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Chemotherapy-Induced Oral Mucositis Treatment & Management

  • Author: Nathaniel S Treister, DMD, DMSc; Chief Editor: William D James, MD  more...
 
Updated: Oct 09, 2015
 

Approach Considerations

Treatment of chemotherapy-induced oral mucositis begins with patient education and reinforcing the importance of good oral care throughout cancer treatment. Mucositis is self-limiting and the goal of treatment is to make the patient as comfortable as possible and to maintain adequate nutrition and hydration. In both inpatient and outpatient settings, patients should be assessed routinely to ensure good symptom control.

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Medical Care

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. 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. Antibacterial rinses with chlorhexidine are effective in reducing the overall bacterial load in the oral cavity. Candidal prophylaxis usually includes nystatin rinses or 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. An oral rinse containing the antidepressant doxepin appears to be effective for easing the pain of acute oral mucositis caused by radiation therapy, with or without chemotherapy.[1, 2] 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 symptom 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. There is increasing evidence supporting the effectiveness of photobiomodulation therapy (low-level laser therapy) for the prevention and management of oral mucositis, but its use remains limited. Regimens, including laser wavelength and intensity, have varied considerably from study to study and specialized equipment is required.

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.

Guidelines

Comprehensive, evidence-based guidelines for the prevention and treatment of oral mucositis are available. See the following:

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Consultations

Patients with poorly controlled symptoms and difficulty eating may benefit from consultation with the following services:

  • Oral medicine
  • Pain and palliative care
  • Nutrition
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Diet

A bland, soft diet is recommended. Patients should avoid acidic, spicy, salty, coarse, and dry foods. 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.

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Activity

Patients with chemotherapy-induced oral mucositis have no specific activity restrictions but typically eat a modified diet and may experience daily pain.

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Surgical Care

Chemotherapy-induced oral mucositis is not managed surgically.

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Complications

A wide range of complications are associated with oral mucositis, including, but not limited to, the following:

  • Inadequate pain control
  • Poor nutrition
  • Dehydration
  • Interruption of cytoreductive therapy
  • Increased length of hospitalization
  • Increased cost of treatment
  • Increased risk of local and systemic infectionOral mucositis is a painful condition, which, when severe, may require intensive pain control and nutritional support. In the context of hemapoietic stem cell transplantation, severe oral mucositis has been associated with increased overall hospital costs and hospital length of stay. [15] If oral intake is severely limited patients may become dehydrated and require intravenous support. Patients with severe and prolonged oral mucositis, for example in the context of hematopoietic cell transplantation, may require total parenteral nutritional support.
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Prevention

See above under Medical Care.

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Long-Term Monitoring

Patients with chemotherapy-induced oral mucositis should be followed for signs and symptoms until complete healing and recovery. Chemotherapy-induced oral mucositis is an acute self-limiting condition. There are no long-term implications.

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Contributor Information and Disclosures
Author

Nathaniel S Treister, DMD, DMSc Assistant Professor of Oral Medicine, Harvard School of Dental Medicine; Associate Surgeon, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital

Nathaniel S Treister, DMD, DMSc is a member of the following medical societies: American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sook-Bin Woo, DMD, MS Associate Professor, Chief, Division of Oral Medicine and Oral Pathology, Department of Oral Medicine and Diagnostic Services, Harvard School of Dental Medicine; Chief of Clinical Affairs, Brigham and Women's Hospital; Consultant, Dana Farber Cancer Institute, Beth Israel/Deaconess Medical Center

Sook-Bin Woo, DMD, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Ponciano D Cruz, Jr, MD Professor and Vice-Chair, Paul R Bergstresser Chair, Department of Dermatology, University of Texas Southwestern Medical Center

Ponciano D Cruz, Jr, MD is a member of the following medical societies: Texas Medical Association

Disclosure: Received consulting fee from RCTS for independent contractor; Received honoraria from Mary Kay Cosmetics for consulting; Received grant/research funds from Galderma for principal investigator.

References
  1. Mulcahy N. ‘New standard of care' for oral mucositis. Medscape Medical News. October 30, 2012. [Full Text].

  2. Mayo Clinic. Doxepin hydrochloride in treating oral mucositis pain in patients with head and neck cancer undergoing radiation therapy with or without chemotherapy. Available at http://tinyurl.com/ClinicalTrialDoxepin. Accessed: November 19, 2012.

