Once mucositis has developed, its severity and the patient's hematologic status govern appropriate oral management. Meticulous oral hygiene and palliation of symptoms are essential. Some established guidelines for oral care include oral assessments twice daily for hospitalized patients and frequent oral care (minimum of every 4 hours and at bedtime) that increases in frequency as the severity of mucositis increases.
Oral care protocols generally include atraumatically cleansing the oral mucosa, maintaining lubrication of the lips and oral tissues, and relieving pain and inflammation. Several health professional organizations have produced evidence-based oral mucositis guidelines. These organizations include but are not limited to the following:
- Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology 
- National Comprehensive Cancer Network 
- European Society of Medical Oncology 
- European Oncology Nursing Society
- The Cochrane Collaboration [28,29]
In many cases, there is similarity in recommendations across the organizations. The Cochrane Collaboration, however, uses a meta-analysis approach and thus provides a unique context for purposes of guideline construction.
Palifermin (Kepivance), also known as keratinocyte growth factor-1, has been approved to decrease the incidence and duration of severe oral mucositis in patients with hematologic cancers undergoing conditioning with high-dose chemotherapy, with or without radiation therapy, followed by hematopoietic stem cell rescue.[Level of evidence: I] The standard dosing regimen is three daily doses before conditioning and three additional daily doses starting on day 0 (day of transplant). Palifermin has also been shown in a randomized, placebo-controlled trial to reduce the incidence of oral mucositis in patients with metastatic colorectal cancer treated with fluorouracil-based chemotherapy.[Level of evidence: I]
Evidence from several studies has supported the potential efficacy of low-level laser therapy in addition to oral care to decrease the duration of chemotherapy-induced oral mucositis in children.[Level of evidence: I][Level of evidence: I]
- Bland rinses:
- Topical anesthetics:
- Lidocaine: viscous, ointments, sprays.
- Benzocaine: sprays, gels.
- 0.5% or 1.0% dyclonine hydrochloride (HCl).
- Diphenhydramine solution.
- Mucosal coating agents:
- Benzydamine HCl topical rinse (not approved in the United States).
- Opioid drugs: oral, intravenous (e.g., bolus, continuous infusion, patient-controlled analgesia [PCA]), patches, transmucosal.
- Growth factor (keratinocyte growth factor-1):
- Palifermin (approved by the FDA in December 2004 to decrease the incidence and duration of severe oral mucositis in patients undergoing high-dose chemotherapy with or without radiation therapy followed by bone marrow transplant for hematologic cancers).
Management of oral mucositis via topical approaches should address efficacy, patient acceptance, and appropriate dosing. A stepped approach is typically used, with progression from one level to the next as follows:
- Bland rinses (e.g., 0.9% normal saline and/or sodium bicarbonate solutions).
- Mucosal coating agents (e.g., antacid solutions, kaolin solutions).
- Water-soluble lubricating agents, including artificial saliva for xerostomia.
- Topical anesthetics (e.g., viscous lidocaine, benzocaine sprays/gels, dyclonine rinses, diphenhydramine solutions).
- Cellulose film-forming agents for covering localized ulcerative lesions (e.g., hydroxypropyl cellulose).