What is the best course of treatment for a patient with a history of chemotherapy who is experiencing ulcers on their tongue, likely due to mucositis?

Management of Chemotherapy-Induced Tongue Ulcers

For established chemotherapy-induced oral mucositis presenting as tongue ulcers, use patient-controlled analgesia with intravenous morphine for severe pain, and consider topical morphine mouthwash (0.2%) or doxepin mouthwash (0.5%) for localized pain relief. 1

Pain Management Algorithm

The primary goal is aggressive pain control, as this directly impacts quality of life and ability to maintain oral intake:

First-Line Pain Management

• For severe mucositis pain: Implement patient-controlled analgesia (PCA) with intravenous morphine—this is the strongest evidence-based approach with Level II recommendation from ESMO guidelines 1
• For moderate localized pain: Use 0.2% morphine mouthwash for targeted relief (Level III evidence) 1
• Alternative topical option: 0.5% doxepin mouthwash can be effective for general mucositis pain (Level IV evidence) 1
• Transdermal fentanyl may be considered for patients receiving conventional or high-dose chemotherapy (Level III evidence) 1

Adjunctive Topical Measures

• Topical anesthetics can provide short-term pain relief on an empiric basis 2
• Benzocaine gel (Zilactin B) has been shown to reduce mucositis pain for up to 3 hours 3
• Benzydamine mouthwash may provide symptomatic relief, though its primary evidence base is for prevention in radiation therapy 2, 4

Basic Supportive Care

Implement universal basic oral care protocols for all patients:

• Maintain gentle oral hygiene with soft brushing and warm saline rinses 1
• Avoid trauma-inducing foods: hot, spicy, sharp, or hard foods that may worsen ulceration 1
• Ensure adequate hydration and nutrition: Consider enteral support if oral intake becomes severely compromised 2

What NOT to Use for Treatment

The evidence strongly recommends against several commonly considered interventions:

• Do NOT use chlorhexidine mouthwash to treat established mucositis (Level II evidence against) 2, 1
• Do NOT use sucralfate mouthwash for treatment (Level I-II evidence against) 2, 1
• Do NOT use GM-CSF mouthwash (Level II evidence against) 2, 1

Prevention Considerations for Future Cycles

While the question addresses established ulcers, consider these evidence-based preventive strategies for subsequent chemotherapy cycles:

• If receiving bolus 5-FU: Use 30 minutes of oral cryotherapy during infusion (Level II recommendation) 2, 1
• If undergoing high-dose chemotherapy with stem cell transplant: Palifermin 60 μg/kg/day for 3 days before and after conditioning (Level I recommendation) 2, 1
• Consider low-level laser therapy if your institution has the specialized equipment and trained personnel (Level II-III evidence) 2, 1, 4, 5

Critical Pitfalls to Avoid

• Do not undertreat pain: Severe mucositis pain requires systemic opioids, not just topical agents 1
• Do not delay nutritional support: Mucositis can lead to inadequate oral intake, local and systemic infection, prolonged hospital stay, and increased treatment costs 3
• Monitor for secondary infections: The mucosal barrier breakdown increases sepsis risk, particularly during periods of neutropenia 2
• Assess for dose-limiting toxicity: Severe mucositis may necessitate chemotherapy dose modifications to prevent life-threatening complications 2

When to Escalate Care

• Inability to maintain oral intake despite pain management warrants consideration of feeding tube or gastrostomy 2
• Signs of systemic infection (fever, sepsis) require immediate evaluation given the compromised mucosal barrier 2
• Grade 3-4 mucositis (severe ulceration, inability to eat/drink) may require hospitalization for IV hydration, nutrition, and pain control 2