Primary prevention
A variety of preventive strategies for oral mucositis (OM) have been validated and recommended.[22] Their use should be tailored to the cancer treatment regimen for each individual. For patients receiving bolus doses of chemotherapy drugs with a short half-life, such as fluorouracil and melphalan, the use of ice chips and/or ice-cold water as "cryotherapy" can reduce the severity of OM.[23] This effect is thought to be mediated by a reduced delivery of the drug to the oral mucosa secondary to local vasoconstriction. Ice chips/ice water should be placed in the mouth, beginning 5 minutes before administration of chemotherapy and replenished as needed for up to 30 minutes.[24][25]
Palifermin (recombinant keratinocyte growth factor) has been approved by the US Food and Drug Administration to decrease the incidence and duration of severe OM in patients with hematologic malignancies receiving high-dose chemotherapy and total body irradiation followed by autologous stem cell transplantation (SCT).[24] If indicated, palifermin is administered intravenously for 3 consecutive days before and 3 consecutive days after chemoradiation. Palifermin may not be available in some countries.
Maintenance of good oral hygiene can reduce the severity of OM in patients receiving chemotherapy.[26] Appropriate dental care before the onset of treatment, and the use of oral care protocols during treatment, may be useful preventive strategies.[24][27] Oral care should include the use of a soft toothbrush that is replaced regularly.
In patients with metal dental restorations, the use of devices such as a dental guard, cotton roll, or wax to separate the metal from the mucosa can prevent adjacent mucositis due to radiation backscatter.[28]
Patients receiving high-dose chemotherapy or chemoradiation before hematopoietic SCT, and patients receiving head and neck radiation therapy without concomitant chemotherapy, may benefit from low-level laser therapy to reduce the severity of OM.[22][24][29] The mechanism of action is not well understood, but is thought to be via promotion of healing and anti-inflammatory effects.[30][31]The Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology recommends following specific photobiomodulation protocols for optimal response.[22]
An anti-inflammatory mouthwash may help reduce mucositis severity in patients receiving head and neck radiation therapy with or without concomitant chemotherapy.[22][32]
All patients at risk of OM require a baseline oral and dental assessment.[33]
The table that follows summarizes recommendations for primary prevention of oral mucositis taken from the MASCC/ISOO clinical practice guidelines.[22]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Patients receiving chemotherapy
All
Intervention
Basic oral care: multiagent combination oral care protocols
Use a protocol that covers timing and frequency of oral hygiene measures and which products to use for brushing, flossing, mouth washes (bland rinses), hydration and lubrication (moisturizing agents).
Suggest professional oral care prior to any cancer therapy.
Goal
Prevent oral mucositis, maintain oral hygiene and improve patient comfort
Patients receiving bolus fluorouracil
Intervention
Oral cryotherapy
Give 30 minutes of oral cryotherapy during fluorouracil transfusion.
Goal
Reduce damage to mucosa by limiting delivery of cytotoxic drug to oral tissue
As cooling is temporary, use of cryotherapy to prevent oral mucositis is limited to chemotherapy delivered over a short time or for chemotherapeutic drugs with a short half-life.
Patients receiving head and neck radiation therapy
All
Intervention
Basic oral care: multiagent combination oral care protocols
Use a protocol that covers timing and frequency of oral hygiene measures and which products to use for brushing, flossing, mouth washes (bland rinses), hydration and lubrication (moisturizing agents).
Consider an anti-inflammatory mouthwash as part of this protocol during treatment period.
Suggest professional oral care prior to any cancer therapy.
Intraoral photobiomodulation using using low-level laser therapy: use a wavelength of 632.8 nm; see local specialist protocol for dosing guidelines.
Honey: combined topical and systemic delivery. Preparations vary; see local specialist protocol for dosing guidelines.
Goal
Prevent oral mucositis
Basic oral care: maintain oral hygiene and improve patient comfort. Anti-inflammatory mouthwash may inhibit production of proinflammatory cytokines.
Intraoral photobiomodulation: improve quality of life by minimizing the adverse effects of oral cancer treatments; may also impact tumor growth.
Honey: inhibits bacterial growth and improves healing.
Patients receiving combination chemotherapy and head and neck radiation therapy
All
Intervention
Basic oral care: multiagent combination oral care protocols
Use a protocol that covers timing and frequency of oral hygiene measures and which products to use for brushing, flossing, mouth washes (bland rinses), hydration and lubrication (moisturizing agents).
Consider an anti-inflammatory mouthwash as part of this protocol during treatment period.
Suggest professional oral care prior to any cancer therapy.
Intraoral photobiomodulation using using low-level laser therapy: use a wavelength of 660 nm; see local specialist protocol for dosing guidelines.
Oral glutamine: consider giving oral glutamine; see local specialist protocol for dosing guidelines.
Honey: combined topical and systemic delivery; preparations vary; see local specialist protocol for dosing guidelines.
Goal
Prevent oral mucositis
Basic oral care: maintain oral hygiene and improve patient comfort.
Intraoral photobiomodulation: improve quality of life by minimizing the adverse effects of oral cancer treatments; may also impact tumor growth.
Oral glutamine: may reduce the severity and duration of oral mucositis and associated pain.
Honey: inhibits bacterial growth and improves healing.
Patients receiving hematopoietic stem cell transplantation
All
Intervention
Basic oral care: multiagent combination oral care protocols
Use a protocol thatcovers timing and frequency of oral hygiene measures and which products to use for brushing, flossing, mouth washes (bland rinses), hydration and lubrication (moisturizing agents).
Suggest professional oral care prior to any cancer therapy.
Goal
Prevent oral mucositis, maintain oral hygiene and improve patient comfort
Patients with conditioning that includes high-dose melphalan
Intervention
Oral cryotherapy
Use oral cryotherapy. Timings vary.
Goal
Reduce damage to mucosa by limiting delivery of cytotoxic drug to oral tissue
As cooling is temporary, use of cryotherapy to prevent oral mucositis is limited to chemotherapy delivered over a short time or for chemotherapeutic drugs with a short half-life.
Patients with conditioning with high-dose CT (with or without total body irradiation)
Intervention
Intraoral photobiomodulation using using low-level laser therapy
Use a wavelength of 632.8 nm or 650 nm.
Goal
Prevent oral mucositis
Improve quality of life by minimizing the adverse effects of oral cancer treatments.
May also impact tumor growth.
Patients with hematologic cancer and with a conditioning regimen that includes high-dose CT and total body irradiation
Intervention
Intravenous palifermin
Give intravenous palifermin, a recombinant keratinocyte growth factor.
Goal
Prevent oral mucositis
Secondary prevention
Secondary prevention strategies for OM are similar to those for primary prevention. These include:[22][24][27]
Maintaining daily oral care
Avoiding trauma to oral tissues (e.g., from sharp or hard foods, removable dentures, firm toothbrushes)
Continuing pain control and preventive measures as appropriate throughout the duration of treatment.
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