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.
Medical Care
Because oral mucositis is self-limited, management of lesions is divided into 4 main approaches, described below.
Basic oral care
Basic oral care is divided into 2 sections: debridement and decontamination. [5] General debridement with a soft or ultra-soft toothbrush or toothettes is recommended. Because patients with oral mucositis lesions are frequently neutropenic and thrombocytopenic, perform oral debridement with caution because tooth brushing 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. The decontamination regimen consists of antifungal and antibacterial rinses. Antibacterial rinses with chlorhexidine are effective in reducing the overall bacterial load in the oral cavity and are used at some hematopoietic cell transplantation (HCT) centers. 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, topical morphine solution) and systemic analgesics are used together to control pain. Topical solutions should be kept in the mouth for 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 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. Increasing evidence supports 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.
Rebamipide 4% liquid, a mucosal protective agent, has shown promise in clinical studies for the prevention of high-grade oral mucositis in patients with head and neck cancer who received chemotherapy and radiotherapy. [19]
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.
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Hairy tongue.
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Multiple mucoceles on the hard palate.
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Erythematous oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the buccal mucosa.
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Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
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Ulcerative oral mucositis lesions on the labial mucosa and the floor of the mouth.
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Oral pseudomembranous candidiasis on the hard palate.
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Herpes simplex virus ulceration on the dorsal surface of the tongue.
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Herpes simplex virus ulceration on the hard and soft palate. Note lesions on the right upper lip and the dorsum of the tongue.
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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.
