What medications are used to treat oral sores (mucositis) in cancer patients?

Medications for Oral Mucositis in Cancer Patients

For cancer patients with oral mucositis, topical anesthetics (particularly lidocaine), bland sodium bicarbonate mouth rinses, and topical morphine 0.2% mouthwash are the most effective treatments for pain relief, while palifermin is recommended for prevention in specific high-risk patients. 1, 2

First-Line Treatment Options

Topical Treatments for Pain Relief

• Topical anesthetics:
  • Lidocaine (gel or liquid formulation) for immediate pain relief 1, 2
  • Benzocaine-containing products for short-term pain relief 3, 4
  • 0.5% doxepin mouthwash 2
  • 0.2% morphine mouthwash (particularly effective for radiation-induced mucositis) 2, 5

Mouth Rinses

• Bland mouth rinses: Sodium bicarbonate solution (4-6 times daily) 1, 2
• NSAID rinses: Benzydamine oral rinse for prevention and treatment 1
• Avoid: Chlorhexidine, sucralfate, and antimicrobial lozenges (lack evidence for effectiveness) 2

Systemic Pain Management

1. First step: Acetaminophen (paracetamol) for mild pain 1
2. Second step: Immediate-release oral opioids for moderate pain 1
3. Third step: Patient-controlled analgesia with morphine for severe mucositis pain, particularly in HSCT patients 2
4. Alternative: Transdermal fentanyl or fast-acting fentanyl preparations for breakthrough pain 1, 2

Prevention Strategies

Cryotherapy

• Ice chips held in mouth for 30 minutes during administration of bolus 5-FU chemotherapy 2
• Effective for preventing mucositis in patients receiving specific chemotherapy agents (melphalan, 5-fluorouracil) 1

Growth Factors

• Palifermin (keratinocyte growth factor-1): 60 μg/kg/day for 3 days before conditioning treatment and 3 days post-transplant for patients undergoing HSCT 2

Other Preventive Approaches

• Low-level laser therapy: Wavelength 650 nm, power 40 mW, tissue energy dose 2 J/cm² for HSCT patients 2
• Good oral hygiene: Soft toothbrushes, daily inspection of oral mucosa 2

Novel Treatments

• Methylene blue 0.05% mouth rinse: Promising for intractable mucositis pain and reducing opioid requirements 6

Treatment Algorithm Based on Severity (WHO Scale)

Grade 1-2 (Mild to Moderate)

1. Basic oral care protocol with sodium bicarbonate rinses
2. Topical anesthetics (lidocaine/benzocaine)
3. Acetaminophen for background pain

Grade 3 (Severe)

1. All of the above plus:
2. Topical 0.2% morphine mouthwash
3. Systemic opioids (oral or transdermal)
4. Consider liquid diet 2

Grade 4 (Life-threatening)

1. All of the above plus:
2. Patient-controlled analgesia with morphine
3. Consider treatment interruption until improvement 2
4. Early enteral nutrition if unable to maintain oral intake 2

Common Pitfalls

• Delaying intervention: Can lead to progression to severe mucositis 2
• Overusing chlorhexidine: Not recommended despite common practice 2
• Neglecting nutritional support: Can worsen outcomes and delay recovery 2
• Failing to modify cancer treatment: May require dose adjustment to prevent complications 2
• Inadequate pain assessment: Should be performed at least daily using validated instruments 2

Special Considerations

• For patients on oral chemotherapy, consider temporary dose reduction or treatment interruption for severe mucositis 2
• For patients with swallowing difficulties, consider alternative administration routes (transdermal, intranasal) 1
• For highly symptomatic or recurrent ulcers, topical high-potency corticosteroids (dexamethasone mouth rinse 0.1 mg/ml or clobetasol gel/ointment 0.05%) may be beneficial 1