What is the treatment for oral ulcers in cancer patients?

Treatment of Oral Ulcers in Cancer Patients

The treatment of oral ulcers in cancer patients should include oral care protocols, pain management with topical and systemic analgesics, and preventive interventions tailored to the specific cancer treatment modality. 1

First-Line Treatments

Basic Oral Care

• Implement oral care protocols for all cancer patients regardless of treatment modality 1
• Use soft toothbrush and mild fluoride toothpaste
• Inspect oral mucosa daily for abnormalities
• Avoid irritants (sharp foods, hot foods, spicy foods)
• Eliminate sources of trauma (sharp edges, ill-fitting prostheses) 1

Pain Management

1. Topical Analgesics:

   • 0.5% doxepin mouthwash for pain relief 1
   • 0.2% morphine mouthwash for patients receiving chemoradiation for head and neck cancer 1
   • Dyclonine HCl 0.5% topical solution as rinse or swab (avoid eating for 60 minutes after use) 2

2. Systemic Analgesics:

   • Patient-controlled analgesia with morphine for patients undergoing HSCT 1
   • Transdermal fentanyl for patients receiving conventional or high-dose chemotherapy 1

Prevention Based on Treatment Type

For Patients Receiving HSCT

1. Recombinant human keratinocyte growth factor-1 (palifermin) at 60 μg/kg/day for 3 days before conditioning and 3 days after transplant 1, 3
2. Low-level laser therapy (wavelength 650 nm, power 40 mW, tissue energy dose 2 J/cm²) 1
3. Oral cryotherapy for patients receiving high-dose melphalan 1

For Head and Neck Cancer Patients Receiving Radiation

1. Benzydamine mouthwash for moderate dose radiation therapy (up to 50 Gy) without chemotherapy 1
2. Low-level laser therapy (wavelength ~632.8 nm) for patients receiving radiotherapy without chemotherapy 1
3. Systemic zinc supplements administered orally 1

Treatment Algorithm Based on Severity

Mild Oral Mucositis (Grade 1-2)

1. Basic oral care protocols
2. Topical pain management:
   • 0.5% doxepin mouthwash
   • Dyclonine HCl 0.5% topical solution

Severe Oral Mucositis (Grade 3-4)

1. Continue basic oral care
2. Aggressive pain management:
   • 0.2% morphine mouthwash for head and neck cancer patients
   • Patient-controlled analgesia with morphine for HSCT patients
   • Transdermal fentanyl for patients receiving chemotherapy
3. Nutritional support if needed

Treatments to Avoid

The following interventions are not recommended based on evidence:

• Sucralfate mouthwash 1
• Chlorhexidine mouthwash for head and neck radiation patients 1
• PTA (polymyxin, tobramycin, amphotericin B) and BCoG antimicrobial lozenges 1
• Iseganan antimicrobial mouthwash 1
• Intravenous glutamine 1
• GM-CSF mouthwash 1

Monitoring and Assessment

• Assess pain at least once daily using an appropriate pain scale 4
• Monitor for systemic disease and complications
• Evaluate effectiveness of interventions regularly
• Grade oral mucositis using WHO scale:
  • Grade 1: Soreness/erythema
  • Grade 2: Erythema, ulcers, can eat solids
  • Grade 3: Ulcers, requires liquid diet only
  • Grade 4: Alimentation not possible 3

Special Considerations

• Cancer therapy-induced oral mucositis can cause intolerable pain affecting eating, speaking, and quality of life 5
• Treatment interruptions due to severe oral mucositis can reduce cancer survival rates 6
• When using topical anesthetics, patients should be warned about the risk of biting trauma due to numbness 2
• Patients with persistent ulcers despite treatment should be evaluated for other underlying conditions 4

Early intervention and aggressive management of oral ulcers in cancer patients are essential to maintain quality of life, ensure adequate nutrition, and prevent treatment interruptions that could affect cancer outcomes.