Chlorhexidine is an antiseptic that has a broad spectrum effect against both gram-positive and -negative bacteria. Chlorhexidine gluconate oral rinse that contains glycerol, coloring, flavoring, and other compounds has been studied in patients with cancer for the prevention and treatment of mucositis. It is important to note that prophylactic use, before development of mucositis, has a different PEP category than the use of chlorhexidine in patients who already have mucositis symptoms.
Cardona, A., Balouch, A., Mohammed, M.A., Sedghizadeh, P.P., & Enciso, R. (2017). Efficacy of chlorhexidine for the prevention and treatment of oral mucositis in cancer patients: A systematic review with meta-analyses. Journal of Oral Pathology and Medicine. Advance online publication.
PHASE OF CARE: Active antitumor treatment
The incidence of mucositis was less with chlorhexidine. Across all studies, the relative risk (RR) ranged from 0.097–0.771 in favor of chlorhexidine (p = 0.05), with an overall RR of 0.899 (95% confidence interval [0.656, 1.232]). The findings for severity of mucositis were mixed.
Chlorhexidine was not associated with reduced severity of mucositis. There was a trend toward lower incidence of mucositis with chlorhexidine.
There are overall mixed findings about the effects of chlorhexidine oral rinses on chemotherapy- and radiation therapy–induced mucositis, with limited evidence in each of these subgroups. It appears that chlorhexidine is not useful for the treatment of mucositis but may have some role in prevention.
Donnelly, J.P., Bellm, L.A., Epstien, J.B., Sonis, S.T., & Symonds, R.P. (2003). Antimicrobial therapy to prevent or treat oral mucositis. Lancet Infectious Diseases, 3, 405–412.
Database searched was Medline (1964–June 2002).
Keywords searched were anti-infective agents and mucositis or stomatitis.
Articles were included in the review if they were written in English language and described human clinical trials.
Studies were excluded if they involved meta-analyses.
Study quality was scored on 0–5 scale (with 5 being the highest) depending on previously established criteria. Five studies scored 4, and eight scored 0. The mean score was 2.1, indicating overall lack of quality in published material.
Thirty-one eligible studies were identified. Twenty-eight of the studies used some kind of control, usually a placebo mouthwash or sterile water. Seventeen studies assessed chlorehexidine, and five studies investigated preparations containing polymyxin, tobramycin, and amphotericin; others included povidone-iodine; fluconazole; clindamycin; bacitracin, clotrimazole, and gentamicin; tetrachlorodecaoxide, ciprofloxacin, or ampicillin with clortrimazole; sucralfate versus sucralfate; ofloxacin, miconazole, tetracain, and guaiazulene; triacetin versus topical anesthetics or system icanalgesics; tetracycline, nystatin; hydrocortisone; and diphenhydramine versus placebo. The chlorexidine studies also included the following agents: benzydamine, nystatin, povidone-iodine, salt and soda, magic mouthwash, and clotrimazole.
The scale used was reported in 22 studies. Scales were World Health Organization (n = 4), Oral Assessment Guide (n = 7), 0–5 scale (n = 1), and 0–4 scale (n = 10).
The number of patients across studies ranged from 12–275.
No clear pattern emerged regarding the benefit of antimicrobial use to manage oral mucositis.
Results draw attention to the multifaceted pathophysiology of oral mucositis, which presents a challenge for effective measures for prevention and treatment of mucositis.
McGuire, D.B., Fulton, J.S., Park, J., Brown, C.G., Correa, M.E.P., Eilers, J., . . . Lalla, R.V. (2013). Systematic review of basic oral care for the management of oral mucositis in cancer patients. Supportive Care in Cancer, 21, 3165–3177.
