Managing Oral Mucositis in Patients With Cancer

By James Radke, PhD
Published: Tuesday, Jun 08, 2010
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One of the most uncomfortable consequences of anticancer therapy is the development of oral mucositis. This painful condition develops in approximately 40% of patients treated with standard chemotherapy, 30%–60% of patients receiving radiation therapy for cancer of the head and neck, 70% of patients who undergo bone marrow transplantation and receive high-dose chemotherapy, and over 90% of patients receiving concomitant chemotherapy and localized radiation.1

Oral mucositis is characterized by erythema, swelling, and ulceration of the mucous membranes. The consequences of this inflammation can greatly affect a patient’s health, quality of life, and anticancer therapy outcome. The disruption of the natural mucosal barrier can increase the risk of systemic infections. Furthermore, the intense pain associated with oral mucositis may impede the patient’s eating and oral hygiene activities which in turn can disrupt the efficacy of cancer therapy.

The economic consequences of oral mucositis are substantial. In patients receiving high-dose chemotherapy for stem-cell transplant, Sonis and colleagues2 observed that the increased infections, disruption of therapy, and increased need for hospitalization caused by oral mucositis added $43,000 per patient. Costs were also dependent on the level of oral mucositis. The authors estimated that for each 1 point rise in the oral mucositis assessment scale (OMAS), there was an additional $25,000 in costs. Similarly, in patients treated with standarddose chemotherapy, a large portion of the extra costs of mucositis arise from the increased need for hospitalization.3

Management of Oral Mucositis

The best management option for oral mucositis however, is preventive therapy—a key component of which is recognizing which patients are at risk (see table 1).

Once it is established that the patient will likely develop oral mucositis, it is imperative that preventive/ educational measures be given to reduce the risk of developing mucositis or to reduce the severity of mucositis. Key educational material should include the importance of oral hygiene to reduce the risk of inflammation and nutritional advice to help the patient get the calories needed during therapy while reducing the discomfort of mucositis.

If the patient does develop oral mucositis, most treatment options are symptomatic to reduce pain (analgesic), swelling (cryotherapy), and/or inflammation (anti-inflammatory). One treatment option that has proven to be safe and effective at reducing the incidence, severity, and duration of oral mucositis is Caphosol® (Supersaturated Calcium Phosphate Rinse).

Risk factors for mucositis include4

Patient Related
  Age (children and patients over 50 yr of age)
  Female sex
  Tumor location (e.g., oral cavity, throat)
  Pre-existing mouth damage
  Periodontal status
  Tobacco and alcohol consumption
  Genetic predisposition

Treatment Related
  Chemotherapy (type of drug, dose and intensity,

  induced neuropenia)
  Radiotherapy (location, fractioning,

  combined with chemotherapy)
  Bone marrow transplantation


Caphosol is a super-saturated Ca2+/PO4 2- solution and is believed to promote healing of the mucosal lesions while helping to cleanse the oral cavity. In this manner, it reduces both the intensity and duration of mucositis in patients given high-dose chemotherapy. This was observed in a prospective, double-blind, randomized clinical trial by Papas and colleagues5 who compared Caphosol used at the initiation of cancer therapy in conjunction with proper oral hygiene with standard fluoride rinse in 95 patients undergoing hematopoietic stem-cell transplantation. During the course of treatment, oral mucositis was scored on a 6 point scale (0-no change; 1-erythema; 2-single ulcer < 1 cm; 3-a few ulcers approximately 1 cm; 4-multiple ulcers < 1 cm; 5-slough) and pain on a 0–100 visual analog scale (VAS). Inflammation (absolute neutrophil counts) and morphine intake were also measured during the study.

One interesting aspect of this study was that it acknowledged the importance of oral hygiene before beginning bone marrow transplant. Before transplant, patients in the Caphosol group received Caphosol and four topical fluoride treatments. After the transplant they received Caphosol at least four times daily. The comparator group was given a placebo gel with fluoride rinse prior to transplant and the fluoride rinse continued after transplant (at least 4 times daily).

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