Again, we cannot say for sure. We know that for about half of the affected patients, the condition will resolveafter a period of time, but no one can predict how long that will be for a particular individual. For the most part,this problem is a nuisance, and it is a frustrating situation for both patients and doctors.

• Types and causes of mouth problems

  This page has information on the types and causes of mouth problems you may have if you have cancer. You can scroll down the page to read all the information here. Or you can use these links to go straight down to these sections

  • About mouth problems     
  • Mouth ulcers     
  • A sore, dry mouth    

  Taste changes     

• Problems with your teeth     
• A stiff jaw     
• Bad breath     
• Difficulty swallowing     
• Mouth infection

About mouth problems
You may have mouth problems because of your cancer or treatment.  Mouth problems caused by treatment will usually go away within a few weeks of your treatment finishing.  But some side effects can last longer.

1 in 3 people who have chemotherapy or radiotherapy to the head and neck, will develop mouth problems.  These problems are often mild, but can sometimes become serious and affect your daily life.  They can make eating, talking and swallowing very difficult.  We tend to take these basic functions for granted when we are healthy.  If you can’t eat comfortably, it can affect your appetite and you may have weight loss.
Below, there is information about the most common mouth problems that people with cancer may have.
 

Mouth ulcers
Mouth ulcers are small sores in the moist tissues inside the mouth.  For their size, they can be extremely painful.  Chemotherapy and radiotherapy work by killing cancer cells, but they usually damage some healthy cells too.  It is this damage to healthy cells that causes side effects.  The cells that line your mouth are very sensitive to damage from cancer treatments.  Treatment may make the inside of your mouth red and sore and this may lead to an ulcer.

These chemotherapy drugs are particularly likely to cause mouth ulcers

• 5 FU     
• Methotrexate     
• Doxorubicin (Adriamycin)     
• Vincristine     
• Docetaxel (Taxotere)

You can also get mouth ulcers because you are run down or not eating properly.  Doctors use several different ways to try to stop mouth ulcers and infections developing after chemotherapy and radiotherapy.  A 2003 Cochrane review found that many of these do help to prevent or reduce the severity of mouth ulcers caused by cancer treatment . These include using antibiotic pastes or pastilles, mouthwashes containing a drug called allopurinol, or sucking ice chips before or during chemotherapy treatment. You can read this review on helping to prevent mouth ulcers in the Cochrane Library.  It was written for researchers and specialists so is not in plain English.

Sore, dry mouth

Dry mouth may be caused by

• Radiotherapy to your head or neck     
• Drug side effects     
• Breathlessness     
• Not eating and drinking normally     
• Dehydration

You may hear your doctor or nurse call dry mouth xerostomia (pronounced zero-stow-mee-a).

Radiotherapy to the head and neck can damage your salivary glands and cause a dry mouth.  This may gradually improve in the months following your treatment.  But sometimes it can be permanent.  You can do several things to help with a dry mouth but it can still be hard to come to terms with.

Some drugs cause dry mouth as a side effect.  For example, painkillers such as morphine; medications used to treat high blood pressure; some drugs for depression (anti depressants) and some anti sickness drugs.

If you are always trying to catch your breath your mouth can become dry and sore.  People who are breathless usually breathe with their mouths open, which rapidly dries the inside of the mouth.  We all notice this when we have a bad head cold.  Oxygen through a facemask can be particularly drying to the moist tissues inside the mouth.

You may be breathless because you have lung cancer or another type of cancer that has spread to your lungs.  Or it may be because you have fluid on the lung (pleural effusion).

Not eating or drinking is one of the main causes of dry, sore mouth in people with advanced cancer.  You are particularly likely to have problems if you aren't drinking enough and you are breathless.  Your lips may become dry and chapped.  Your mouth can become so dry that the skin inside cracks, which is very painful.  The best way to avoid this is regular mouth care.  When people are very ill and either sleeping all the time or semi conscious, they need to have their mouths cleaned and moistened at least every two hours.

Dehydration means you haven't got enough fluid on board.  If you are dehydrated, your skin, nose and mouth will all be very dry.  You may be dehydrated because you aren't taking enough fluid in.  Or you may be losing too much fluid because you are being sick (vomiting), have bad diarrhoea or are passing a lot of urine.  Being sick a lot can cause dehydration and so make your mouth very dry.  It can also leave a bad taste in your mouth.  The stomach acid in vomit can damage your teeth and make your mouth feel dry and uncomfortable.

