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Some cancer treatments cause painful mouth sores. See a dentist first if you can, check your mouth daily, keep brushing gently with a soft brush even when counts are low, rinse with salt and baking soda rather than an alcohol mouthwash, and tell your team early about pain or sores. Depending on treatment, the team may add ice chips during the drip, a benzydamine mouthwash or a low-level laser.
MASCC/ISOO (2020) build prevention on basic oral care: a multiagent combination oral care protocol (brushing, flossing, bland rinses, moisturising) is suggested during chemotherapy, head and neck radiotherapy and haematopoietic stem cell transplant (level III), with dental evaluation and treatment before cancer therapy as expert opinion. Their 2024 practice statement says toothbrushing with a soft or very soft brush twice daily should continue through neutropenia and thrombocytopenia, and that brushes are preferred over foam swabs. Chlorhexidine is not to be used to prevent mucositis during head and neck radiotherapy.
Targeted measures depend on the treatment. Oral cryotherapy (ice chips) is recommended for 30 minutes during bolus 5-fluorouracil and during high-dose melphalan conditioning before autologous transplant (level II). Benzydamine mouthwash is recommended for head and neck radiotherapy at moderate dose, below 50 Gy (level I), and suggested with chemoradiotherapy (level II). Intraoral photobiomodulation with low-level laser is recommended for adults having high-dose conditioning for transplant (level I), head and neck radiotherapy alone (level II) and head and neck chemoradiotherapy (level I), using one of the protocols the guideline specifies. For children, the 2021 paediatric guideline uses cryotherapy only for older cooperative children on short melphalan or 5-fluorouracil infusions and photobiomodulation across transplant and head and neck radiotherapy. Topical 0.2% morphine mouthwash is suggested for mucositis pain in head and neck chemoradiotherapy (level III), and honey for head and neck radiotherapy or chemoradiotherapy (level II).
The NCI patient guide (2024) gives the home routine: dentist at least two weeks before, check the mouth daily, extra-soft brush after meals and at bedtime, fluoride toothpaste, no alcohol mouthwash, a baking soda and salt rinse three to four times a day, gentle flossing (ask if platelets are low), keep the mouth moist, soft cool foods, and call if it hurts a lot.
Why: Infected teeth and gums can cause infections when the immune system is weak; the panel advises this although trials have not proved it prevents mucositis.
“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 2020 · III (no guideline possible; expert opinion)
Why: A routine that the patient and staff follow keeps the mouth cleaner and is linked with fewer and milder sores.
“The panel suggests that implementation of multiagent combination oral care protocols is beneficial for the prevention of OM during CT.”
MASCC and ISOO, Cancer 2020 · III (suggestion)
Why: Sores and thrush are easier to treat when caught early.
“Check your mouth and tongue every day.”
National Cancer Institute 2024 · Not graded (patient guide)
Why: Gentle, frequent cleaning removes food and germs without damaging the lining of the mouth.
“Brush your teeth, gums, and tongue after each meal and at bedtime.”
National Cancer Institute 2024 · Not graded (patient guide)
Why: Stopping brushing lets plaque build up, which causes more gum bleeding and infection, not less.
“It is advised for patients to continue toothbrushing during leukopenia, neutropenia, or thrombocytopenia.”
Why: Swabs remove debris but do not clean plaque off the teeth.
“Toothbrushes do not need to be replaced daily and are preferred over cleansing swabs.”
Why: Careful cleaning between the teeth helps, but someone new to it is more likely to injure the gums while counts are low.
“However, it should be noted that for inexperienced patients who do not routinely use interproximal cleaning devices, episodes of leukopenia and/or thrombocytopenia are not the best times to initiate their use.”
Why: Alcohol stings and dries a sore mouth; a bland rinse washes the mouth and is soothing.
“Do not use mouthwash that has alcohol. Instead, rinse your mouth three to four times a day with a solution of baking soda, salt, and warm water followed by a plain water rinse.”
National Cancer Institute 2024 · Not graded (patient guide); MASCC/ISOO: no guideline possible, expert opinion supports bland rinses
Why: Chlorhexidine did not prevent mucositis in head and neck radiotherapy.
“The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT.”
MASCC and ISOO, Cancer 2020 · III (suggestion against)
Why: A dry mouth is sore and more prone to infection and tooth decay.
