Management Of Chemotherapy and Radiotherapy-Induced Oral Mucositis in Head and Neck Cancer: A Review
Keywords:
Oral mucositis, Head and neck cancer, Chemoradiotherapy, Supportive careAbstract
Background Oral mucositis (OM) is one of the most common and severe complications associated with chemotherapy and radiotherapy in head and neck cancer (HNC) patients. It significantly impairs nutritional intake, increases the risk of infection, and may lead to dose reductions or interruptions in cancer therapy.
Objective This review aims to critically evaluate current evidence regarding the pathophysiology, prevalence, risk factors, preventive strategies, and therapeutic interventions for managing OM in patients undergoing treatment for HNC.
Methods A narrative review methodology was employed. A systematic literature search was conducted across PubMed, Scopus, Web of Science, and ScienceDirect. A total of 152 articles were identified, of which 45 met the inclusion criteria based on relevance, quality, and scope. Data were thematically synthesized with emphasis on clinical applicability.
Results The included studies reported OM prevalence rates approaching 100% in concurrent chemoradiotherapy settings. Key risk factors include high-dose radiation, poor oral hygiene, and specific chemotherapeutic agents. Evidence-based interventions such as oral care protocols, low-level laser therapy, cryotherapy, and palifermin have shown varying degrees of efficacy. Multidisciplinary preventive strategies were consistently associated with better outcomes.
Conclusion Effective OM management requires a proactive, multidisciplinary approach tailored to patient-specific risk factors. While promising interventions exist, variability in outcome measures highlights the need for standardized guidelines and further clinical research.
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References
Trotti A, Bellm LA, Epstein JB, Frame D, Fuchs HJ, Gwede CK, et al. Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: a systematic literature review. Radiother Oncol. 2003;66(3):253–62.
Berger K, Schopohl D, Bollig A, Strobach D, Rieger C. Burden of oral mucositis: a systematic review and implications for future research. Oncol Res Treat. 2018;41(6):399–405.
Iovoli AJ, Turecki LM, Qiu ML, Khan M, Smith K, et al. Severe oral mucositis after intensity-modulated radiation therapy for head and neck cancer. JAMA Netw Open. 2023;6(10):e2331091.
Bossi P, Bergamini C, Miceli R, Cova A, Orlandi E, Resteghini C, et al. Salivary cytokine levels and oral mucositis in head and neck cancer patients treated with chemotherapy and radiation therapy. Int J Radiat Oncol Biol Phys. 2016;96(1):E343.
Nicolatou-Galitis O, Kouloulias V. Oral mucositis, pain and xerostomia in 135 head and neck cancer patients receiving radiotherapy with or without chemotherapy. Open Cancer J. 2011;4:7–17. doi: 10.2174/1874079001104010007
Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys. 2007;68(4):1110–20.
Epstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, et al. Oral complications of cancer and cancer therapy: From cancer treatment to survivorship. CA Cancer J Clin. 2012;62(6):400–22.
Sonis ST. The pathobiology of mucositis. Nat Rev Cancer. 2004;4(4):277–84.
Cheng KKF, Lee V, Li CH, Goggins WB, Thompson DR, Yuen HL, et al. Incidence and risk factors of oral mucositis in patients receiving chemotherapy: a longitudinal study. Support Care Cancer. 2012;20(7):1733–40.
Elad S, Cheng KKF, Lalla RV, Yarom N, Hong C, Logan RM, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423–31.
He Y, Zhang M, He N, Wang Y, Ma X, Guo J. Efficacy of low-level laser therapy in the prevention and treatment of chemotherapy-induced oral mucositis: a meta-analysis. Oral Oncol. 2018;83:64–73.
Villa A, Sonis ST. Mucositis: pathobiology and management. Curr Opin Oncol. 2015;27(3):159–64.
Svanberg A, Öhrn K, Birgegård G. Oral cryotherapy reduces mucositis and improves nutrition—a randomised controlled trial. J Clin Nurs. 2010;19(15–16):2146–51.
Elting LS, Shih YC, Stiff PJ, Bensinger W, Cantor SB, Cooksley C, et al. Economic impact of palifermin on the costs of hospitalization for hematopoietic stem-cell transplant. Biol Blood Marrow Transplant. 2007;13(7):806–14.
Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2011;(4):CD000978.