  3. Scully C, Sonis S, Diz PD. Oral mucositis. Oral Dis. 2006 May. 12(3):229-41. [Medline].

  4. [Guideline] Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014. 120:1453-61. [Medline].

  5. Rosen LS, Abdi E, Davis ID, et al. Palifermin reduces the incidence of oral mucositis in patients with metastatic colorectal cancer treated with fluorouracil-based chemotherapy. J Clin Oncol. 2006 Nov 20. 24(33):5194-200. [Medline].

  6. Sonis S, Treister N, Chawla S, Demetri G, Haluska F. Preliminary characterization of oral lesions associated with inhibitors of mammalian target of rapamycin in cancer patients. Cancer. 2010 Jan 1. 116(1):210-5. [Medline].

  7. Pilotte AP, Hohos MB, Polson KM, Huftalen TM, Treister N. Managing stomatitis in patients treated with Mammalian target of rapamycin inhibitors. Clin J Oncol Nurs. 2011 Oct. 15(5):E83-9. [Medline].

  8. Sonis ST. Pathobiology of oral mucositis: novel insights and opportunities. J Support Oncol. 2007 Oct. 5(9 Suppl 4):3-11. [Medline].

  9. Cutler C, Li S, Kim HT, Laglenne P, Szeto KC, Hoffmeister L, et al. Mucositis after allogeneic hematopoietic stem cell transplantation: a cohort study of methotrexate- and non-methotrexate-containing graft-versus-host disease prophylaxis regimens. Biol Blood Marrow Transplant. 2005 May. 11 (5):383-8. [Medline].

  10. Vagliano L, Feraut C, Gobetto G, Trunfio A, Errico A, Campani V, et al. Incidence and severity of oral mucositis in patients undergoing haematopoietic SCT--results of a multicentre study. Bone Marrow Transplant. 2011 May. 46 (5):727-32. [Medline].

  11. Elad S, Raber-Durlacher JE, Brennan MT, et al. Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and the European Society for Blood and Marrow Transplantation (EBMT). Support Care Cancer. 2015 Jan. 23 (1):223-36. [Medline].

  12. Cutler C, Li S, Kim HT, et al. Mucositis after allogeneic hematopoietic stem cell transplantation: a cohort study of methotrexate- and non-methotrexate-containing graft-versus-host disease prophylaxis regimens. Biol Blood Marrow Transplant. 2005 May. 11(5):383-8. [Medline].

  13. Stiff PJ, Erder H, Bensinger WI, et al. Reliability and validity of a patient self-administered daily questionnaire to assess impact of oral mucositis (OM) on pain and daily functioning in patients undergoing autologous hematopoietic stem cell transplantation (HSCT). Bone Marrow Transplant. 2006 Feb. 37(4):393-401. [Medline].

  14. [Guideline] Lalla RV, Bowen J, Barasch A, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2014 May 15. 120 (10):1453-61. [Medline]. [Full Text].

  15. Vera-Llonch M, Oster G, Ford CM, Lu J, Sonis S. Oral mucositis and outcomes of autologous hematopoietic stem-cell transplantation following high-dose melphalan conditioning for multiple myeloma. J Support Oncol. 2007 May. 5 (5):231-5. [Medline].

  16. Brizel DM, Murphy BA, Rosenthal DI, et al. Phase II study of palifermin and concurrent chemoradiation in head and neck squamous cell carcinoma. J Clin Oncol. 2008 May 20. 26(15):2489-96. [Medline].

  17. Vadhan-Raj S, Trent J, Patel S, et al. Single-dose palifermin prevents severe oral mucositis during multicycle chemotherapy in patients with cancer: a randomized trial. Ann Intern Med. 2010 Sep 21. 153(6):358-67. [Medline].

  18. Spielberger R, Stiff P, Bensinger W, et al. Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med. 2004 Dec 16. 351(25):2590-8. [Medline].

 
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Hairy tongue.
Multiple mucoceles on the hard palate.
Erythematous oral mucositis lesion on the buccal mucosa.
Ulcerative oral mucositis lesion on the buccal mucosa.
Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Ulcerative oral mucositis lesions on the labial mucosa and the floor of the mouth.
Oral pseudomembranous candidiasis on the hard palate.
Herpes simplex virus ulceration on the dorsal surface of the tongue.
Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
Acute graft versus host disease involving the dorsal surface of the tongue. This is a keratinized site that is usually not involved by oral mucositis.
 
 
 
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