Chemotherapy-Induced Oral Mucositis Treatment & Management

Because oral mucositis (OM) is self-limited, management of lesions is divided into 5 main approaches, including the following:

• Oral debridement: Because patients with oral mucositis lesions are frequently neutropenic and thrombocytopenic, perform oral debridement with caution because toothbrushing can cause gingival bleeding and, more importantly, result in transient bacteremia. In some centers, sponge-tipped applicators and gauze soaked in sodium chloride solution are used for oral debridement because of these concerns. Dried secretions may become caked on the mucosal surfaces, particularly the palate (and often misdiagnosed as candidiasis). Mucolytic agents, such as Alkalol, help to soften and dislodge them.
• Oral decontamination (mouth care): This regimen consists of antifungal and antibacterial rinses. The fluoride rinses and gels used in some oral care regimens are used primarily for antibacterial activity against gingival plaque; they are not used expressly for the prevention of dental caries. Candidal prophylaxis usually includes nystatin rinses and clotrimazole troches. If patients have a very dry mouth, troches are not as effective because they do not dissolve well in a dry environment. Amphotericin rinses also are occasionally used in place of nystatin. Fluconazole may be used for candidal prophylaxis or for treatment of suspected candidiasis. None of these treatments has been shown to specifically reduce the risk of developing oral mucositis.
• Topical and systemic pain management: Pain in patients with oral mucositis may be severe and not just limited to the oral mucosa. Local rinses (eg, 2% viscous lidocaine, magic mouthwash preparations, and topical morphine solution) and systemic analgesics are used together to control pain. Topical solutions should be kept in the mouth from 2-5 minutes, as tolerated. Frequent rinsing with sodium chloride solution helps to keep the mucosa moist, reduces caking of secretions, and soothes inflamed/ulcerated mucosa. Topical devices, such as Gelclair (EKR Therapeutics, Inc.) and Caphosol (EUSA Pharma) have also been approved by the US Food and Drug Administration (FDA) for mucositis pain management.
• Prophylaxis/prevention: Cryotherapy with ice chips has been shown to effectively attenuate the onset and severity of mucositis in patients undergoing bolus chemotherapy with 5-fluorouracil and melphalan. Patients should suck on ice chips for 30 minutes prior to and during the chemotherapy infusion. Palifermin (keratinocyte growth factor) is FDA approved for the prevention of oral mucositis in patients undergoing hematopoietic cell transplantation (HCT) with myeloablative conditioning (see below). Antimicrobial prophylaxis is generally limited to antivirals to prevent herpes simplex virus (HSV) reactivation; however, some centers use fluconazole as prophylaxis against candidiasis. Neither antiviral nor antifungal prophylaxis prevents mucositis.
• Control of bleeding: Maintaining platelets at 20,000 cells/µL and using topical thrombin packs and topical antifibrinolytic agents, such as tranexamic acid, may control bleeding from ulcers.

Comprehensive, evidence-based guidelines for the prevention and treatment of oral mucositis was published in 2007.^[2] Note the clinical guideline summary, Updated clinical practice guidelines for the prevention and treatment of mucositis. Additional related clinical guideline summaries include the following:

• American Academy of Pediatric Dentistry - Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation
• American Dietetic Association - Oncology evidence-based nutrition practice guideline
• American Society of Clinical Oncology - American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants
• American Cancer Society -Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices

Involving dentists and oral medicine specialists in the care of a patient with oral mucositis is important because oral hygiene modifies the occurrence and the severity of oral mucositis and alpha-hemolytic streptococcal sepsis has become increasingly prevalent (in patients undergoing hematopoietic cell transplantation [HCT]).

In the outpatient setting, a dentist or an oral medicine specialist should see patients several weeks or months prior to the initiation of chemotherapy, especially in the case of HCT. If this is not possible, the patient should be seen for an evaluation during his or her hospitalization for a baseline dental evaluation, even if intervention may not be possible at that visit.

• The role of the dentist/oral medicine specialist is to identify and remove dental/oral sources of infection prior to myelosuppression and HCT.
• Procedures may include but are not limited to comprehensive oral and head and neck examination, full mouth series of dental radiographs, and pulp-vitality testing.
• Appropriate therapy includes identification and management of soft tissue lesions, restoration of carious teeth, extraction of nonsalvageable teeth, extraction of third molars as necessary (particularly those that are not full bony impacted and not fully erupted), and scaling and root planing. Treatment should be completed at least 1 week before initiation of conditioning therapy for HCT.

After the patient has been admitted to the hospital, the dentist/oral medicine specialist should follow up with these patients to monitor oral mucositis, identify signs and symptoms of secondary infection, evaluate slow healing of oral mucositis, identify non–oral mucositis oral mucosal pathology, and adjust the oral care regimen as needed.

A bland, soft diet is recommended. Patients should keep the mouth moist with frequent sips of water, ice chips, or popsicles. Patients with severe oral mucositis may require total parenteral nutrition. Patients should avoid acidic, spicy, salty, coarse, and dry foods.

Patients with chemotherapy-induced oral mucositis have no specific activity restrictions but typically eat a modified diet and may experience daily pain. For patients being followed in a hospital, activities are prescribed for them as part of the daily physical therapy regimen.