Dehydration can be dangerous because the chemical balance in your body can become upset.  Do tell your doctor immediately if you have severe vomiting or diarrhoea for more than 48 hours.  If you are taking drugs to help you lose fluid (diuretics), there is a risk that they may work too well and so cause dehydration.  Contact your doctor or nurse if you are worried that this may be happening to you.

There is information about controlling sickness in the section on feeling and being sick on CancerHelp UK.
Taste changes
Radiotherapy and some chemotherapy drugs may affect your taste buds.  You may notice changes in the way your food tastes.  Some people say their food has a 'metallic', bitter or salty taste.  Others complain that all foods taste the same.

With chemotherapy, taste changes are often temporary.  The drugs most likely to cause these problems include

• Cisplatin     
• Carboplatin     
• Cyclophosphamide     
• Dacarbazine (DTIC)     
• Doxorubicin (Adriamycin)     
• 5 fluorouracil (5FU)     
• Methotrexate     
• Paclitaxel (Taxol)     
• Vincristine

Some people say the immunotherapy drugs interferon and interleukin 2 can alter your sense of taste, but this isn’t a recognised side effect as yet.

With radiotherapy to some parts of the head and neck these side effects can be longer lasting and sometimes permanent.  Ask your doctor before you start your treatment if it is likely to affect your taste.  There are some tips on how to cope with taste changes in this section of CancerHelp UK.

Tooth problems

Having radiotherapy to your mouth means you are more likely to get tooth decay.  Sometimes you need to have teeth removed before you have treatment, particularly teeth that are not healthy.  So your radiotherapy specialist may arrange a dental appointment for you before you have your cancer treatment.

If you wear dentures, they are likely to be a bit uncomfortable if your mouth is sore.  Do ask your dentist's advice.  It isn't a good idea to leave dentures out for long periods.  If you do, your gums can change shape and they may no longer fit.

Stiff jaw
There are muscles in your face that help to move your jaw.  These can become stiff during radiotherapy or surgery to the head or neck area.  There is more about jaw stiffness in this section of CancerHelp UK.

Bad breath
Your doctor may call this halitosis.  Most people have bad breath at some time or other.  But cancer and treatment may make it worse.  Bad breath can be caused by

• A cancer in your mouth , cancer of the voice box (larynx), cancer of the gullet (oesophagus) or stomach cancer     
• A dry mouth     
• Unclean dentures     
• Bits of food trapped in the mouth and teeth     
• Not eating for long periods of time     
• Nose and sinus infections     
• Gum disease     
• Smoking     
• Lung infections (rare)     
• Kidney failure (rare)     
• Liver failure (rare)

There is information about preventing bad breath in this section of CancerHelp UK.

Difficulty swallowing

A cancer in your mouth or throat may be a physical barrier to swallowing.  Treatment can sometimes make things worse for a while.  Some people have to have tube feeding for a time during radiotherapy for oesophageal cancer because swelling in the throat can get worse before it gets better.  Many people also have tube feeding after surgery for cancer of the voice box (larynx).  If you can't swallow, you do need very regular mouth care  – at least two hourly.

Mouth infection

People with cancer get mouth infections for a variety of reasons.  The mouth ulcers you sometimes get with chemotherapy can become infected.  People with advanced cancer, or who are very run down from treatment, often get an infection in the mouth called thrush.  Thrush causes white patches to develop.  The skin underneath can be very red and sore.

As ever, prevention is better than cure if at all possible.  If you do get a mouth infection, you must continue regular mouth care and use all the medicines you’ve been given to get rid of it, such as mouthwashes and lozenges.  Antifungal drugs can also help to prevent thrush infection in the mouth.  A 2004 Cochrane review found that antifungal drugs that are taken up by the body work best.  These include miconazole and fluconazole, but there are several others.  Antifungal drugs, such as  nystatin, that aren’t absorbed by the body don’thelp to prevent thrush infections.

  Click images for larger view  
 

Taste Buds Explained

Did you ever wonder why your favorite foods taste so good? Well, you can thank your taste buds for letting you appreciate the saltiness of pretzels and the sweetness of ice cream. Taste buds are sensory organs that are found on your tongue and allow you to experience tastes that are sweet, salty, sour, and bitter. How exactly do your taste buds work? Well, stick out your tongue and look in the mirror.

