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).
Normal saline solution is prepared by adding approximately 1 tsp of table salt to 32 oz of water. The solution can be administered at room or refrigerated temperatures, depending on patient preference. The patient should rinse and swish approximately 1 tbsp, followed by expectoration; this can be repeated as often as necessary to maintain oral comfort. Sodium bicarbonate (1–2 tbsp/qt) can be added, if viscous saliva is present. Saline solution can enhance oral lubrication directly as well as by stimulating salivary glands to increase salivary flow.
A soft toothbrush that is replaced regularly should be used to maintain oral hygiene. Foam-swab brushes do not effectively clean teeth and should not be considered a routine substitute for a soft nylon-bristled toothbrush; additionally, the rough sponge surface may irritate and damage the mucosal surfaces opposite the tooth surfaces being brushed.
On the basis of nonoral mucosa wound-healing studies, the repeated use of hydrogen peroxide rinses for daily preventive oral hygiene is not recommended, especially if mucositis is present, because of the potential for damage to fibroblasts and keratinocytes, which can cause delayed wound healing.[36,37,38,39] Using 3% hydrogen peroxide diluted 1:1 with water or normal saline to remove hemorrhagic debris may be helpful; however, this approach should only be used for 1 or 2 days because more extended use may impair timely healing of mucosal lesions associated with bleeding.
Focal topical application of anesthetic agents is preferred over widespread oral topical administration, unless the patient requires more extensive pain relief. Products such as the following may provide relief:
- 2% viscous lidocaine
- Diphenhydramine solution
- One of the many extemporaneously prepared mixtures combining the following coating agents with topical anesthetics:
- Milk of magnesia.
- Kaolin with pectin suspension.
- Mixtures of aluminum.
- Magnesium hydroxide suspensions (many antacids).