Bensadoun RJ, Magné N, Marcy PY. Chemotherapy- and radiotherapy-induced mucositis in head and neck cancer patients: new trends in pathophysiology, prevention and treatment. Eur Arch Otorhinolaryngol. 2001;258(9):481–7. Available from
Volpato LER, Silva TC, Oliveira TM, Sakai VT. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otorrinolaringol. 2007;73(4):562–8. doi: 10.1590/S0034-72992007000400017
Scully C, Epstein J, Sonis S. Oral mucositis: a challenging complication of radiotherapy, chemotherapy, and radiochemotherapy: part 1, pathogenesis and prophylaxis of mucositis. Head Neck. 2003;25(12):1057–70. doi: 10.1002/hed.10318
Sonis ST. Oral mucositis in head and neck cancer: risk, biology, and management. Am Soc Clin Oncol Educ Book. 2013. Available from
Kawashita Y, Soutome S, Umeda M, Saito T. Oral management strategies for radiotherapy of head and neck cancer. Oral Health Dent Manag. 2020. Available from
Lalla RV, Brennan MT, Gordon SM, Sonis ST. Oral mucositis due to high-dose chemotherapy and/or head and neck radiation therapy. JNCI Monographs. 2019;2019(53):lgz011. Available from
De Sanctis V, Bossi P, Sanguineti G, Trippa F. Mucositis in head and neck cancer patients treated with radiotherapy and systemic therapies: Literature review and consensus statements. Crit Rev Oncol Hematol. 2016. Available from
Moslemi D, Nokhandani AM, Otaghsaraei MT. Management of chemo/radiation-induced oral mucositis in patients with head and neck cancer: A review of the current literature. Radiother Oncol. 2016. Available from
Plevova P. Prevention and treatment of chemotherapy- and radiotherapy-induced oral mucositis: a review. Oral Oncol. 1999. Available from
Trucci VM, Veeck EB. Current strategies for the management of oral mucositis induced by radiotherapy or chemotherapy. Rev Odonto Ciênc. 2009. Available from
Elad S, Cheng KKF, Lalla RV, Yarom N, Hong C, Logan RM, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423–31. doi: 10.1002/cncr.33100
Villa A, Sonis ST. Mucositis: pathobiology and management. Curr Opin Oncol. 2015;27(3):159–64. doi: 10.1097/CCO.0000000000000174
Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin North Am. 2008;52(1):61–77. doi: 10.1016/j.cden.2007.10.002
Daugelaite G, O’Connell N, Coughlan J. Oral mucositis in patients undergoing cancer treatment: a narrative review. Dent J. 2021;9(6):67. doi: 10.3390/dj9060067
Raber-Durlacher JE, Elad S, Barasch A. Oral mucositis. Hematol Oncol Clin North Am. 2014;28(1):75–93. doi: 10.1016/j.hoc.2013.11.007
Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M, Hauer-Jensen M, et al. Perspectives on cancer therapy-induced mucosal injury. Cancer. 2004;100(9 Suppl):1995–2025. doi: 10.1002/cncr.20162
Peterson DE, Bensadoun RJ, Roila F. Management of oral and gastrointestinal mucositis: ESMO Clinical Practice Guidelines. Ann Oncol. 2011;22(Suppl 6):vi78–84. doi: 10.1093/annonc/mdr391
Epstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, et al. Oral complications of cancer and cancer therapy: From cancer treatment to survivorship. CA Cancer J Clin. 2012;62(6):400–22. doi: 10.3322/caac.21157
Sonis ST. The pathobiology of mucositis. Nat Rev Cancer. 2004;4(4):277–84. doi: 10.1038/nrc1318
Worthington HV, Clarkson JE, Bryan G, Furness S, Glenny AM, Littlewood A, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2011;(4):CD000978. doi: 10.1002/14651858.CD000978.pub5
Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber-Durlacher JE, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007;109(5):820–31. doi: 10.1002/cncr.22484
Cheng KKF, Molassiotis A, Chang AM, Wai WC, Cheung SS. Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in pediatric cancer patients. Eur J Cancer. 2001;37(16):2056–63. doi: 10.1016/S0959-8049(01)00240-4
Devi S, Das AK, Ghosh S, Kar S. Oral mucositis in cancer patients: A scoping review of current practices. J Family Med Prim Care. 2020;9(1):16–22. doi: 10.4103/jfmpc.jfmpc_1003_19
Cheng KKF, Lee V, Li CH, Goggins WB, Thompson DR, Yuen HL, et al. Incidence and risk factors of oral mucositis in patients receiving chemotherapy: a longitudinal study. Support Care Cancer. 2012;20(7):1733–40. doi: 10.1007/s00520-011-1265-1
Eilers J, Million R. Prevention and management of oral mucositis in patients with cancer. Semin Oncol Nurs. 2011;27(4):e1–16. doi: 10.1016/j.soncn.2011.08.006
Sharma A, Sharma S, Singh K. Prophylactic and therapeutic strategies for oral mucositis in cancer patients: a systematic review. Int J Clin Oncol. 2020;25(5):927–45. doi: 10.1007/s10147-019-01556-5
Liao Y, Shen J, Zhang M, Guo J, He N, Ma X, et al. Cryotherapy for preventing oral mucositis in patients undergoing hematopoietic stem cell transplantation: a systematic review and meta-analysis. J Oncol. 2019;2019:ID 3453792. doi: 10.1155/2019/3453792
Mills M, Estes B. Advances in the management of cancer therapy-induced oral mucositis. Nurse Pract. 2005;30(3):46–53. doi: 10.1097/00006205-200503000-00006
He Y, Zhang M, He N, Wang Y, Ma X, Guo J. Efficacy of low-level laser therapy in the prevention and treatment of chemotherapy-induced oral mucositis: a meta-analysis. Oral Oncol. 2018;83:64–73. doi: 10.1016/j.oraloncology.2018.06.015
Elting LS, Shih YC, Stiff PJ, Bensinger W, Cantor SB, Cooksley C, et al. Economic impact of palifermin on the costs of hospitalization for hematopoietic stem-cell transplant: modeling results for patients with hematologic malignancies. Biol Blood Marrow Transplant. 2007;13(7):806–14. doi: 10.1016/j.bbmt.2007.03.002
Campos MI, Campos CN, Aarestrup FM, Aarestrup BJ. Oral mucositis in cancer treatment: natural history, prevention and treatment. Oncol Lett. 2014;7(6):1792–6. doi: 10.3892/ol.2014.2036
Niscola P, Romani C, Scaramucci L, Giovannini M, Cartoni C, Cupelli L, et al. Mucositis in patients with hematologic malignancies. Hematol Rep. 2011;3(1):e2. doi: 10.4081/hr.2011.e2
Sorensen JB, Skovsgaard T, Bork E. Influence of cisplatin, cyclophosphamide and 5-fluorouracil on the frequency of chemotherapy-induced oral mucositis. Cancer. 1985;55(5):1124–9. doi: 10.1002/1097-0142(19850301)55:5<1124::AID-CNCR2820550526>3.0.CO;2-4
Nicolatou-Galitis O, Kouloulias V, Sotiropoulou-Lontou A. Oral mucositis: understanding the pathology and management. Oral Oncol. 2012;48(6):e44–51. doi: 10.1016/j.oraloncology.2011.11.010
Svanberg A, Öhrn K, Birgegård G. Oral cryotherapy reduces mucositis and improves nutrition—a randomised controlled trial. J Clin Nurs. 2010;19(15–16):2146–51. doi: 10.1111/j.1365-2702.2009.03181.x
Cheng KKF, Molassiotis A, Chang AM, Wai WC, Cheung SS. Evaluation of the effectiveness of an oral care protocol in the prevention of chemotherapy-induced oral mucositis in pediatric cancer patients. Eur J Cancer. 2001;37(16):2056–63. doi: 10.1016/S0959-8049(01)00240-4
Maiorini E, Rapoport BL, Sibaud V, Sonis ST, Lacouture ME. Management of cancer therapy–induced mucocutaneous toxicities. Oncologist. 2021;26(5):e846–55. doi: 10.1002/onco.13679
Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys. 2007;68(4):1110–20. doi: 10.1016/j.ijrobp.2007.01.053
Cheng KKF, Yuen HL, Lam W, Cheng L, Sham JS. The effect of cryotherapy on chemotherapy-induced oral mucositis in patients with solid tumors: a meta-analysis. J Clin Nurs. 2011;20(17–18):2664–73. doi: 10.1111/j.1365-2702.2010.03691.x
Dodd MJ, Dibble SL, Miaskowski C, Paul SM, Cho M, MacPhail L. A randomized clinical trial of the effectiveness of a self-care intervention to manage chemotherapy side effects. Cancer Nurs. 2010;33(2):E1–E17. doi: 10.1097/NCC.0b013e3181c75f04
Gouvea Lima GM, Ferreira CG, de Castro Junior G. Prevention and treatment of oral mucositis: a review. Braz J Med Biol Res. 2010;43(8):814–20. doi: 10.1590/S0100-879X201000750008
Al-Ansari S, Zecha JA, Barasch A, de Lange J, Rozema FR, Raber-Durlacher JE. Oral mucositis induced by anticancer therapies. Curr Oral Health Rep. 2015;2:202–11. doi: 10.1007/s40496-015-0061-1
Rugo HS, Wilks S, Mehta RS, Banu A, Henry D, Azarnia N, et al. Prevention of oral mucositis in patients receiving everolimus: a randomized clinical trial. Support Care Cancer. 2021;29(2):961–70. doi: 10.1007/s00520-020-05555-7
Cheng KKF, Molassiotis A, Chang AM. An oral care protocol intervention to prevent chemotherapy-induced oral mucositis in pediatric cancer patients: a pilot study. Eur J Cancer. 2001;37(16):2056–63. doi: 10.1016/S0959-8049(01)00240-4
Bardy J, Molassiotis A, Ryder WD, McCollum C, Clarke S, White P, et al. A phase I study on the safety and efficacy of GM-CSF mouthwashes to treat oral mucositis. Eur J Cancer. 2005;41(4):501–6. doi: 10.1016/j.ejca.2004.11.001
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