What are the best treatment options for oral ulcers in patients undergoing chemotherapy? What do you recommend for dry mouth associated with chemotherapy? —Nathan Britt, ANP-C
Oral ulcers Unfortunately, therapeutic advances in the treatment of mucositis are limited. Most studies on preventive or treatment methods for mucositis have been small, uncontrolled trials. Results tend to be conflicting, and overall, no therapy has demonstrated consistent efficacy in preventing or hastening recovery of mucositis.
The most important recommendation is to maintain good oral health care (salt and soda rinses, brushing with a soft toothbrush). A variety of mucosal coating agents have been used to protect the mucosal surfaces in the oral cavity (eg, Gelclair, Orabase, topical kaolin/pectin, and oral antacids). However, use of these agents is not supported by evidence. Use of Gelclair is popular; it provides a physical adherent barrier over the mucosal surfaces, thus shielding the oral lesion(s) from the effects of food, liquids, and saliva. If the oral ulcers are associated with pain, then topical lidocaine may be used.
Magic mouthwash is an option as well. This consists of equal parts of viscous lidocaine, diphenhydramine, and magnesium hydroxide/aluminum hydroxide (Maalox). Systemic opiates such as morphine are recommended for pain control. Multinational Association of Supportive Care in Cancer (MASCC) provides clinical practice guidelines for the prevention and treatment of mucositis. MASCC recommends using a patient-controlled analgesia with morphine as the treatment of choice for patients undergoing hematopoietic stem cell transplantation (HSCT). In addition, MASCC recommends palifermin (Kepivance), a keratinocyte growth factor-1, 60 mcg/kg/d for 3 days prior to treatment and 3 days posttransplantation for the prevention of mucositis in patients receiving high-dose chemotherapy regimens with or without total body irradiation plus HSCT. Cryotherapy is recommended with high dose melphalan regimens.
Xerostomia Pilocarpine (Isopto Carpine, Salagen, generics) is recommended to improve xerostomia in patients undergoing radiation therapy for head and neck cancer. It should be administered following radiation therapy, not during therapy. Use of parotid-sparing intensity-modulated radiation therapy (IMRT) is the recommended radiotherapy modality for patients with head and neck cancer because risks for salivary gland hypofunction and xerostomia are lower. Oral mucosal lubricants or saliva substitutes (Biotene) are recommended for short-term improvement of xerostomia following radiation. For a nonpharmacologic option, acupuncture can be used to stimulate salivary gland secretion, which will alleviate xerostomia. —Sandra Cuellar, PharmD, BCOP
■ Keefe DM, Schubert MM, Elting LS, et al; Mucusotitis Study Section of the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007;109(5):820-831.
■ Mouth sores due to chemotherapy. Chemocare.com Web site. http://chemocare.com/managing/mouth_sores_due_to_chemotherapy.asp. Accessed September 18, 2012.
■ Summary of Evidence-based Oral Care Study Group, Multinational Association for Supportive Care in Cancer/International Society of Oral Oncology clinical practice guidelines for care of patients with other oral complications. http://www.mascc.org/assets/documents/Oral_Care-Summary_of_Evidence_Table.pdf. Accessed September 18, 2012.