See all those bumps? Those are called papillae (say: puh-pih-lee), and most of them contain taste buds. Taste buds have very sensitive microscopic hairs called microvilli (say: mye-kro-vih-lye). Those tiny hairs send messages to the brain about how something tastes, so you know if it's sweet, sour, bitter, or salty. The average person has about 10,000 taste buds and they're replaced every 2 weeks or so. But as a person ages, some of those taste cells don't get replaced. An older person may only have 5,000 working taste buds. That's why certain foods may taste stronger to you than they do to adults. Smoking also can reduce the number of taste buds a person has.

But before you give taste buds all the credit for your favorite flavors, it's important to thank your nose. Olfactory (say: ahl-fak-tuh-ree) receptors inside the uppermost part of the nose contain special cells that help you smell. They send messages to the brain. Here's how it works: While you're chewing, the food releases chemicals that immediately travel up into your nose. These chemicals trigger the olfactory receptors inside the nose. They work together with your taste buds to create the true flavor of that yummy slice of pizza by telling the brain all about it!

When you have a cold or allergies, and your nose is stuffy, you might notice that your food doesn't seem to have much flavor. That's because the upper part of your nose isn't clear to receive the chemicals that trigger the olfactory receptors (that inform the brain and create the sensation of flavor). Try holding your nose the next time you eat something. You'll notice that your taste buds are able to tell your brain something about what you're eating - that it's sweet, for instance - but you won't be able to pick the exact flavor until you let go of your nose. So the next time you chomp on an apple or slurp up some soup, thank your tongue - and your nose! Without them, life wouldn't have any flavor.

Burning Mouth Syndrome

Burning mouth syndrome also referred to as burning tongue or glossodynia is usually described as a continuous though variable superficial burning pain within the tongue, mouth and occasionally lips. It can often be made worse by spicy foods, carbonated drinks, and hot foods. It is most commonly found in women of menopausal age. Several factors may contribute to this disorder. The most common cause is a dry mouth or xerostomia caused by medications such as antidepressants, muscle relaxers, anti-psychotic, antihistamines antiarryhythmics, anxiolytics, anti-hypertensive and diuretics. Other systemic diseases such as Lupus, Sjogrens, and hemolytic anemia can cause dry mouth as well. In addition other factors such as mouth breathing, anxiety, radiation and chemotherapy may contribute to dry mouth as well.

Oral allergies and irritants such as can be found in many types of toothpaste and mouthwashes can cause burning pains. Minor traumatic irritation through chronic tongue thrusting habits and ill fitting dentures have also been identified as a cause. Burning pain can also be elicited by neuropathic causes such as the herpes virus, trauma caused by dental procedures, and trigeminal neuralgia or glossopharyngeal neuralgia.

Treatment starts by identifying the cause, and if possible, by eliminating the causative factor. Neuropathic causes are more likely to be controlled through medications.

aeeeiiii! You probably screamed something like that (or something less printable) the last time you unsuspectingly bit into one of those small, superhot peppers that make a blowtorch seem like a cool breeze. Oh, the pain! It's so exquisite, so beyond ordinary pain, that some people actually seem to enjoy it, and they eat those little red devils with gusto. Whew! Just thinking about it brings on the hot sweats.

Count yourself lucky if your mouth has never been seared like that. You're definitely unlucky, however, if you have stomatopyrosis, unpopularly known as burning mouth syndrome (BMS). Chances are you've never even heard of BMS, let alone known anyone who's had it, even though it's been estimated to affect over one million Americans.¹ BMS is a chronic burning or stinging sensation in the mouth, in the absence of visible lesions or any other obvious cause. It's not as acute as hot-pepper pain, but it can still be very painful (as bad as a toothache in some cases) and it disrupts its victims' lives.

And who are its victims? By a large margin, BMS afflicts mainly postmenopausal women. (This has led to the suspicion that hormonal factors may be involved, yet there is little convincing evidence that hormone replacement therapy is effective in treating the disorder.) The statistics may be skewed, however, by the fact that women are far more likely to seek medical help for what ails them than men are, so BMS may be more common in men than appears to be the case.