STUDY PURPOSE: To systematically review oral care interventions for the prevention and treatment of oral mucositis (OM) in patients undergoing cancer treatment
TYPE OF STUDY: Systematic review
DATABASES USED: Ovid MEDLINE
KEYWORDS: mucositis, stomatitis, cancer, oral care, oral care protocol, dental care, dental cleaning, oral decontamination, oral hygiene, saline, sodium bicarbonate, baking soda, chlorhexidine, magic/miracle mouthwash, calcium phosphate
INCLUSION CRITERIA: Primary research article, reflects a variety of research designs, rested the effects of intervention on severity of OM or mucositis-related symptoms
EXCLUSION CRITERIA: Review articles, clinical case reports, literature reviews, non-research articles
TOTAL REFERENCES RETRIEVED = 129
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Hadorn et al. criteria was used to assess the flaws in the selected publications, and levels of evidence were rated using the Somerfield schema.
FINAL NUMBER STUDIES INCLUDED = 52
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Not stated
PHASE OF CARE: Active antitumor treatment
The guidelines are as follows.
Oral care protocols are recommended to patients for the prevention and treatment of OM. Chlorhexidine is not recommended for patients with head and neck cancer who receive radiotherapy treatment.
Evidence for interventions to prevent and treat OM are limited, making guideline recommendations difficult.
Nurses should teach patients appropriate oral care to help prevent OM.
Qutob, A.F., Gue, S., Revesz, T., Logan, R.M., & Keefe, D. (2013). Prevention of oral mucositis in children receiving cancer therapy: A systematic review and evidence-based analysis. Oral Oncology, 49, 102–107.
To investigate, critically appraise, and rate the evidence regarding agents used for the prevention of mucositis in children
Databases searched included CINAHL, Cochrane library, Ovid MEDLINE, PubMed, BioMed Central, and other internet-based sources. A total of 19 databases were searched.
Search keywords were mucositis, stomatitis, oral inflammation, mouth mucosal inflammation, prophylaxis, management, and prevent; in addition to keywords to identify children and all types of cancer therapy.
Studies were included in the search if they
Studies were excluded if they
The authors concluded that oral care protocols should be used; oral sucralfate suspension, prostaglandin E2, and GM-CSF mouthwash should not be considered based on current evidence; and chlorhexidine (without use as part of an oral care protocol), laser therapy, and glutamine should not be considered because of conflicting evidence.
Findings provide further support for use of oral care protocols. Results provided no other useful recommendations for preventive therapies but identified the need for further research in this area.
Cheng, K.K., Molassiotis, A., Chang, A.M., Wai, W.C., & Cheung, S.S. (2001). Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in pediatric cancer patients. European Journal of Cancer, 37, 2056–2063.
The study was conducted over an eight-month period. The first four months were with the control group, which received routine care, no oral protocol, and the center's standard use of 0.9% sodium chloride (NaCl) and benzydamine hydrochloride rinse to control oral mucositis (OM) when it developed.
The last four months involved the experimental group, which received an oral care protocol consisting of patient education, maintenance of patient diaries, and rinsing with normal saline chlorhexidine every two hours on days 1–21. The oral protocol prescribed toothbrushing; NaCl solution rinse for gums, tongue, and soft tissue; and chlorhexidine rinse every morning and evening, as well as NaCl rinse after each meal and every two hours for the second week only.
This was a prospective, comparative study.
Although the sample is small, the evidence supports the use of normal saline found in other studies.
Cheng, K.K., Chang, A.M., & Yuen, M.P. (2004). Prevention of oral mucositis in pediatric patients treated with chemotherapy: A randomized crossover trial comparing two protocols of oral care. European Journal of Cancer, 40, 1208–1216.
To compare two oral care protocols with children receiving chemotherapy using either benzydamine or chlorhexidine oral rinses
Patients used each mouthwash for three weeks and then crossed over. Patients also used a standard mouthcare protocol consisting of toothbrushing using the Bass method and mouth rinsing with either of the allocated rinses in the early morning and at bedtime, normal saline rinsing within 30 minutes of meals, and normal saline rinsing every 4 hours in the first and third week and every 2 hours in the second week after chemotherapy. Patients were instructed in using a ballooning and sucking motion of the cheeks for 30 seconds without swallowing. Researchers provided reinforcement practice sessions every week and a cartoon reminder.
