From the Guidelines
Mucositis due to chemotherapy is best managed through a combination of preventive measures and targeted treatments, with a focus on oral hygiene, pain management, and nutritional support, as recommended by the ESMO clinical practice guidelines 1.
Prevention and Treatment
For prevention, patients should maintain meticulous oral hygiene with gentle brushing using a soft toothbrush and alcohol-free mouthwashes. The panel recommends that 30 min of oral cryotherapy be used to prevent oral mucositis in patients receiving bolus 5-fluorouracil chemotherapy (II) 1. Additionally, low-level laser therapy (wavelength at 650 nm, power of 40 mW, and each square centimeter treated with the required time to a tissue energy dose of 2 J/cm2) is recommended to prevent oral mucositis in patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation (II) 1.
Pain Management
Once mucositis develops, pain management is essential using topical agents like 2% viscous lidocaine or "magic mouthwash" formulations containing lidocaine, diphenhydramine, and antacids. The panel recommends that patient-controlled analgesia with morphine be used to treat pain due to oral mucositis in patients undergoing HSCT (II) 1.
Nutritional Support
Nutritional support is crucial, focusing on soft, bland foods and avoiding spicy, acidic, or rough-textured items. Patients should stay well-hydrated and may require nutritional supplements or even temporary parenteral nutrition in severe cases.
Key Recommendations
- Oral cryotherapy for patients receiving bolus 5-fluorouracil chemotherapy (II) 1
- Low-level laser therapy for patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation (II) 1
- Patient-controlled analgesia with morphine for pain management in patients undergoing HSCT (II) 1
- Avoidance of certain interventions, such as chlorhexidine mouthwash, GM-CSF mouthwash, misoprostol mouthwash, systemic pentoxifylline, and systemic pilocarpine, as suggested by the panel 1
From the Research
Mucositis due to Chemotherapy
- Mucositis is a complication of intensive chemotherapy and radiotherapy with no effective treatment 2.
- Palifermin (recombinant human keratinocyte growth factor) has been shown to decrease oral mucosal injury induced by cytotoxic therapy 2, 3, 4.
- The incidence of oral mucositis of World Health Organization (WHO) grade 3 or 4 was reduced in patients treated with palifermin compared to those treated with a placebo 2.
- Palifermin was also associated with significant reductions in the incidence of grade 4 oral mucositis, patient-reported soreness of the mouth and throat, the use of opioid analgesics, and the incidence of use of total parenteral nutrition 2.
- Other interventions, such as allopurinol mouthwash, vitamin E, immunoglobulin, and human placental extract, have shown some promise in improving or eradicating mucositis, but the evidence is weak and unreliable 5.
Management of Mucositis
- Assessing and managing chemotherapy-induced mucositis pain is a major clinical problem 6.
- An assessment tool that includes physical, functional, and pain parameters is necessary to minimize patient distress 6.
- Interventions for treating oral mucositis or its associated pain in patients with cancer receiving chemotherapy and/or radiotherapy have been studied, but further well-designed, placebo-controlled trials are needed 5.
- Patient-controlled analgesia (PCA) has been compared to the continuous infusion method for controlling pain, and while there is no evidence of a difference, less opiate was used per hour for PCA, and the duration of pain was shorter 5.