Prevention

Prevention strategies are often ineffective at stopping the development of OM, particularly in high-risk patients, but they may reduce its severity.6 Guidelines agree that prevention begins with a dental examination and patient education concerning the importance of good oral hygiene (eg, brushing with a soft toothbrush, flossing, and nonmedicated rinses).2,6,18,21 Preexisting dental issues should be addressed before anticancer therapy.21 Patients should be told to use a soft toothbrush and avoid foods or substances that could damage oral tissues.18,21


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Palifermin is the only FDA-approved drug for the prevention of OM. Approval was based on results from a randomized, placebo-controlled phase 3 trial in adults scheduled to receive high-dose chemotherapy plus total body irradiation before HSCT.22 The palifermin arm had a significantly lower rate of grade 3/4 and grade 4 OM than the placebo group. Palifermin was also associated with fewer days of OM (grade 3/4 or any grade).22

Patients taking palifermin used fewer opioid analgesics than patients taking placebo and were less likely to require total parenteral nutrition. MASCC/ISOO guidelines recommend pretreatment with palifermin for patients undergoing high-dose chemotherapy and radiotherapy prior to autologous HSCT.2 The palifermin label was recently changed to restrict its indication for those patients undergoing myeloablative therapy who are predicted to develop grade 3 or 4 OM.18

The MASCC/ISOO review did not find evidence for the use of palifermin in any other setting. Other interventions MASCC/ISOO guidelines recommend for preventing OM include 30 minutes of cryotherapy with ice chips during bolus 5-FU chemotherapy, low-level laser therapy for patients undergoing myeloablative therapy before HSCT, and benzydamine mouthwash for patients receiving moderate-dose radiotherapy for HNC.2

A meta-analysis of randomized clinical trials that evaluated oral cryotherapy showed it greatly reduced the incidence of OM of all grades in adults receiving 5-FU.23 Weaker recommendations include low-level laser therapy for patients receiving radiotherapy for head and neck therapy and oral zinc supplementation for patients undergoing radiotherapy or chemoradiation for oral cancer.2

The guidelines also list several preventive interventions that are not recommended because data strongly showed they were not effective or evidence supporting their effectiveness was weak (Table 2).2  

Table 2. Interventions Not Recommended by MASCC/ISOO Guidelines to Prevent Oral Mucositis2

Intervention

Population

Evidence of Effectiveness

PTA or BCoG antimicrobial lozenges, PTA paste

HNC patients receiving RT

Strong evidence against

Iseganan antimicrobial mouthwash

Patients receiving HDC before HSCTa; HNC patients receiving RT/chemoradiation

Strong evidence against

Sucralfate mouthwash

Any patients receiving chemotherapy or HNC patients receiving RT or chemoradiation

Strong evidence against

IV glutamine

Patients receiving HDC for HSCTa

Weak evidence against

Chlorhexidine or misoprostol mouthwash

HNC patients receiving RT

Weak evidence against

GM-CSF

Patients receiving HDC before HSCT

Weak evidence against

Oral systemic pentoxifylline

Patients undergoing BMT

Weak evidence against

Oral systemic pilocarpine

HNC patients receiving RT or patients receiving HDC before HSCTa

Weak evidence against

aWith or without irradiation.
Abbreviations: BCoG, bacitracin, clotrimazole, and gentamicin; BMT, bone marrow transplant; GM-CSF, granulocyte-macrophage colony-stimulating factor; HDC, high-dose chemotherapy; HNC, head and neck cancer; IV, intravenous; PTA, polymyxin, tobramycin, amphotericin B; RT, radiotherapy.