The study was conducted from April 2000 to April 2001.
This was a prospective randomized, non-blinded, two-period crossover study with continual sequential analysis.
This study did not demonstrate the superiority of the oral rinses over oral care.
Dodd, M.J., Dibble, S.L., Miaskowski, C., MacPhail, L., Greenspan, D., Paul, S.M., et al. (2000). Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 90(1), 39–47.
Test the effectiveness of three mouthwashes used to treat chemo-induced OM. Compared: salt/soda, (1 t each/pint of water) chlorhexidine and magic mouthwash (lidocaine, benadryl Maalox).
Also used the Pro-Self program for all patients. Nurses presented the Pro-Self Mouth Aware program to patients and provided them with mouthwash. This program incorporates good oral hygiene, new toothbrush, daily flossing, regular oral assessments, and instruction of oral conditions that the patient must bring attention to the nurse.
Oral assessment and oral protocol 4x/day. Swished MW for 20 sec and then discard. The MW bottles were collected after their sx subsided or after 12 days supply. Measured amount remaining in bottles.
The mean age was 59.05 years.
Chemo- not RT to head and neck or leukemia
23 outpatient/office settings, 202 patients (142 final pts)
Randomized, double-blind trial to 1 of 3 mouthwashes.
Forty-seven patients dropped out, 11 took > 12 days to report a cessation of s/s.
No significance in three groups of demographics, disease-related variables. No significant difference in the time to reported cessation of the signs and symptoms from chemo-induced mucositis among the three groups (p = 0.59).
The average pain scores did not differ significantly (p = 0.79).
Patient reports, no clinician assessment during mucositis
Limitation of OAG tool – this guide addresses information of oral cavity changes and not strictly mucositis
Structure of oral care program may have been the greatest effect on mucositis.
Findings support use of NS/baking soda over chlorhexidine and magic mouthwash – especially with established oral care program.
Pitten, F.A., Kiefer, T., Buth, C., Doelken, G., & Kramer, A. (2003). Do cancer patients with chemotherapy-induced leukopenia benefit from an antiseptic chlorhexidine-based oral rinse? A double-blind, block-randomized, controlled study. Journal of Hospital Infection, 53(4), 283–291.
To assess the benefit of antiseptic mouthwash in patients with leukopenia because of a decrease in micro-organisms
Chlorhexidine did not provide a clinical benefit against mucositis.
Sorensen, J.B., Skovsgaard, T., Bork, E., Damstrup, L., & Ingeberg, S. (2008). Double-blind, placebo-controlled, randomized study of chlorhexidine prophylaxis for 5-fluorouracil–based chemotherapy-induced oral mucositis with nonblinded randomized comparison to oral cooling (cryotherapy) in gastrointestinal malignancies. Cancer, 112(7), 1600–1606.
To evaluate chlorhexadine prophylaxis for flouruoracil- (5-FU-) based chemotherapy versus normal saline or cryotherapy
The study involved three arms. Arm A received chlorhexidine mouth rinse three times per day for three weeks (n = 70), Arm B received normal saline placebo (n = 64), and Arm C received cryotherapy with crushed ice for 45 minutes during chemotherapy (n = 63).
The study was conducted from 2001–2005.
This was a double-blind, placebo-controlled, randomized study, powered for 225 patients (75 in each arm).
The National Cancer Institute (NCI) Common Toxicity Criteria (CTC) for oral mucositis was used.
Mucositis grade 3–4 occurred more frequently in arm B (33%) than in arm A (13%) (p < 0.01) and arm C (11%) p > 0.005). Duration was significantly longer in arm B than arm A (p = 0.035) and arm C (p = 0.003).