“Ask your doctor or nurse about saliva substitutes if your mouth is always dry.”
National Cancer Institute 2024 · Not graded (patient guide)
Why: Rough, hot or acidic food hurts and damages the sore lining further.
“Choose foods that are moist, soft, and easy to chew or swallow.”
National Cancer Institute 2024 · Not graded (patient guide)
Why: Cold narrows the blood vessels in the mouth, so less of the drug reaches the lining while the level in the blood is highest.
“The panel recommends using 30 min of oral cryotherapy to prevent OM in patients receiving bolus 5‐FU CT during the infusion of the CT.”
MASCC and ISOO, Cancer 2020 · II (recommendation)
Why: Melphalan is given as a short infusion and clears quickly, so cooling during it protects the mouth.
“The panel recommends using oral cryotherapy to prevent OM in patients undergoing autologous HSCT when the conditioning includes high‐dose melphalan.”
MASCC and ISOO, Cancer 2020 · II (recommendation)
Why: Benzydamine is an anti-inflammatory rinse; trials showed fewer and milder sores at moderate radiotherapy doses.
“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 2020 · I (recommendation)
Why: Low-level light reduces the inflammation that leads to sores; it works only with the right wavelength, dose and schedule.
“For all PBM guidelines, it is recommended that the specific PTPs of the selected protocol will be followed for optimal therapy.”
MASCC and ISOO, Cancer 2020 · I (recommendation) for transplant and for head and neck chemoradiotherapy; II for head and neck radiotherapy alone
Why: The guideline asks for care because the light is aimed at tissue near the tumour.
“safety considerations unique to patients with oral cancer should be considered.”
Why: Severe mucositis may need prescribed pain relief, treatment for infection, feeding support or a change to treatment.
“Call your doctor, nurse, or dentist if your mouth hurts a lot.”
National Cancer Institute 2024 · Not graded (patient guide)
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 international guideline on mucositis prevention and its most recent full update; no later update was found. It grades the targeted measures by treatment: benzydamine mouthwash in head and neck radiotherapy below 50 Gy (level I) and photobiomodulation in transplant conditioning and head and neck chemoradiotherapy (level I) have the strongest evidence; ice chips during bolus 5-fluorouracil and high-dose melphalan are level II recommendations. Basic oral care is a level III suggestion in every setting, and its 2024 practice statement settles the common disputes in haematology: keep brushing through low counts, prefer a brush over swabs, and do not count chlorhexidine as mucositis prevention. The 2021 paediatric guideline agrees on cryotherapy and photobiomodulation and differs on who can use cryotherapy and on palifermin (see variants). For the daily routine at home, the NCI patient guide (2024) gives the practical detail: dental check beforehand, daily self-checks, a soft brush after meals, bland rinses instead of alcohol mouthwash, and early reporting; saline and bicarbonate rinses have too little evidence for a guideline but are supported as bland and comforting.
MASCC and ISOO, Cancer 2020 · MASCC and ISOO, Supportive Care in Cancer 2024 · European Journal of Cancer 2021 · National Cancer Institute 2024
Where it differs: Uses cryotherapy only for older cooperative children receiving short infusions of melphalan or 5-fluorouracil, because young children cannot keep ice in the mouth; uses intraoral photobiomodulation (620 to 750 nm) for autologous or allogeneic transplant and for head and neck carcinoma treated with radiotherapy; advises against routine palifermin.
Evidence: Systematic reviews of randomised trials in children and adults: severe mucositis risk ratio 0.49 with cryotherapy and 0.40 with photobiomodulation; palifermin 0.81 but with adverse effects. Read as an abstract only.
Where it differs: Gives palifermin intravenously to adults with blood cancers having autologous transplant with high-dose chemotherapy and total body irradiation.
Evidence: MASCC/ISOO recommend it at level I in that setting only; the paediatric guideline advises against routine use in children because of adverse effects.
MASCC and ISOO, Cancer 2020 · European Journal of Cancer 2021
Where it differs: Many haematology units use chlorhexidine mouthwash routinely.
Evidence: The 2024 MASCC/ISOO statement says chlorhexidine may reduce the risk of oral infections but was not found to reduce the risk of oral mucositis; the 2020 guideline suggests against it for mucositis prevention in head and neck radiotherapy (level III). It remains in use for other purposes, such as dental plaque control, in some local protocols.