BMS Is a Mystery

BMS can affect any part of the mouth, including the lips, but it occurs most often on the tongue, along with various other areas. (There's a special type of BMS that affects only the tongue; it's cleverly called burning tongue, or glossopyrosis in medical jargon). Most studies have found that it's often accompanied by other symptoms, notably xerostomia (dry mouth) and altered taste sensations (typically a persistent bitter or metallic taste).²

The disorder is poorly understood, to put it mildly. There is much speculation on what may cause it and how best to treat it, but it remains largely a mystery. Treatment strategies vary all over the map, from the mundane to the exotic, and they are notable for being highly unreliable.

Can Lipoic Acid Shed Light on BMS?

Naturally, researchers are always looking for something new and better to try, and recently they hit upon a familiar nutritional supplement, lipoic acid. This natural substance (our bodies make it in tiny quantities) is a powerful, versatile antioxidant with remarkable properties, not the least of which is that it's soluble in both water and fat. It is the linchpin in the body's "antioxidant network" and has well-documented health benefits in many areas. (See "Lipoic Acid, the 'Antioxidant's Antioxidant'" and "Lipoic Acid Helps Heart Health" in Life Enhancement, July and September 2001, respectively.) We'll get back to lipoic acid shortly.

BMS Appears to Have Multiple Causes

BMS often occurs for no apparent reason, although a number of possible causes have been suggested: ill-fitting dentures, which can injure the oral mucosae (the sensitive mucous membranes lining the mouth); dysfunction of the salivary glands, which can cause dry mouth; psychiatric disorders, especially anxiety and depression; nutritional deficiencies, especially of vitamins B1, B2, B6, or B12, or of folic acid (which is also a B-vitamin, but without a number); gastrointestinal disorders; food allergies; type 2 (age-related) diabetes; and certain drugs, notably antihypertensives such as ACE inhibitors.^3,4 Many cases turn out to have multiple causes - when causes can be determined in the first place.

Diagnosing BMS is by a process of elimination - ruling out anything else that could cause pain in the mouth, such as canker sores or other kinds of lesions, benign or malignant.* Basically, if the patient's mouth looks fine and tests fine but burns anyway, it's BMS. The burning sensation may be sporadic or constant. In the latter case, the condition is typically mild in the morning and gets worse throughout the day (it tends to disappear during the night, though). This is not only painful but also depressing to the patient.

Most sores in the mouth, however painful they may be, are relatively benign and will probably heal in a few days to a few weeks. Any sore that lasts for more than 2 weeks should be examined by a physician or dentist, especially if it's not painful - these can be more serious than the ones that hurt. Sores that are cancerous or precancerous may or may not hurt, so don't take any chances.

Treating BMS Is a Challenge

Also depressing is the fact that treatment is difficult and often unsuccessful. It may require the expertise of several different kinds of specialists, including those whose entire focus is on chronic pain. One of the things they prescribe (in addition to painkillers and all kinds of other things) is low-dose antidepressants; taken at bedtime, these have often been found to be beneficial.

Whether treated or not, it is not uncommon for BMS to disappear as mysteriously as it arose (spontaneous remission), but it can also spontaneously worsen. Worst of all, it often lasts for years - even for the rest of the patient's life. They just learn to live with it.

The goal of life enhancement, of course, is not to live with things but to live for things - for all the good things in life - and to live better and longer through wise lifestyle choices, including the judicious use of nutritional supplements.

Is There a BMS-Diabetes Connection?

A collaboration of researchers from universities in Naples and London decided to investigate the possibility that lipoic acid (technically, alpha-lipoic acid, and also known as thioctic acid) might be good for treating BMS, because of an intriguing link that may exist between BMS and diabetes, for which lipoic acid is known to be helpful.

It had been noted long ago that many patients with BMS have high blood glucose levels, although no consistent or causal relationship has been documented.⁵ More recent studies of various kinds have led to the suspicion that BMS, despite its maddeningly ambiguous and seemingly numerous origins, is a kind of peripheral neuropathy, a common symptom of long-term, poorly controlled diabetes (it can also occur independently of diabetes).

In medicine, peripheral means far from the center of the body, which usually means the extremities, but in this case it means the mouth (far enough). Neuropathy means nerve damage, and there are different causes, including high glucose levels, although how glucose damages nerves is not clear. Neuropathy generally manifests either as severe pain or as a loss of feeling - an all-or-nothing deal.

