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Supportive Care Editorial Mucositis—Supportive Care During Radiotherapy or Chemoradiotherapy of Head and Neck Cancer Eli Sapir, MD 1 and Avraham Eisbruch, MD 2 1. Post-graduate Fellow in Radiation Oncology; 2. Professor of Radiation Oncology, Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, US Abstract Painful ulcers and sores and related dysphagia, thick saliva, taste impairment, and weight loss significantly affect the quality of life of head and neck cancer patients undergoing radiation treatment with or without concomitant chemotherapy. The available data for mucositis prophylaxis and treatment could be heterogeneous for clinical interpretation. In this editorial, we will describe what is already known and to outline the most important aspects of mucositis care. Keywords Chemoradiotherapy, head and neck cancer, mucositis, radiotherapy, supportive care Disclosure: Eli Sapir, MD, and Avraham Eisbruch, MD, have no conflicts of interest to declare. No funding was received in the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: February 4, 2015 Accepted: February 4, 2015 Citation: Oncology & Hematology Review, 2015;11(1):50–2 Correspondence: Avraham Eisbruch, MD, Department of Radiation Oncology, University of Michigan Hospital, Ann Arbor, MI 48109, US. E: Eisbruch@umich.edu The majority of patients undergoing radiation therapy for head and neck (HN) cancer will develop oral mucositis, which is a clinical syndrome characterized by erythema, ulcerations, and odynophagia (see Table 1). It is almost universal and more severe among patients with oral cavity, oropharynx, and nasopharynx primaries. 1–3 Although therapeutic ratio and outcomes are improved by concominant chemotherapy 4,5 or altered fractionation, 6 both are related to dose-limiting mucositis and increase the risk for consequential dysphagia. Finally, mucositis is associated with unplanned breaks in radiation therapy, hospital admissions for pain management or insertion of enteral feeding tube, 3 and is associated with increased costs. 7 Reducing mucositis could be achieved by different means. This editorial will describe the available data and future perspectives in mucositis management. Mouth Hygiene and Preventive Dental Care Basic oral care protocols including daily topical fluoride, flossing, and frequent mouth rinses can be helpful for preventing and alleviating of mucositis. 8,9 The evidence to support this approach is not strong, yet maintaining oral hygiene is supported by the Multinational Association of Supportive Care in Cancer and International Society of Oral Oncology (MASCC/ISOO) Clinical Practice Guidelines. 10 Although different mouthwash preparations are available (normal saline, sodium bicarbonate, calcium phosphate), none of them had been consistently recommended by the gathered evidence-based data, but the panel suggested that they might be considered for oral care. The only rinse that the MASCC/ISOO recommended against was chlorhexidine mouthwash. 10 50 Pretreatment dental care reduces risk for osteoradionecrosis. 11 In addition, designing dental protective stents to prevent electron back-scatter off metal caps/bridges into the neighboring soft tissue could be beneficial for mucositis risk reduction. 12–14 Reducing Mucositis by Antiviral/Antibacterial/ Mucosal Coating Agents Different preparations including acyclovir, nystatin, fluconazole, sucralfate, and aluminum salt of sulfated sucrose were evaluated by multiple (mostly conflicting) studies. None of the above can be recommended to reduce chemoraditherapy mucositis. 15 Newer mucosal protectants are available for HN cancer patients. Keratinocyte growth factor (palifermin) stimulates differentiation of mucosal cells. Two randomized studies have shown reduction of likelihood and median duration of severe mucositis, but narcotic use, patient-reported pain, and chemoradiotherapy compliance were not different from placebo. 16,17 Marketed mucoadhesive hydrogel has been reported to significantly reduce patient-reported oral soreness and mucositis World Health Organization (WHO) score on the last day of radiation therapy compared with placebo, 18 but it was not evaluated versus other preparations. Pain Management Pain is the main debilitating symptom of mucositis. Topical anesthetics, narcotics, and antidepressants could control it. While the former could not be advocated based on the available data, 15 both topical morphine 19,20 and Touch ME d ica l ME d ia