Oral Mucositis: Chemotherapy-Associated Toxicity

Clinical Management

There are several guidelines available that provide prevention and treatment recommendations based on clinical trials and expert opinion. The primary management guideline was developed by the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO) with the latest update published in 2014.³ The European Society for Medical Oncology (ESMO) published a guideline based on the MASCC/ISOO recommendations in 2015,¹ and a National Comprehensive Cancer Network (NCCN) task force last published recommendations in 2008.¹² Although there are some evidence-based recommendations for reducing the symptoms of OM, there are many preventative and treatment strategies with inconsistent or insufficient evidence.

Prevention

Recommended preventative measures include a dental exam to identify any potential sources of trauma (eg, ill-fitting prostheses), education about appropriate oral hygiene, cryotherapy, and recombinant human keratinocyte growth factor-1 (KGF-1; palifermin), and low-level laser therapy (LLLT; Table 4).¹

Table 4. Recommendations and Suggestions for the Prevention of OM³

Treatment	Population Recommended	Population Suggested
Appropriate oral hygiene	All	–
Cryotherapy	Bolus 5-fluorouracil	High-dose melphalan with or without total body irradiation as conditioning for HSCT
Palifermin	High-dose chemotherapy and total body irradiation followed by ASCT for a hematologic malignancy	–
LLLT	High-dose chemotherapy with or without total body irradiation followed by HSCT	Head and neck cancer undergoing radiotherapy without concomitant chemotherapy
Benzydamine mouthwash	Head and neck cancer receiving up to 50 Gy radiation, without concomitant chemotherapy	–
Zinc supplement	–	Oral cancer receiving radiation or chemoradiation

Abbreviations: ASCT, autologous stem cell transplantation; HSCT, hematopoietic stem cell transplantation; LLLT, low-level laser therapy; OM, oral mucositis.

An appropriate oral hygiene regimen is the only preventative measure with consistent evidence of benefit and is recommended for all populations (Table 5).³ An oral hygiene regimen should include toothbrushing, flossing, and use of alcohol-free mouth rinses.

There is insufficient evidence to recommend a specific type of mouth rinse or mouthwash for all populations, including magic mouthwash that is often formulated by institutions or pharmacies.^3,13 Magic mouthwash typically contains lidocaine, diphenhydramine, a coating agent, and sometimes an antifungal agent.¹³

Benzydamine mouthwash is recommended for patients with head and neck cancer receiving up to 50 Gy of radiation without concomitant chemotherapy.³ Chlorhexidine mouthwash, however, is not recommended for patients with head and neck cancers.

Table 5. Example of an Oral Hygiene Regimen to Prevent OM^1,3

Toothbrushing	Soft-bristle brush or swab after meals and before sleep but at least 2 times daily; change toothbrush monthly
Toothpaste	Mild, nonfoaming with fluoride
Flossing	Once daily, if already doing so*; floss, toothpick, or brushes can be used
Mouth rinse/mouthwash	Upon awakening and at least 4 times daily; non-alcohol formulation; swish for 1 minute; avoid eating and drinking for 30 minutes after
Denture care	Brush dentures with toothpaste and rinse; clean gums
Painful stimuli	Avoid alcohol, acidic (eg, tomatoes, citrus), hot, spicy, raw, or crusty foods

*Interdental cleaning should not be initiated during cancer therapy due to the likelihood of breaking the epithelial barrier.

Oral cryotherapy, which consists of placing ice chips within the mouth during chemotherapy infusion, is recommended for patients receiving bolus 5-fluoruracil and may also be of benefit to patients receiving high-dose melphalan as part of a conditioning regimen for hematopoietic stem cell transplantation (HSCT).³