Chemotherapy-Induced Oral Mucositis Treatment & Management
- Author: Nathaniel S Treister, DMD, DMSc; Chief Editor: William D James, MD more...
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.
Because oral mucositis (OM) is self-limited, management of lesions is divided into 5 main approaches, including the following:
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.
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.
Comprehensive, evidence-based guidelines for the prevention and treatment of oral mucositis are available. See the following:
Oncology National Comprehensive Cancer Network - NCCN Task Force Report: Prevention and Management of Mucositis in Cancer Care
Patients with poorly controlled symptoms and difficulty eating may benefit from consultation with the following services:
Pain and palliative care
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.
Patients with chemotherapy-induced oral mucositis have no specific activity restrictions but typically eat a modified diet and may experience daily pain.
Chemotherapy-induced oral mucositis is not managed surgically.
A wide range of complications are associated with oral mucositis, including, but not limited to, the following:
Inadequate pain control
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.  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.
See above under Medical Care.
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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