®) (TLS Green)

Alternative: (TLS Blue)

Artificial saliva spray (Glandosane^®, AS Saliva Orthana^®)

Specific indication: (TLS Blue)

Saliva replacement gel (Biotene Oralbalance^®)

• Sicca syndrome & palliative care
• Biotene OralBalance^® is also available for use on advice of Speech & Language Therapy

Salivix^® pastilles

Parasympathomimetics

Specific indication: (TLS Blue)

Pilocarpine tablets (TLS Amber Specialist Recommended)

Excess Salivary Secretions

Hyoscine hydrobromide (tablet and transdermal as Scopoderm TTS^® Patch) (off label use)(TLS Green)

Amitriptyline (off label use) (TLS Green)

 Glycopyrronium bromide (TLS Amber 3 months)

• For hypersalivation in line with SCP for the treatment of hypersalivation in people with swallowing problems and with neurological conditions, motor neurone disease or Parkinson's Disease in line with the hypersalivation pathway document

Botulinum toxin type A (TLS Red) 

• For drooling in patients with motor neurone disease and Parkinson's Disease where oral pharmacological treatments have failed
• NICE TA605 Xeomin^® - For treating chronic sialorrhoea

See Botulinum Toxin Pathways page for more information

12.3.2 Oral hygiene

Chlorhexidine 0.2% mouthwash (TLS Green)

Chlorhexidine 1% dental gel (TLS Green)

Hydrogen peroxide mouthwash 6% (TLS Green)

N.B. Hydrogen peroxide mouthwash solution needs to be diluted prior to use

Mouthwash solution tablet (TLS Green)

Caphosol^® mouthwash (TLS Red)

• For patients undergoing bone marrow transplant treatment and haematology patients on multiple drug regimens that include high dose methotrexate

Sucralfate liquid (oral) (TLS Red) 

• For treatment of oral mucositis for oncology and haematology patients

12.3.3 Oral hygiene, dental caries

High Strength Toothpaste (Duraphat 5000ppm)

The BNSSG Joint Formulary Group consider that the most appropriate clinician to prescribe high strength fluoride toothpaste such as Duraphat is the patient's dentist.

Patients with head and neck cancer/following radiotherapy

Where High Strength Toothpaste (Duraphat 5000ppm) is required for patients with head and neck cancer or who have undertaken a course of radiotherapy, this should be prescribed by the general dental practitioner, if the patient has an NHS dentist. 

If patients are not registered with an NHS dentist or can’t access their NHS dentist to start treatment in a timely way as advised by their oncology team, the GP practice may prescribe High Strength Toothpaste (Duraphat 5000ppm) to support patient care and timely access to treatment in this small cohort of patients.

This pathway has been agreed by NHS England South West.

Where NHS dentistry is available, the NHS dentist remains the preferred route for supply of High Strength Toothpaste (Duraphat 5000ppm).

12.3.4 Oral ulceration and inflammation

Corticosteroids

Hydrocortisone 2.5mg muco-adhesive buccal tablets (TLS Green)

Betamethasone soluble tablets (TLS Green)

• TLS green for recurrent aphthous ulceration and non-specific oral ulceration and inflammation
• Betamethasone mouthwash Patient Information Leaflet

Betamethasone soluble tablets (TLS Amber Specialist Recommended)

• TLS Amber Specialist Recommended for oral lichen planus, behcet's syndrome, pemphigus vulgaris, pemphigoid, lupus, oral erythema multiforme, oral-facial granulomatosis
• Betamethasone mouthwash Patient Information Leaflet

Dexamethasone soluble tablets (oral rinse) (TLS Amber Specialist Recommended)

• For topical management of oral ulceration/oral erosions and inflammation
• Dexamethasone mouthwash Patient Information Leaflet

Fluocinolone Acetonide 0.025% gel (Synalar^®) (oral) (TLS Amber Specialist Recommended)

• For topical management of oral ulceration / oral erosions and inflammation

See Guide for Primary Care on the use of off-label topical steroids for inflammatory oral conditions within the Oral Medicine Department

Non-steroidal anti-inflammatory drugs

Benzydamine 0.15% oral rinse/spray (Difflam^®) (TLS Green)

Salicylates

Choline salicylate gel (Bonjela^®) (TLS Green)

Specific indication: (TLS Blue)

Gelclair^® gel

• Haematology, Oncology and Palliative care use only for pain associated with mucositis

Other

Dapsone (oral) (TLS Amber 3 months) (SCP)

• for treatment of dermatoses and oral ulceration
• see 5.2 bacterial infection and 5.3 fungal infection for other indications

12.3.5 Oropharyngeal bacterial infections

Link to BNF Oropharyngeal bacterial infections

See local antibiotic guidelines

BNSSG Primary Care Antimicrobial Guidelines

• NBT antibiotic guidelines click here (N.B. Only available via Trust intranet )

• UHB antibiotic guidelines click here (N.B. Only available via Trust intranet)

• WAHT see local guidance

12.3.6 Oropharyngeal fungal infections

Link to BNF Oropharyngeal fungal infections

Nystatin oral suspension (TLS Green)

• Nystatin suspension should be continued for 48 hours after lesions have resolved
• Consider systemic treatment with oral fluconazole

Miconazole oral gel (TLS Green)

12.3.7 Devices

See funding policy for information about temporomandibular jaw motion rehabilitation devices e.g. therabite

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