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Radiotherapy to the head and neck makes the lining of the mouth and throat sore, usually from the second or third week. Keeping the mouth clean on a regular routine, a benzydamine mouthwash, and in many centres a low-level light treatment inside the mouth help prevent it; pain relief and help with eating matter as much as anything else.
The MASCC/ISOO 2020 guideline (the latest full edition) is the reference. For head and neck radiotherapy it suggests a multiagent combination oral care protocol (level III), recommends benzydamine mouthwash for moderate-dose radiotherapy below 50 Gy (level I) and suggests it with chemoradiotherapy (level II), and recommends intraoral photobiomodulation with low-level laser for radiotherapy alone (level II) and for chemoradiotherapy (level I), following the parameters of one of the protocols in its Table 2 and telling patients that animal data on tumour effects conflict. It suggests against chlorhexidine for prevention (level III), recommends against sucralfate, suggests honey (level II) and, with caution, oral glutamine with chemoradiotherapy (level II), and suggests topical morphine 0.2% mouthwash for pain with chemoradiotherapy (level III). Professional oral care, patient education and saline or bicarbonate rinses carry expert opinion only: dental assessment before treatment, education to support self-care, and bland rinses for clearance and comfort. The MASCC/ISOO Delphi (2024) adds how to assess: the WHO scale by the clinician, weekly or more often in high-grade mucositis, with a patient-reported measure (OMWQ and OMDQ, or PRO-CTCAE items). Where no intervention is recommended, pain relief, dietary support and preventing secondary infection carry management.
Why: Bad teeth or gums are a source of infection during treatment, and some dental work is safer done before the jaw is irradiated.
“An expert opinion complements this guideline: Although there was insufficient evidence to support the use of professional oral care for OM prevention, the panel is of the opinion that dental evaluation and treatment as indicated before cancer therapy are desirable to reduce risk for local and systemic infections from odontogenic sources.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (expert opinion)
Why: A regular routine of cleaning the mouth lowers the chance and severity of a sore mouth, mostly by making daily mouth care happen.
“The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during H&N RT.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (suggestion)
Why: People who understand the routine are more likely to keep to it when the mouth is sore.
“An expert opinion complements this guideline: The panel is of the opinion that educating patients about the benefits of BOC strategies is still appropriate because this may improve self‐management and adherence to the recommended oral care protocol during cancer treatment.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (expert opinion)
Why: They are harmless, wash debris away and can make the mouth feel better, though they have not been shown to prevent mucositis.
“An expert opinion complements this guideline: Despite the limited data available for both saline and sodium bicarbonate, the panel recognizes that these are inert, bland rinses that increase oral clearance, which may be helpful for maintaining oral hygiene and improving patient comfort.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (expert opinion)
Why: Benzydamine is an anti-inflammatory rinse that reduces mucositis in trials of moderate-dose head and neck radiotherapy.
“The panel recommends benzydamine mouthwash for the prevention of OM in patients with H&N cancer receiving a moderate dose RT (<50 Gy).”
MASCC and ISOO (Cancer; Elad et al.) 2020 · I (recommendation)
Why: The evidence is weaker with chemoradiotherapy, but points the same way.
“The panel suggests the use of benzydamine mouthwash for the prevention of OM in patients with H&N cancer who receive RT‐CT.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · II (suggestion)
Why: Low-energy red light inside the mouth reduces how severe mucositis gets; the benefit depends on using settings that were tested.
“The panel recommends the use of intraoral PBM therapy using low‐level laser therapy for the prevention of OM in adults receiving RT‐CT for H&N cancer (Table 2); safety considerations unique to patients with oral cancer should be considered.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · I (recommendation, chemoradiotherapy); II (recommendation, radiotherapy alone)
Why: Animal studies disagree on whether the light affects tumour cells; follow-up of treated patients has not shown more recurrence, but the data are hard to analyse.
“Considering the conflicting evidence from animal models regarding the effect of PBM on tumor behavior, the clinician is advised to inform patients about the expected benefits and potential risks of PBM.”
Why: Trials found it does not prevent radiation mucositis; it remains acceptable for a mouth infection.
“The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (suggestion against)
Why: Regular scoring catches worsening early, and the patient's own report shows how much it affects eating and pain.
“Weekly or more in high grade mucositis”
MASCC Mucositis Study Group and ISOO (eClinicalMedicine; Abdalla-Aslan et al.) 2024 · Delphi consensus (more than 80% agreement)
Why: Pain is what stops people eating and drinking; a morphine rinse can help where chemotherapy is part of treatment.
“Topical morphine 0.2% mouthwash is suggested for the treatment of OM‐associated pain in patients with H&N cancer who receive RT‐CT.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · III (suggestion)
Why: Trials found the combined mouth-and-swallowed form did not help.
“Sucralfate (combined topical and systemic) is not recommended for the prevention of OM‐associated pain in patients with H&N cancer who receive RT.”
