How should oral complications like mucositis, xerostomia, infection, and bleeding be managed in a patient receiving chemotherapy?

Management of Oral Complications During Chemotherapy

All patients receiving chemotherapy should implement a comprehensive basic oral care protocol immediately, which includes brushing teeth twice daily with a soft toothbrush, rinsing with alcohol-free mouthwash at least 4 times daily, avoiding trauma-inducing foods and behaviors, and maintaining optimal hydration—this approach forms the foundation for preventing and managing all oral complications including mucositis, xerostomia, infection, and bleeding. 1

Essential Basic Oral Care Protocol

Tooth Brushing:

• Brush teeth twice daily (after meals and at bedtime) using a soft toothbrush with gentle technique 1
• Store the toothbrush with the brush head facing upward to prevent contamination 1
• Critical caveat: If you are not already using interdental cleaners (floss, toothpicks, brushes) regularly, do NOT start during chemotherapy as this can break the epithelial barrier and cause gingival bleeding 1

Mouth Rinsing:

• Rinse with alcohol-free mouthwash upon awakening and at least 4 times daily after brushing 1
• Use approximately 15 mL, swish for 1 minute, gargle, then spit out 1
• Avoid eating or drinking for 30 minutes after rinsing 1
• For patients on targeted therapies (EGFR/VEGFR inhibitors): Use saline-containing mouthwashes instead of plain water due to increased microbial burden and infection risk 1

Denture Management:

• Remove dentures before performing oral care 1
• Brush dentures with toothpaste and rinse with water; clean the gums 1
• Defer wearing dental prostheses as much as possible until oral tissues heal 1
• If hospitalized, soak dentures for 10 minutes in 0.2% chlorhexidine before insertion 1

Avoid Painful Stimuli:

• Eliminate smoking and alcohol 1
• Avoid tomatoes, citrus fruits, hot drinks, and spicy, hot, raw, or crusty foods 1
• Remove sources of trauma such as sharp tooth edges and ill-fitting prostheses 1

Prevention of Mucositis (Treatment-Specific)

For Bolus 5-Fluorouracil Chemotherapy:

• Administer 30 minutes of oral cryotherapy (sucking on ice chips) during infusion—this is a Level II recommendation with strong evidence for preventing mucositis 1, 2

For High-Dose Chemotherapy with Autologous Stem Cell Transplant:

• Use palifermin (KGF-1) at 60 μg/kg/day for 3 days before conditioning treatment and 3 days after transplant for patients with hematological malignancies receiving total body irradiation—this is a Level II recommendation 1, 2

For High-Dose Melphalan Conditioning:

• Consider oral cryotherapy (Level III evidence) 1, 2

For HSCT with High-Dose Chemotherapy:

• Consider low-level laser therapy (wavelength 650 nm, power 40 mW, tissue energy dose 2 J/cm²)—Level II recommendation 1, 2

Management of Established Mucositis Pain

For HSCT Patients with Severe Pain:

• Use patient-controlled analgesia with intravenous morphine—this is the strongest evidence-based approach (Level II) 1, 3, 2

For Localized Oral Mucositis Pain:

• Prescribe 0.2% morphine mouthwash for chemoradiation patients—Level III evidence and significantly more effective than "magic mouthwash" 1, 3, 2

Alternative Pain Management Options:

• 0.5% doxepin mouthwash (Level IV evidence) 1, 3, 2
• Transdermal fentanyl for patients receiving conventional or high-dose chemotherapy (Level III evidence) 1, 3, 2

Important Note on "Magic Mouthwash":

• The European Society for Medical Oncology found no evidence that magic mouthwash effectively treats oral mucositis 3
• Morphine mouthwash is significantly more effective and more satisfactory to patients 3
• If magic mouthwash is used, never swallow it—swish and spit only 3

Management of Xerostomia (Dry Mouth)

Primary Approach:

• Maintain adequate hydration throughout the day to keep oral mucosa moist 1, 3
• Use alcohol-free mouthwash frequently (at least 4 times daily) 1, 3
• Note: Xerostomia may be worsened by anti-emetic or other anti-cholinergic drugs administered during chemotherapy 1

Management of Infection Risk

Preventive Measures:

• Patients with leucopenia have significantly higher infection risk (P = 0.005) 1
• In patients treated with EGFR inhibitors, 38% develop infections at sites of mucosal injury, with 22.6% positive for Staphylococcus aureus and 5.4% for MRSA 1
• Candida infections are common (5.9% incidence) 1
• Use saline-containing mouthwashes for patients on targeted therapies due to increased microbial burden 1

Pre-Treatment Dental Evaluation:

• All patients should have dental examination before starting chemotherapy to assess and treat potential infection sources 1, 4, 5

Management of Bleeding Risk

Key Principles:

• Use only soft toothbrushes with gentle technique 1
• Do NOT start using interdental cleaners during chemotherapy if not already in routine use—this breaks the epithelial barrier and causes gingival bleeding 1
• Avoid trauma from ill-fitting dentures or sharp tooth edges 1

Nutritional Support

Critical Consideration:

• Screen all patients for malnutrition risk, as comorbid malnutrition significantly worsens outcomes 1, 6
• Initiate early enteral nutrition if swallowing difficulties develop 1, 6

Interventions to AVOID (Strong Evidence Against)

Do NOT Use the Following:

• Chlorhexidine mouthwash for prevention (Level III evidence against) 1, 2
• Sucralfate mouthwash for prevention or treatment (Level I-II evidence against) 1, 2
• Intravenous glutamine for HSCT patients (Level II evidence against) 1, 2
• GM-CSF mouthwash for HSCT patients (Level II evidence against) 1, 2
• Iseganan antimicrobial mouthwash (Level II evidence against) 1, 2
• PTA or BCoG antimicrobial lozenges (Level II evidence against) 1, 2

Common Pitfalls to Avoid

• Never recommend starting new interdental cleaning habits during chemotherapy—this is a critical error that causes mucosal barrier breakdown 1
• Never use alcohol-containing mouthwashes—these cause additional mucosal irritation 1
• Never prescribe chlorhexidine or sucralfate for mucositis—strong evidence shows these are ineffective 1, 2
• Never delay nutritional assessment—malnutrition significantly worsens all oral complications 1, 6
• Never ignore early signs of infection in leucopenic patients—these patients have significantly higher infection risk requiring prompt intervention 1