MASCC and ISOO, Supportive Care in Cancer 2024 · MASCC and ISOO, Cancer 2020
Where it differs: Uses honey, topically or swallowed, to prevent mucositis.
Evidence: Suggested by MASCC/ISOO 2020 for head and neck radiotherapy or chemoradiotherapy only (level II); trials were small and used different honeys.
Where it differs: The NCI patient guide tells everyone to floss gently every day, asking the team first if platelets are low, and to use a sponge swab if brushing hurts.
Evidence: Patient guide, not graded. The 2024 MASCC/ISOO statement prefers a toothbrush over swabs and advises people not used to cleaning between the teeth not to start during low counts.
National Cancer Institute 2024 · MASCC and ISOO, Supportive Care in Cancer 2024
Holding ice chips in the mouth for half an hour around a quick injection of fluorouracil, or high-dose melphalan before a stem cell transplant, cools the mouth while the drug level peaks. A review of 14 trials found it prevents mouth ulcers in about one in four people given fluorouracil, and a guideline recommends it. How often it is offered is not measured.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Multiagent combination oral care protocols during chemotherapy, head and neck radiotherapy and transplant | III (suggestion) | MASCC and ISOO, Cancer 2020 |
| No chlorhexidine for mucositis prevention during head and neck radiotherapy “The panel suggests that CHX not be used in the prevention of OM in patients undergoing H&N RT.” | III (suggestion against) | MASCC and ISOO, Cancer 2020 |
| Saline or bicarbonate rinses “No guideline was possible regarding the use of saline or sodium bicarbonate rinses in the prevention or treatment of OM in patients undergoing cancer therapy because of limited data.” | No guideline possible, LoE III (expert opinion supports them as bland rinses) | MASCC and ISOO, Cancer 2020 |
| Topical 0.2% morphine mouthwash for mucositis pain in head and neck chemoradiotherapy “Topical morphine 0.2% mouthwash is suggested for the treatment of OM‐associated pain in patients with H&N cancer who receive RT‐CT.” | Suggestion, LoE III | MASCC and ISOO, Cancer 2020 |
| Dental visit at least two weeks before chemotherapy “Visit a dentist at least two weeks before starting chemotherapy.” | Not graded (patient guide) | National Cancer Institute 2024 |
| Benzydamine mouthwash, head and neck radiotherapy below 50 Gy | I (recommendation) | MASCC and ISOO, Cancer 2020 |
| Benzydamine mouthwash, head and neck chemoradiotherapy “The panel suggests the use of benzydamine mouthwash for the prevention of OM in patients with H&N cancer who receive RT‐CT.” | II (suggestion) | MASCC and ISOO, Cancer 2020 |
| Intraoral photobiomodulation, adults having transplant with high-dose conditioning “The panel recommends the use of intraoral PBM therapy using low‐level laser therapy for the prevention of OM in adult patients receiving HSCT conditioned with high‐dose CT, with or without TBI, using one of the selected protocols listed in Table 2 .” | I (recommendation) | MASCC and ISOO, Cancer 2020 |
| Intraoral photobiomodulation, head and neck radiotherapy without chemotherapy | II (recommendation) | MASCC and ISOO, Cancer 2020 |
| Intraoral photobiomodulation, head and neck chemoradiotherapy | I (recommendation) | MASCC and ISOO, Cancer 2020 |
| 30 minutes of oral cryotherapy during bolus 5-fluorouracil | II (recommendation) | MASCC and ISOO, Cancer 2020 |
| Oral cryotherapy with high-dose melphalan before autologous transplant “The panel recommends using oral cryotherapy to prevent OM in patients undergoing autologous HSCT when the conditioning includes high‐dose melphalan.” | II (recommendation) | MASCC and ISOO, Cancer 2020 |
| Intravenous palifermin, autologous transplant with high-dose chemotherapy and total body irradiation “The use of KGF‐1 intravenously is recommended for the prevention of OM in patients with hematologic cancer undergoing autologous HSCT with a conditioning regimen that includes high‐dose CT and TBI.” | I (recommendation) | MASCC and ISOO, Cancer 2020 |
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