MASCC and ISOO (Cancer; Elad et al.) 2020 · II (recommendation against)
Why: Where no treatment prevents mucositis, nutrition, pain relief and stopping infection are what carry people through.
“Until more research is available, pain relief, dietary support, and secondary infection prevention are key elements in patient management.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
MASCC/ISOO 2020 is the only current international guideline read and the reference for this protocol: a combination oral care routine with dental assessment beforehand, benzydamine mouthwash (level I below 50 Gy, level II with chemotherapy), intraoral photobiomodulation with the tested parameters (level I with chemoradiotherapy, level II with radiotherapy alone) after explaining its uncertain tumour safety, no chlorhexidine or sucralfate for prevention, weekly WHO-scale assessment with a patient-reported measure (MASCC/ISOO Delphi 2024), and early pain relief and dietary support. Honey (level II) and oral glutamine with chemoradiotherapy (level II, with caution) are suggestions, not recommendations.
MASCC and ISOO (Cancer; Elad et al.) 2020 · MASCC Mucositis Study Group and ISOO (eClinicalMedicine; Abdalla-Aslan et al.) 2024
Where it differs: Adds honey, applied in the mouth and swallowed, through radiotherapy or chemoradiotherapy.
Evidence: MASCC/ISOO 2020 suggests it (level II); the trials were small, mixed radiotherapy and chemoradiotherapy, and used different honeys, so only a suggestion was possible.
Where it differs: Adds oral glutamine during chemoradiotherapy.
Evidence: MASCC/ISOO 2020 suggests it (level II) on two randomised trials, with caution: "The suggestion is with caution because of the higher mortality rate seen in patients undergoing HSCT who receive parenteral glutamine." The dose printed in the guideline's discussion is not reproduced here because it could not be checked against the trials.
Where it differs: Some centres still give zinc or a misoprostol rinse.
Evidence: MASCC/ISOO 2020 withdrew the 2014 suggestion for zinc and the 2014 suggestion against misoprostol, reversing both to no guideline possible: "The previous suggestion made for zinc in the 2014 MASCC/ISOO guidelines for patients with H&N cancer who received RT or RT‐CT was reversed in the current guidelines to NGP."
Where it differs: Uses chlorhexidine as the standard rinse through radiotherapy.
Evidence: MASCC/ISOO 2020 suggests against it for preventing mucositis (level III) but keeps it for infection: "If CHX is indicated because of concurrent oral infection and OM, it is acceptable to use it for the oral infection."
Radiotherapy to the head and neck usually makes the mouth and throat raw and painful. Shining low-level laser light inside the mouth during treatment reduces this, and the international supportive care guideline has recommended it since 2020, with its highest level of evidence for people also having chemotherapy. In a survey of 25 Italian radiotherapy centres, one used it.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Multiagent combination oral care protocols during head and neck radiotherapy | III (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Benzydamine mouthwash with moderate-dose radiotherapy (below 50 Gy) | I (recommendation) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Benzydamine mouthwash with chemoradiotherapy | II (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Intraoral photobiomodulation with radiotherapy alone “The panel recommends the use of intraoral PBM therapy using low‐level laser therapy for prevention of OM in adults receiving RT to the H&N (without CT) (Table 2); safety considerations unique to patients with oral cancer should be considered.” | II (recommendation) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Intraoral photobiomodulation with chemoradiotherapy | I (recommendation) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Follow the specific parameters of the selected photobiomodulation protocol “For all PBM guidelines, it is recommended that the specific PTPs of the selected protocol will be followed for optimal therapy.” | Recommendation (ungraded note to the table) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Chlorhexidine not to be used to prevent mucositis in head and neck radiotherapy | III (suggestion against) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Topical morphine 0.2% mouthwash for pain with chemoradiotherapy | III (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Sucralfate not recommended for prevention or treatment of pain with radiotherapy | II (recommendation against) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Oral glutamine with chemoradiotherapy “The panel suggests oral glutamine for the prevention of OM in patients with H&N cancer who receive receiving RT‐CT.” | II (suggestion, with caution) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Honey with radiotherapy or chemoradiotherapy “Honey is suggested for the prevention of OM in patients with H&N cancer who receive treatment with either RT or RT‐CT.” | II (suggestion) | MASCC and ISOO (Cancer; Elad et al.) 2020 |
| Patient-reported measure for head and neck (chemo)radiotherapy in practice “OMWQ and OMDQ or PRO-CTCAE questions related to mucositis” | Delphi consensus (more than 80% agreement) | MASCC Mucositis Study Group and ISOO (eClinicalMedicine; Abdalla-Aslan et al.) 2024 |
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Shares Photobiomodulation (low-level laser) for oral mucositis, Mucositis and stomatitis.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.
Shares Oropharyngeal cancer (tonsil and base of tongue), Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma.