Canterbury DHB

Mucositis

Mucosal atrophy and ulceration are common in leukaemic and bone marrow transplant patients. To make the patient more comfortable, reduce local trauma as much as possible, e.g. atraumatic diet, remove ill-fitting dentures, use a Tepe special care soft brush.

Warm saline mouthwashes are often a useful addition for pain relief.

Topical Pain Relief

• Difflam® (benzydamine hydrochloride 0.15%) mouth rinse

  15 mL gargled or rinsed for thirty seconds may be used every 2 - 3 hours as required for pain. However, it contains alcohol and may irritate mucosa.

• Xylocaine viscous (lignocaine hydrochloride 2% viscous oral solution)

  Topical preparations need to be used with care, otherwise the mouth and throat can be made quite numb and the cheeks or tongue accidentally bitten. Xylocaine viscous prior to meals and fluids.

  Topical pain relief may need to be supplemented by systemic pain medication, e.g. paracetamol preparation or morphine infusion.

• Gelclair® mouth rinse coats the surface of the mouth forming a protective barrier.

  Note: If the patient has developed a thick mucoid, sticky saliva, bicarbonate of soda/salt mouth rinses are useful to dissolve these sticky secretions. It is made with 2 teaspoons of salt and 2 teaspoons of baking soda in 1 L of water. Use as a vigorous gargle/rinse up to eight times daily if necessary. When patients' mouths are very ulcerated (e.g. during BMT), making mouth care very difficult, it may be helpful to irrigate the mouth using IV administration tubing attached to a litre bag of normal saline.

Systemic Pain Relief

Morphine treatment for mucositis: see Pain Management.

Suspected Herpes Simplex

Take swabs for herpes simplex DNA. Valaciclovir should be started before the results of investigations are available if the clinical suspicion is strong.

Angular Cheilitis

Two organisms are usually involved: either S. aureus or candida. Therefore, a swab of the angular fold is indicated to distinguish between the organisms. Moist creases at the angle of the mouth as well as immunosuppression predispose patients to angular cheilitis. Simple “waterproofing” of the mouth creases can often help to alleviate the problem, e.g. Vaseline, barrier cream.

• In fungal infections, nystatin ointment (not cream) is the preferred medication.
• In S. aureus infections, mupirocin ointment 2% applied TDS for 7 days.

Lip Care

Barrier creams are often water-soluble and do not last long. Therefore a waxy lip balm such as Chapstick® or Vaseline® may be used. Xylocaine ointment (2% lignocaine) can be useful, as it is waxier if lips are cracked.

Xerostomia

To ease the discomfort of dry mouth:

• Chew sugar-free gum. This stimulates the salivary glands.
• Take frequent sips of water (avoid drinks containing sugar).
• Take a saliva substitute. Oralube® 125 mL comes in a spray from the pharmacy (not subsidised for outpatients).
• Use pilocarpine oral solution 2.5 mg four times a day, swallowed. Up to 15 mg may be prescribed. The dose should be adjusted to patient response. (Or 1 to 2 drops of 4% eye drops solution.) There are side effects such as nausea, sweating, vomiting, and diarrhoea associated with this drug. It should be prescribed by the patient’s haematological Consultant, or oral medicine specialist only. Pilocarpine should be continued for six to eight weeks before it is considered to have failed^.5 (Compounded product from pharmacy.)
• To aid denture retention and to provide lubricant in the presence of dentures, try products such as Polygrip® or Fixodent® (cream-type denture adhesives). These may improve patient comfort.
• If dryness of the mouth persists for longer than three months, consider dental referral for preventative care.

Oral cryotherapy for the prevention of high dose melphalan induced stomatitis

• The rationale for using oral cryotherapy is the coldness causes vasoconstriction, which can decrease the damage to the mucosa from chemotherapy drugs with a short half-life, such as melphalan.
• Recommended treatment: Patients should commence sucking ice 30-60 minutes prior to the administration of the drug and continue until an hour after the drug infusion.

Topic Code: 4986