Cancer Health Center

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Management of pain due to oral mucositis

Oral mucositis pain is associated with release of proinflammatory cytokines and neurotransmitters that activate nociceptors at the site of injury and may be increased by secondary mucosal infection. Pain experience is influenced by anxiety, depression, sociocultural variation, and quality and quantity of sleep.

Topical approaches for mucosal pain relief

Topical anesthetics have a limited duration of effect in mucositis pain (15-30 minutes), may sting with application on damaged mucosa, and affect taste and the gag reflex. Some patients will apply local anesthetics directly to specific sites of ulceration, but no controlled studies have been reported.

Topical anesthetics are often mixed with coating and antimicrobial agents such as milk of magnesia, diphenhydramine, or nystatin but have not been subjected to controlled studies. However, these mixtures result in dilution of each component, which may limit the therapeutic effect. In addition, various agents in the mix may interact, reducing the effect of the components.

Topical benzydamine (not available in the United States), an anti-inflammatory and analgesic/anesthetic agent, has been shown in randomized controlled studies to reduce pain in oral mucositis and reduce the need for systemic analgesics.[2] Other topical approaches include the following:

• A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for 4 hours or longer.[1] Besides producing an extended period of pain relief, application of topical doxepin to damaged mucosa is not accompanied by burning.
• Topical morphine has been shown to be effective for relieving pain,[1] but there is concern about dispensing large volumes of the medication.
• Topical fentanyl prepared as lozenges administered in a randomized placebo-controlled study showed relief of oral mucositis pain.
• Topical capsaicin has been studied for the control of oral mucositis pain [3] but is poorly tolerated by patients. Pretreatment initiation of capsaicin may represent an approach to desensitize patients before the onset of mucositis.

Topical coating agents may reduce pain in mucositis. Coating agents such as sucralfate may have a role to play in mucosal pain management but not in reducing tissue damage.

Systemic medications

Pain management strategies directed at diagnoses and pain mechanisms include the following:

• Topical anesthetics/analgesics.
  • Topical before systemic therapies; if topicals are effective, continue while adding systemic analgesics.
• Systemic analgesics.
• Adjuvant medications (muscle relaxants, anti-inflammatories, antianxiety medications, antidepressants, anticonvulsants).
• Adjuvant therapies (physiotherapy, relaxation, cognitive-behavioral therapies, counseling).
• Palliative radiation therapy.

Additional and nonpharmacologic pain management techniques in oncology include the following:

• Transcutaneous electrical nerve stimulation.
• Cold/moist heat applications.
• Hypnosis.
• Acupuncture.
• Psychological approaches:
  • Distraction.
  • Relaxation/imagery.
  • Cognitive/behavioral therapy.
  • Music therapy, drama therapy.
  • Counseling.

Suggestions for the use of opioids in cancer pain include the following:

• Use the lowest effective dose.
• Base time-contingent prescription on drug characteristics.
• Provide analgesics for breakthrough pain.
• Combine with nonopioid analgesics.
• Provide prophylaxis/treatment for constipation.
• Conduct regular pain assessment and modify management, depending on pain control.
• Follow steps in World Health Organization (WHO) analgesic ladder.