Lipoic Acid Works Well on BMS

So what we have is an apparent peripheral neuropathy with a possible connection to diabetes - and it's known that lipoic acid is effective in treating neuronal (nerve-cell) damage, especially in diabetic neuropathy.^6-8 You connect the dots. The Italian-British research team certainly did, and the initial result was a randomized, placebo-controlled - but open (not blinded) - clinical trial of the efficacy of lipoic acid on the one symptom of burning mouth syndrome: pain.⁹ The study involved 42 patients (two age- and sex-matched groups of 21 each), all with classic cases of BMS and no other conditions that might confound the results.

The results were highly positive: 76% of the test subjects taking lipoic acid (600 mg/day for 20 days, followed by 200 mg/day for 10 days) showed some improvement, with 43% showing "decided" improvement. By contrast, only 14% of the control subjects taking placebo showed some improvement (0% had decided improvement). When the controls were then switched over to lipoic acid for 30 days, their improvement rate increased to 67% (52% had decided improvement). No side effects were reported, which is consistent with lipoic acid's excellent reputation for safety.

Lipoic Acid Works Really Well on BMS

Encouraged by these results - which bolstered their belief that BMS may be a form of peripheral neuropathy - the same research team undertook a more rigorous study (randomized, placebo-controlled, and double-blind) with the same objective.¹⁰ This time, 60 patients were involved (two groups of 30 each).

This time the results were even better: 97% of the subjects on lipoic acid (600 mg/day for 2 months) showed some improvement (73% had decided improvement), whereas 40% of the controls showed some improvement (0% had decided improvement). In the lipoic acid group, four patients (13%) showed "resolution," i.e., a complete cessation of pain, which amounts to a cure; this did not occur in any of the controls. None of the patients on lipoic acid got worse during the course of the study, whereas six (20%) of the controls did. Again, there were no side effects.

In a follow-up examination conducted one year later, it was found that any improvement achieved with lipoic acid had been maintained completely in 72% of the test subjects, whereas all the controls who had improved during the study had deteriorated to some extent in the interim.

But What If I Don't Have BMS?

If you don't have BMS, be grateful! But what if you, like millions of Americans, are at risk for the disease it may be related to - diabetes? It makes sense to take whatever precautions you can to minimize that risk, because diabetes is a dreadful - yet largely preventable - disease. In European medical practice, lipoic acid has been used for over two decades to prevent and alleviate the symptoms of diabetes. Although it does not cure the disease itself, "it is highly likely that lipoic acid supplements may help prevent the onset of type 2 diabetes in the first place," in the words of a renowned authority on antioxidants, Dr. Lester Packer, a professor of molecular and cell biology at the University of California, Berkeley.¹¹

Dr. Packer goes on to say, "Much of the destruction that is inflicted by this disease is caused either directly or indirectly by free radicals. . . . Diabetes is very much an oxidative stress disease - that is, people who are diabetic have significantly lower levels of antioxidants than normal."

Make Sure You Get Your Lipoic Acid

Thus it would be a good idea to ensure that your levels of antioxidants, especially lipoic acid, are suitably high, in accord with the knowledge gained through research studies such as those discussed above. Its protective function for many organs and systems throughout the human body make it one of the most valuable nutritional supplements in nature's larder.

Article by Dr. Harold Katz - Founder, California Breath Clinics

Saliva is a very important part of Oral Health. With regards to the topic at hand, Saliva provides 3 important functions:

1. Provides enzymes to help with digestion of food
2. Provides a method to stabilize the pH (keep the acid levels in check)
3. Provides high levels of oxygen in order to keep oral tissues healthy and fresh.

If you suffer from dry mouth (Xerostomia) symptoms, you naturally have less saliva. In turn, less saliva means less oxygen. If there is less oxygen available in the oral environment you have an anaerobic environment, which is perfect for these sulfur-producing bacteria. In essence, the bacteria are now capable of making high levels of sulfur gases, which in turn make the breath and taste worse.

We are the only National Breath Center that includes in their standard treatment an all natural Breath Mint designed to stimulate saliva flow AND freshen your breath. Containing no sugar, aspartame, or saccharin, this breath lozenge uses its patented zinc/oxygen/xylitol formula to naturally stimulate the salivary glands to produce an oxygen-rich type of saliva, which works extremely well with our Stabilized Chlorine Dioxide oral rinse and oral gel in order to restrict the production of the foul-smelling and tasting sulfide and mercaptan compounds.

