Palifermin is a human growth factor approved by the U.S. Food and Drug Administration (FDA) to decrease the incidence and duration of severe OM among patients with hematologic malignancies undergoing conditioning with high-dose chemotherapy and total body irradiation for autologous stem cell transplant.14 In its pivotal trial, palifermin significantly reduced the duration of severe OM compared with placebo (3 vs 9 days; P < .001) and reduced the incidence of grade 4 OM by 42% (P < .001).15 Palifermin also reduced patient-reported mouth soreness, opioid use, and need for total parenteral nutrition.

LLLT, which uses 650 nm with a power of 40 mW, and tissue energy dose of 2 J/cm2, is recommended for patients receiving high-dose chemotherapy conditioning for HSCT, with or without irradiation.3 LLLT may also benefit patients with head and neck cancer undergoing radiation without concomitant chemotherapy; there is insufficient evidence for patients receiving combination radiation and chemotherapy. A meta-analysis published in 2017 that included 57 studies and 5261 patients receiving radiation for head and neck cancer found that LLLT resulted in better outcomes compared with other preventative measures for preventing severe OM.16

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Nonsteroidal anti-inflammatory benzydamine hydrochloride–containing mouthwash reduces the production of proinflammatory cytokines, and is recommended for patients with head and neck cancers who receive a moderate dose radiation therapy (up to 50 Gy) without concomitant chemotherapy.3 There was conflicting evidence for the use of amifostine mouthwash, and there was insufficient evidence for other agents including diphenhydramine, prostaglandin E2, immunoglobulins, corticosteroids, indomethacin, azelastine, mesalazine, aspirin, orgotein, flurbiprofen, histamine, colchicine, and placentrex. Mucosal coating agent–containing lozenges and mouthwash are not recommended for the prevention of OM.

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Antimicrobial mouthwashes or lozenges are currently not recommended for the prevention of OM.3 However, some studies have shown that lozenges containing polymyxin-E or tobramycin and mouthwash containing ciprofloxacin or ampicillin may prevent severe OM.4 In addition, the FDA recently granted fast track designation to brilacidin-OM, which is an oral rinse that contains the antimicrobial agent defensin-mimetic brilacidin.4 A novel agent, the short synthetic peptide dusquetide, which modulates the immune response to microbial insult and accelerates healing of damaged tissue, also has a fast tract designation and is currently being evaluated in a phase 3 trial.17

Zinc lozenges may benefit patients with head and neck cancer undergoing radiation or chemoradiation.3 There was insufficient or conflicting evidence regarding other natural remedies including glutamine, vitamin A, vitamin E, honey, aloe vera, chamomile, Chinese medicine, and manuka oil.

Pain Control

OM is very painful and frequently requires opioid analgesics. Patient-controlled morphine is recommended for patients with OM undergoing high-dose chemotherapy conditioning for HSCT. Mouthwash containing 0.2% morphine is suggested to treat pain associated with OM among patients with head and neck cancer receiving chemoradiation, and 0.5% doxepin mouthwash can be used for any patient with OM.

Other options for pain control, which are not discussed by the MASCC/ISOO guideline, include a 2% lidocaine viscous gel before meals, dyclonine hydrochloride, benzocaine gel or lozenges, and magic mouthwash (which contains lidocaine).4

Other Interventions

Other supportive interventions can help manage or alleviate symptoms associated with OM. For example, over-the-counter saliva substitutes as a spray or gel can help relieve mucosal dryness in mild cases of OM.4


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