Management of Mucositis Secondary to Cancer Therapy

Publication Date: June 30, 2020
Last Updated: March 14, 2022

Guidelines

Basic Oral Care

The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during CT. (Level III)
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The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during H&N RT. (Level III)
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The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during HSCT. (Level III)
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No guideline was possible regarding the use of professional oral care for the prevention of OM in patients with hematologic, solid, or H&N cancers because of limited and inconsistent data. (Level III)
  • An expert opinion complements this guideline: Although there was insufficient evidence to support the use of professional oral care for OM prevention, the panel is of the opinion that dental evaluation and treatment as indicated before cancer therapy are desirable to reduce risk for local and systemic infections from odontogenic sources.
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No guideline was possible regarding the use of patient education for the prevention of OM in patients with hematologic cancer during HSCT or CT because of limited and inconsistent data. (Level III)
  • An expert opinion complements this guideline: The panel is of the opinion that educating patients about the benefits of BOC strategies is still appropriate because this may improve self-management and adherence to the recommended oral care protocol during cancer treatment.
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No guideline was possible regarding the use of saline or sodium bicarbonate rinses in the prevention or treatment of OM in patients undergoing cancer therapy because of limited data. (Level III)
  • An expert opinion complements this guideline: Despite the limited data available for both saline and sodium bicarbonate, the panel recognizes that these are inert, bland rinses that increase oral clearance, which may be helpful for maintaining oral hygiene and improving patient comfort.
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The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT. (Level III)
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Anti-inflammatory Agents

The panel recommends benzydamine mouthwash for the prevention of OM in patients with H&N cancer receiving a moderate dose RT (<50 Gy). (Level I)
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The panel suggests the use of benzydamine mouthwash for the prevention of OM in patients with H&N cancer who receive RT-CT. (Level II)
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Photobiomodulation

The panel recommends the use of intraoral PBM therapy using low-level laser therapy for the prevention of OM in adult patients receiving HSCT conditioned with high-dose CT, with or without TBI, using one of the selected protocols listed in Table 2. (Level I)
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The panel recommends the use of intraoral PBM therapy using low-level laser therapy for prevention of OM in adults receiving RT to the H&N (without CT) (Table 2); safety considerations unique to patients with oral cancer should be considered. (Level II)
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The panel recommends the use of intraoral PBM therapy using low-level laser therapy for the prevention of OM in adults receiving RT-CT for H&N cancer (Table 2); safety considerations unique to patients with oral cancer should be considered. (Level I)
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For all PBM guidelines, it is recommended that the specific PTPs of the selected protocol will be followed for optimal therapy. ()
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Cryotherapy

The panel recommends using oral cryotherapy to prevent OM in patients undergoing autologous HSCT when the conditioning includes high-dose melphalan. (Level II)
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The panel recommends using 30 min of oral cryotherapy to prevent OM in patients receiving bolus 5-FU CT during the infusion of the CT. (Level II)
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Antimicrobials, coating agents, anesthetics, and analgesics

Topical morphine 0.2% mouthwash is suggested for the treatment of OM-associated pain in patients with H&N cancer who receive RT-CT. (Level III)
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Sucralfate (combined topical and systemic) is not recommended for the prevention of OM-associated pain in patients with H&N cancer who receive RT. (Level II)
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Sucralfate (combined topical and systemic) is not recommended for the treatment of OM-associated pain in patients with H&N cancer who receive RT. (Level II)
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Sucralfate (combined topical and systemic) is not recommended for the treatment of OM-associated pain in patients with solid cancer who receive CT. (Level II)
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Growth factors and cytokines

The use of KGF-1 intravenously is recommended for the prevention of OM in patients with hematologic cancer undergoing autologous HSCT with a conditioning regimen that includes high-dose CT and TBI. (Level I)
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The evidence suggests that topical GM-CSF should not be used for the prevention of OM in patients undergoing HSCT. (Level II)
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Natural and miscellaneous

The panel recommends against the use of glutamine (parenteral) for the prevention of OM in patients undergoing HSCT. (Level I)
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The panel suggests oral glutamine for the prevention of OM in patients with H&N cancer who receive receiving RT-CT. (Level II)
  • The suggestion is with caution because of the higher mortality rate seen in patients undergoing HSCT who receive parenteral glutamine.
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Honey is suggested for the prevention of OM in patients with H&N cancer who receive treatment with either RT or RT-CT. (Level II)
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Chewing gum is not suggested for the prevention of OM in pediatric patients with hematological or solid cancer who receive CT. (Level III)
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Gastrointestinal Mucositis

The panel suggests that probiotics containing Lactobacillus spp. may be beneficial for the prevention of RT-induced or RT-CT–induced diarrhea in patients with pelvic malignancy. (Level III)
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The panel suggests that hyperbaric oxygen is an effective way to treat RT-induced proctitis in patients with pelvic malignancy. (Level II)
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Table 2. Recommended Intraoral Photobiomodulation Therapy Protocols for the Prevention of Oral Mucositis

Having trouble viewing table?
Cancer Treatment Modality Wavelength, nm Power Density (Irradiance), mW/cm2 Time per Spot, s Energy Density (Fluence), J/cm2 Spot Size, cm2 No. of Sites Duration
HSCT 632.8 31.25 40 1.0 0.8 18 From the d after cessation of conditioning for 5 d
650 1000b 2 2.0 0.04 54-70 From the first d of conditioning to d + 2 post-HSCT (for 7-13 d)
RT 632.8 24 125 3.0 1.00 12 Entire RT course
RT-CT 660 417b 10 4.2 0.24 72 Entire RT course
660 625b 10 6.2 0.04 69 Entire RT course
5-FU, 5-fluorouracil; BOC, basic oral care; CHX, chlorhexidine; CT, chemotherapy; GM-CSF, granulocyte-macrophage colony–stimulating factor; Gy, grays; H&N, head and neck; HSCT, hematopoietic stem-cell transplantation; KGF-1, keratinocyte growth factor 1; LoE, level of evidence; OM, oral mucositis; PBM, photobiomodulation; PTPs, photobiomodulation therapy parameters; RT, radiotherapy; TBI, total body irradiation.

Recommendation Grading

Overview

Title

Management of Mucositis Secondary to Cancer Therapy

Authoring Organization

Multinational Association of Supportive Care in Cancer

Publication Month/Year

June 30, 2020

Last Updated Month/Year

February 6, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Ambulatory, Hospital, Long term care

Intended Users

Social worker, physician, nurse, nurse practitioner, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D052016 - Mucositis

Keywords

Mucositis, secondary cancer therapy, erythema, Oral mucositis

Source Citation

Elad, S, Cheng, KKF, Lalla, RV, Yarom, N, Hong, C, Logan, R M., Bowen, J, Gibson, R, Saunders, DP, Zadik, Y, Ariyawardana, A, Correa, ME, Ranna, V, Bossi, P; for the Mucositis Guidelines Leadership Group of the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020: 126: 4423– 4431. https://doi.org/10.1002/cncr.33100

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
271
Literature Search Start Date
December 31, 2010
Literature Search End Date
June 29, 2016