Peterson, D.E., Bensadoun, R.J., & Roila, F. (2011). Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines. Annals of Oncology, 22(Suppl 6), vi78–vi84.

DOI Link

Purpose & Patient Population

To summarize the oral and gastrointestinal mucositis guidelines developed by the Mucositis Study Group of Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO) for patients receiving high-dose chemotherapy, standard-dose chemotherapy, radiation therapy, and combination chemotherapy/radiation therapy

Type of Resource/Evidence-Based Process

The resource type is guidelines. The process of development was not explained.

Phase of Care and Clinical Applications

Patients were undergoing the active treatment phase of care.

This study has clinical applicability for the following.

  • High-dose (HD) head and neck radiation
  • Hematopoietic stem cell transplant (HSCT)
  • Standard multicycle chemotherapy
     

Guidelines & Recommendations

This report contains few changes compared to previous versions published in 2008 and 2010. The oral mucositis (OM) guidelines are as follows.

  • Basic oral care and good clinical practice
    • ​Multidisciplinary development and evaluation of oral care protocols that include frequent use of nonmedicated oral rinses (e.g., saline mouth rinses 4–6 times per day) is recommended. Patient and staff education in the use of such protocols is recommended.
    • Alcohol-based mouth rinses should be avoided.
    • Interdisciplinary development of systemic oral care protocols is suggested. The protocol should include the use of a soft toothbrush that is replaced on a regular basis.
    • Patient-controlled analgesia with morphine is recommended as the treatment of choice for OM pain in patients undergoing HSCT. Regular oral pain assessment using validated instruments for self-reporting is essential.
    • All patients should be screened for nutritional risk, and early enteral nutrition should be started if patients cannot swallow.
    • Topical anesthesia can provide short-term pain relief for OM on an empiric basis.
  • ​Prevention of OM associated with radiotherapy (RT)
    • ​Use of midline radiation blocks and three-dimensional RT to reduce mucosal injury is recommended.
    • Benzydamine oral rinse for prevention of radiation-induced mucositis in patients with head and neck cancer receiving moderate-dose RT is recommended. (This is not available in the United States.) 
    • Chlorhexidine is not recommended for patients with head and neck cancer.
    • Antimicrobial lozenges are not recommended
  • ​Prevention of OM for patients receiving standard-dose (SD) chemotherapy
    • ​Oral cryotherapy recommended for prevention of OM in patients receiving bolus 5-FU and reduction of OM with bolus edatrexate.
    • Including granulocyte-colony stimulating factor (G-CSF) in Taxotere®, Adriamycin, cyclophosphamide (TAC) breast cancer regimens has been associated with significant reduction in toxicities, including OM.
    • IV acyclovir and its analogs are not recommended to prevent OM in SD chemotherapy. However, antivirals may be indicated to treat viral infections that may coexist with OM.
    • IV palifermin in solid tumors needs additional research.
  • Prevention of OM in patients receiving HD chemotherapy with or without total body irradiation (TBI) plus HSCT
    • Palifermin is recommended.
    • Oral cryotherapy is recommended with HD melphalan.
    • Topical pentoxifylline is not recommended.
    • Granulocyte macrophage-colony stimulating factor (GM-CSF) mouthwashes are not suggested.
    • Low-level laser therapy (LLLT) is suggested to reduce OM and pain associated with OM, if available.
  • Treatment of OM associated with RT
    • Oral sucralfate is not recommended.
  • Treatment of OM with SD chemotherapy
    • Chlorhexidine oral rinses are not recommended.
    • Approved devices for OM, including Gelclair®, CaphasolTM, and Biotene®, have a limited research evidence base but are safe and may offer some benefit for some patients.

Other recommendations are listed in the article for gastrointestinal mucositis prevention and treatment.

Nursing Implications

  • Few changes were made from previously published guidelines.
  • Revisions to these guidelines are expected in the next 2–5 years because of newer technology, better understanding of the clinical impact of OM, molecular pathobiology, and emerging targeted cancer therapy.
  • Oncology nurses should recommend evidence-based management for prevention and treatment of OM because some therapies may be expensive and have not been proven effective. For example, “magic mouthwash” continues to be prescribed without evidence to support its use.    
  • Consistent oral care with bland rinses continues to be recommended, is easy to use, and is inexpensive.