Treatment is supportive and mainly aimed at symptom control:
•Removal of dentures, atraumatic cleansing, and oral rinses with a weak solution of salt and baking soda (one-half teaspoon of salt and one teaspoon of baking soda in a quart of water) every four hours. (See ‘Routine oral care’ above.)
•The oral cavity should be rinsed and wiped after meals, and dentures cleaned and brushed often to remove plaque. Rinsing with artificial saliva may lessen the duration and severity of mucositis. A soft toothbrush or foam swab (Toothette) cleans teeth effectively but may be too harsh for patients with moderate to severe stomatitis.
•The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided. If the patient is unable to swallow foods or liquids, parenteral fluid and/or nutritional support may be needed.
•For patients with established oral mucositis, a variety of mucosal protective agents are available, including topical kaolin/pectin, Orabase, diphenhydramine, oral antacids, and maltodextrin (Gelclair). There are no randomized trials comparing any of these treatments, and no single approach can be recommended over the others. Consistent with guidelines from the American Academy of Nursing (AAN) and Oncology Nursing Society (ONS), we suggest not using compounded mixtures (such as “miracle mouthwashes”) that contain coating agents, often in combination with topical anesthetics and other medications (Grade 2C). (See ‘Mucosal-protective agents’ above and ‘Analgesia’ above.)
•Adequate analgesia can sometimes be provided topically (eg, using viscous lidocaine or capsaicin candies), but many patients require systemic opioids. (See ‘Analgesia’ above.)
•There is no evidence that prophylactic administration of nystatin suspension or oral fluconazole reduces the frequency of superinfection with Candida albicans, and we recommend against this practice (Grade 1B). We recommend topical, (clotrimazole troches or nystatin suspension) rather than systemic, antifungal therapy for patients who develop superficial oropharyngeal candidiasis as a complication of oral mucositis (Grade 1B). (See ‘Oral candidiasis’ above.)
•The possibility of herpes simplex virus (HSV) infection should be considered in a patient who has intraoral vesicles or unusually painful oral ulcerative lesions. In such cases, we recommend a swab for viral culture and initiation of empiric antiviral therapy (ie, parenteral or oral acyclovir, or oral valacyclovir) while awaiting culture results (Grade 1B). We recommend that antiviral prophylaxis be limited to patients who are seropositive for HSV and who are undergoing high-dose chemotherapy for a hematologic malignancy or HCT (Grade 1B). (See ‘HSV infection’ above.)
•The role of topical vitamin E is not established, and we suggest not pursuing this strategy (Grade 2C). (See ‘Vitamin E’ above.)
•Few trials have been conducted to either prevent or treat oral mucositis in patients receiving molecularly targeted agents. Our suggested approach mirrors that endorsed by the European Society of Medical Oncology (ESMO), which is based on expert opinion rather than published high-quality evidence. The suggested approach includes prophylactic oral care protocols including prophylactic mouth rinses with sodium bicarbonate-containing mouthwashes to prevent mucositis across all targeted therapy modalities, and adequate analgesia for pain management, and steroids (topical, intralesional, or systemic) for patients who develop ulcers during therapy. (See ‘Management of patients receiving molecularly targeted agents’ above.)
Xerostomia — Xerostomia is an uncommon complication of chemotherapy. Therapy is symptomatic (eg, rinsing with saline or the use of commercially available saliva substitutes). Dry, cracked lips can be treated with petroleum lubricants. (See ‘Xerostomia’ above and “Treatment of dry mouth and other non-ocular sicca symptoms in Sjögren’s syndrome”.)
Gingival bleeding — Gingival bleeding is most commonly caused by thrombocytopenia. If significant spontaneous bleeding occurs, gauze soaked in topical thrombin can be locally applied to obtain hemostasis. Bleeding usually resolves rapidly as platelet counts increase following the hematologic nadir. Platelet transfusions are rarely required. (See ‘Gingival bleeding’ above.)