Narrative review of the management of oral mucositis during chemoradiation for head and neck cancer

Abstract

Oral mucositis (OM) can be a significant problem for patients undergoing radiation or chemoradiation for head and neck cancer. In modern clinical trials, grade 3-4 OM can be seen in over 40% of patients and can cause a significant impact on their quality of life (QOL). Despite this fact, strategies for the prevention and treatment of OM vary widely, with options including both lifestyle modifications and pharmaceuticals. Here we evaluate and summarize the current clinical interventions for the management of radiation-induced OM. The majority of the current evidence focuses on reducing OM related pain.These agents are detailed over multiple clinical trials including treatment modalities such as: GC4419, doxepin mouthwash, diphenhydramine-lidocaine-antacid (DLA) mouthwash, gabapentin, and methadone.While several strategies have been employed to prevent radiation-induced OM, there is currently no strong evidence for the routine use of these agents in the clinic. After summarization of these treatments, we offer practical guidance for the treatment of OM in the clinic. We recommend a multiagent approach of pharmacological and non-pharmacological treatments including oral rinses, home humidification, escalating doses of gabapentin, doxepin or DLA mouthwash, over the counter analgesics, and lastly methadone. These interventions are tailored to address the expected increase of severity of symptoms during the course of head and neck radiotherapy.

Severe Oral Mucositis After Intensity-Modulated Radiation Therapy for Head and Neck Cancer

“…Management of OM varies greatly at different institutions. Our institutional standard strongly emphasizes oral hygiene, hydration, and nutrition at the start of treatment and uses prescription medications when necessary as patients develop worsening OM symptoms . For OM pain control, we prescribe all eligible patients prophylactic gabapentin and recommend alternating between over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs before prescribing opioids.…”

“…Patients were encouraged to gargle with a saline and baking soda mouthwash rinse as many times as possible per day (eg, 20 times) and use a compounded elixir of diphenhydramine, xylocaine, and antacid in a 1:1:1 ratio 4 times per day for pain. Further details of our institutional management of OM have been previously reported …”

Prophylactic High-Dose Gabapentin Reduces Opiate Use during Radiation Therapy for Head and Neck Squamous Cell Carcinoma

“…All patients completed a staging workup with computed tomography (CT) of the head and neck with contrast and/or positron emission tomography-computed tomography (PET/CT). All patients who underwent definitive radiation therapy were treated with intensity-modulated radiation therapy (IMRT; 70 Gy/35 fractions to the primary tumor, 56 Gy/35 fractions to elective lymph nodes) with or without concurrent chemotherapy, as previously described [ 7 ]. All patients who underwent adjuvant radiation therapy were treated with IMRT with the dose depending on pathologic risk factors (60–66 Gy/30–33 fractions to the post-operative bed, 54 Gy/30–33 fractions to the elective lymph nodes).…”

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

“…The substantial symptom burden among patients with head and neck cancer 42,43 necessitates intensive symptom management. 49 Effective symptom management is important for the patient's quality of life 50 and incidentally may curtail financial toxicity. Patient quality of life during therapy for cancer has been shown to affect survival.…”