Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

undergoing haematopoietic stem cell transplant: preventive measures

1st line – palifermin

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INITIAL
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undergoing haematopoietic stem cell transplant: preventive measures
1st line – 

palifermin

Palifermin (recombinant keratinocyte growth factor) may be used to decrease the incidence and duration of severe oral mucositis in patients with haemotological malignancies receiving high-dose chemotherapy and total body irradiation followed by autologous stem cell transplantation.[24][46]​​​

Administered for 3 consecutive days before and 3 consecutive days after chemoradiation.

It may be considered in patients undergoing allogeneic transplants.[47][48]

Palifermin may not be available in some countries.

Primary options

palifermin: 60 micrograms/kg intravenously once daily for 3 consecutive days before and 3 consecutive days after chemotherapy

Consider – oral cryotherapy during chemotherapy infusion

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INITIAL
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undergoing haematopoietic stem cell transplant: preventive measures
Consider – 

oral cryotherapy during chemotherapy infusion

Additional treatment recommended for SOME patients in selected patient group

Ice chips and/or ice-cold water held in the mouth before, during, and immediately after chemotherapy infusion is recommended in patients receiving high-dose melphalan as part of a myeloablative regimen.[22][23][25]​​​​ [ Cochrane Clinical Answers logo ]

Consider – intra-oral low-level laser therapy

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INITIAL
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undergoing haematopoietic stem cell transplant: preventive measures
Consider – 

intra-oral low-level laser therapy

Additional treatment recommended for SOME patients in selected patient group

Patients receiving high-dose chemotherapy or chemoradiation before haematopoietic stem cell transplantation may benefit from low-level laser therapy to reduce the severity of oral mucositis.​[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 recommend following specific photobiomodulation protocols for optimal response.[22]

receiving bolus fluorouracil: preventive measures

1st line – oral cryotherapy during chemotherapy infusion

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INITIAL
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receiving bolus fluorouracil: preventive measures
1st line – 

oral cryotherapy during chemotherapy infusion

Ice chips and/or ice-cold water held in the mouth before, during, and immediately after chemotherapy infusion is recommended in patients receiving these agents.[22][23][25]​​​​ [ Cochrane Clinical Answers logo ]

receiving radiotherapy to oral cavity: preventive measures

1st line – radiation protection measures

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INITIAL
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receiving radiotherapy to oral cavity: preventive measures
1st line – 

radiation protection measures

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]​​

Consider – anti-inflammatory mouthwash

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INITIAL
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receiving radiotherapy to oral cavity: preventive measures
Consider – 

anti-inflammatory mouthwash

Additional treatment recommended for SOME patients in selected patient group

An anti-inflammatory mouthwash is helpful in reducing mucositis severity in patients receiving moderate-dose head and neck radiation therapy (up to 50 Gy) with or without concomitant chemotherapy.​[22][32][50]​​ However, most therapeutic radiation therapy protocols for head and neck cancer involve doses of 60-70 Gy.

Evidence supports the use of benzydamine mouthwash; however, it is no longer available in some countries. Consult local protocols for guidance on choice.

Consider – intra-oral low-level laser therapy

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INITIAL
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receiving radiotherapy to oral cavity: preventive measures
Consider – 

intra-oral low-level laser therapy

Additional treatment recommended for SOME patients in selected patient group

Patients receiving head and neck radiotherapy to the oral cavity, with or without concomitant chemotherapy, may benefit from intra-oral low-level laser therapy to reduce the severity of OM.[24][29]​ The mechanism of action is not well understood, but is thought to be via promotion of healing and an anti-inflammatory effect.[30][31]​ The MASCC/ISOO recommend following specific photobiomodulation protocols for optimal response.[22]

ACUTE

established oral mucositis

1st line – oral care

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ACUTE
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established oral mucositis
1st line – 

oral care

Oral care protocols should be initiated in all patients.[22][24]​​[27]​​[33]​ These should include standard oral hygiene, such as brushing and flossing, and use of a soft toothbrush to avoid traumatising the oral tissues.

Professional irrigation and debridement of tooth surfaces, with atraumatic cleansing of the oral mucosa, may be appropriate.

Oral lubrication may be improved by use of a simple mouth rinse consisting of a half-teaspoon of baking soda in a cup or more of warm water or chamomile several times a day. Other lubricants, such as hydroxyethylcellulose solutions, can also be considered.

Plus – analgesic or topical anaesthetic

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ACUTE
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established oral mucositis
Plus – 

analgesic or topical anaesthetic

Treatment recommended for ALL patients in selected patient group

For patients with mild to moderate mucositis, simple oral analgesics (e.g., paracetamol, ibuprofen) and the use of topical lidocaine gel or rinse may be adequate for pain control.[22]

Morphine mouthwash can also reduce pain. This formulation may need to be compounded by a pharmacist.[45]

For severe ulcerative mucositis, systemic opioid analgesics may be needed to achieve adequate pain control. Examples include tramadol, oxycodone, or morphine.

In patients undergoing haematopoietic stem cell transplantation, patient-controlled analgesia with morphine has been found to result in less opioid used per hour and shorter duration of pain.[24][45]​​​

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

lidocaine topical: (2% viscous solution) 15 mL every 3 hours when required (swish around in mouth and spit out), maximum 8 doses/day

Secondary options

tramadol: 50 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

oxycodone: 10 mg orally (controlled-release) every 12 hours when required

OR

morphine sulfate: 2.5 to 10 mg intravenously every 2-6 hours when required

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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