It is also true that some tongue formations are also more conducive to dry mouth than others. Generally, the rougher one's tongue, the more likely they are to have a bad breath problem. This is connected to the belief by some that "bad breath" can be an inherited trait. Truthfully, one cannot inherit the bacteria of bad breath, but one can inherit a specific "shape or geography" of tongue, just as one would inherit a parent's eye color, hair color, height, and ear shape.

In the graphic on this page, one sees a deep groove going down the middle of the tongue; this is known as a "fissured" tongue and it may lead to a great deal of the anaerobic bacteria breeding at the bottom of this fissure, because Oxygen cannot get to the bottom of the fissure (another reason why tongue scraping without oxidizing products, is a waste of time.)

Some people may have a condition known as "hairy tongue", which again describes the fibers that make up the tongue (papillae), being slightly longer than the norm. The longer the papillae, the more rough the appearance of the tongue and of course the better to trap the sulfur producing bacteria.

Once the tongue becomes very dry, or if the tongue becomes abused by extra hard scraping or brushing, the outer layer becomes very sensitive. One prevalent condition among older people is "burning tongue syndrome". It is common among both sexes, but slightly higher among women. That fact has caused some scientists to believe that there is a hormonal component to "burning tongue syndrome". Many patients who are diabetic, may notice a burning of the tongue, once they become thirsty. It is important, when one has these types of symptoms, to stay away from alcohol-based oral rinses. The resulting pain is indescribably painful according to many of my patients.

The standard recommendation for Burning Tongue Syndrome and Dry Mouth is the following:
(among patients we have treated)

1. Stop using commercial any dry mouth aids or oral products which contain Alcohol and/or Sodium Lauryl Sulfate (see list of oral products at "Oral Products That Create Halitosis").

2. Stop drinking citrus juices (tomato, orange, grapefruit, etc.)

3. Avoid coffee

4. Do not smoke

5. See your physician regarding possibility of Diabetes or Thyroid Problems

Daily Oral Regimen for Those who Have Burning Tongue Syndrome or Dry Mouth:

    a. Coat tongue twice daily with TheraBreath ToothGel and let sit on tongue for 90 seconds.

    b. Rinse with 1-2 capfuls of Oral Rinse for 90 seconds.

    c. Drink 8 glasses of water per day.

    d. Take Vitamin C on a daily basis as recommended on label.

 

Tonsils and Tonsilloliths:
(Those white-yellow globs that get stuck in your throat).

These bacteria can breed very easily in the back of the throat, and especially the tonsils (if you have them.) One important fact to remember: The bacteria never start off in the throat or tonsils. They only get there because the "bugs" originate on the back of the tongue – which contacts the throat & tonsils EVERY TIME you swallow. When someone has post nasal drip or allergies, it is possible to form little "white globs" – scientifically known as Tonsilloliths. They are a combination of sulfur compounds (produced by the bacteria) and mucous (from post nasal drip). Their smell (if you’ve checked them out) is very STRONG! Do not attempt to pick them out yourself – you’ll cause a lot of bleeding. Many dentists and physicians don’t know what they are – they are not food particles and it is not the sign of infection. Do not run out and have a tonsillectomy – because you will still have bad breath – because the bugs are still on the back of your tongue. (If you no longer have your tonsils, a similar reaction takes place if you have had a history of sore throats – your throat is much rougher).

Here's what an increasing number of my patients have done to solve this problem: We have recently developed a concentrated tablet, known as "AktivOxigen Tabs", as an addition to our TheraBreath product line. When added to an 8 oz. bottle of water, the tablet will create a powerful Oxygenating solution which one can use as their mouthwash and Gargle. Patients with tonsils, post nasal drip, or a white coating on their tongue have told me that if they Drink 4-5 capfuls of this solution, even their morning breath disappears! (It's because the oxygenation attacks the bacteria and their odorous sulfur production on the very back of the tongue, throat and/or tonsils – which cannot be reached through any other method.) You can also make a double strength Solution by adding 2 tablets to the 8 oz. bottle. AktivOxigen Tabs are easy to carry around and the resulting Unflavored solution is also very refreshing!