Nashwan, A. J. (2011). Use of chlorhexidine mouthwash in children receiving chemotherapy: A review of literature. Journal of Pediatric Oncology Nursing, 28, 295–299.

To evaluate the effectiveness of chlorhexidine mouthwash in children receiving chemotherapy

Databases searched were PubMed and ScienceDirect.

Search keywords were oral chlorhexidine, chemotherapy-induced mucositis/stomatitis, and pediatrics/children.

Studies were included in the review if they

• Were published between 1980 and January 1, 2010, in English.
• Involved human clinical trials in children between 0–18 years of age.
• Were prospective trials published in peer-reviewed journals.
• Used any antimicrobial agent for management of oral mucositis (OM).

Studies were excluded if they

• Included adults.
• Were meeting abstracts, letters, comments, case reports, or review articles.
• Were animal or in vitro, pharmacokinetic or pharmacodynamic, or retrospective and meta-analysis studies.

• A total of 13 references were retrieved, and five met the inclusion criteria. 
• All five studies assess chlorhexidine using a scale to assess OM. Three of them used the Modified Oral Assessment Guide 1–3 scale, one used the World Health Organization (WHO) 10-cm visual analog scale (VAS), and one study did not report the method of oral assessment (both groups were measured by presence of OM, bacteremia, and length of hospital stay).
• Antimicrobial treatment began before the start of OM in four studies and after the start of OM in one study.
• The duration of treatment for OM ranged from 6 weeks to 6 months.
• The five studies differed regarding types of patient, age groups, types of cancer treatment, concentrations of chlorhexidine rinse, how OM was assessed, and outcomes measured.

• A total of 175 patients were involved in the fix studies, with samples across studies ranging from 14–47.
• Two of the studies involved patients undergoing bone marrow transplant. All studies involved patients undergoing chemotherapy.
• All five studies used a control, usually a placebo mouthwash or sterile water.

• Patients were undergoing the active treatment phase of care.
• This study has clinical applicability for pediatrics.

• Three studies reported on the benefit of using chlorhexidine over benzydamine (Cheng & Chang, 2003; Cheng et al., 2004).
• One study showed benefit over placebo (Costa et al., 2003).
• One study showed no benefit using chlorhexidine over placebo (Raether et al., 1989).
• One study reported acceptance and tolerability of chlorhexidine (Cheng, 2004).

• Chlorhexidine may play a part in reducing OM during chemotherapy in pediatric patients.
• Further clinical trials are needed to examine more effective methods to prevent and manage OM.

• Most studies involved a small number of patients.
• The different scoring systems were not validated and were subjective.
• Studies were not blinded
• Studies differed in type of patient, age groups, type of cancer treatment, concentration of chlorhexidine rinse, how OM was assessed, and what outcomes were measured
• Literature evaluated was published over a 20-year period.

• Oral rinses for prevention or treatment of OM are a usually a good vehicle for treatment as long as they are easy to use, well tolerated, provide some quick relief of discomfort from OM, and are cost effective and accessible.
• The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology recommends nonmedicated oral rinses for prevention of oral mucositis in adult patients with solid tumors of the head and neck and who are undergoing radiation therapy. 
• Oncology nurses are well positioned to educate children and their caregivers on proper use of oral rinses.