Dry mouth, Stomatitis and Mucositis

Topical Melatonin: Radiation-Induced Oral Mucositis

For 21 days post-radiation to the tongue, male Wistar rats were treated with 45 mg/day melatonin gel or vehicle, locally applied into their mouths. The application of melatonin gel restored physiological melatonin levels in the tongue and prevented mucosal disruption and ulcer formation. Melatonin gel protected the mitochondria from radiation damage and blunted the inflammasome signaling activation in the tongue, suggesting a potential preventive therapy for mucositis in patients with cancer.

J Pineal Res. 2015 Jan;58(1):34-49.
Melatonin blunts the mitochondrial/NLRP3 connection and protects against radiation-induced oral mucositis.
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L-Glutamine Decreases the Severity of Chemotherapy-Induced Mucositis and Oral Pain

Glutamine is a nutrient for rapidly dividing cells and the major energy source for intestinal epithelium. The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. A double-blind, randomized, placebo-controlled showed that glutamine significantly decreased the maximal mucositis grade and pain score at weeks 4, 5 and 6.

Nutrition. 2015 Jan;31(1):200-4.
Effects of oral glutamine during abdominal radiotherapy on chronic radiation enteritis: a randomized controlled trial.
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Anderson et al. of the Mayo Clinic reported that administration of glutamine suspension after chemotherapy (2 g/m2/dose for adults, swish and swallow twice daily on days of chemotherapy and for at least 14 additional days) has resulted in significant amelioration of stomatitis (duration of mouth pain was 4.5 days less when compared to placebo). The severity of oral pain was also reduced significantly when glutamine was provided with chemotherapy - the amount of days mucositis restricted oral intake to soft foods was 4 days less with glutamine. No toxicity of glutamine was observed. Oral glutamine appears to be a simple and useful measure to increase the comfort of many patients at high risk of developing mouth sores as a consequence of chemotherapy.

Cancer 1998 Oct 1;83(7):1433-9
Oral glutamine reduces the duration and severity of stomatitis after cytotoxic cancer chemotherapy.
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Oral mucositis (mouth sores and/or difficulty swallowing) continues to be a common and debilitating side effect of the conditioning regimens that use high-dose chemotherapy with or without radiation for pediatric bone marrow transplantation. Severe mucositis is a common cause of morbidity in hematopoietic stem cell transplant (HSCT) recipients. Physicians may want to consider oral glutamine supplementation as a routine part of supportive care of Stem Cell Transplantation (SCT) patients.

Oncol Rep. 2015 Jan;33(1):33-9.
L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial.
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Topical Oral Solutions for the Treatment of Chemo-Induced Oral Mucositis

“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. As compounding pharmacists, we recognize the need for practitioners to have the ability to prescribe customized preparations to meet specific patient needs. We can compound various medications into a stable, pleasantly-flavored, alcohol-free suspension.

J Oncol Pharm Pract. 2005 Dec;11(4):139-43.
Survey of topical oral solutions for the treatment of chemo-induced oral mucositis.
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Misoprostol: Mucosal Protectant and Anti-Secretory

Misoprostol is a synthetic prostaglandin E1 analogue, with mucosal cytoprotectant and antisecretory properties. A mouthrinse containing misoprostol and lidocaine in a non-irritating neutral vehicle can be used to provide immediate pain relief and aid in the healing of the oral cavity.

A mucoadhesive powder containing misoprostol can be used to aid in the healing of mucosal ulcers and irritations. It is applied by using a powder "puffer" or by direct application of the powder to the affected area. The carriers will hydrate and adhere to the mucosal surface, keeping the misoprostol in prolonged contact with the area.

Int'l J Pharm Compounding. May/June 2000; 4(3):211
Misoprostol 0.001% and Lidocaine 0.5% Oral Rinse
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Int'l J Pharm Compounding. May/June 2000; 4(3):212
Misoprostol 0.0027% Mucoadhesive Powder
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Int'l J Pharm Compounding. Jan/Feb 1999; 3(1):48
Misoprostol 0.0024% and Lidocaine 1% in Glycerin Mouth Paint
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Burning Mouth Syndrome (BMS) Relieved with Alpha Lipoic Acid (ALA)

A double blind, controlled study compared alpha lipoic acid with placebo for two months on 60 patients with constant BMS, in whom there was no laboratory evidence of deficiencies in iron, vitamins or thyroid function and no hyperglycemia. Following treatment with alpha lipoic acid 600 mg orally daily, there was a significant symptomatic improvement compared with placebo. This improvement was maintained in over 70% of patients at the 1 year follow-up.

J Oral Pathol Med. 2002 May;31(5):267-9.
Burning mouth syndrome (BMS): double blind controlled study of alpha-lipoic acid (thioctic acid) therapy.
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Saliva Substitute for Dry Mouth/Throat

Saliva replacement is an important adjunct to relieving the symptoms of xerostomia in patients with Sjogren's Syndrome. Saliva substitutes which contain thickening agents like carboxymethylcellulose are used because water alone can not adequately moisten and lubricate the oral mucosa and teeth. Dry mouth or throat secondary to a number of conditions can be relieved with a customized saliva substitute that can be administered throughout the day and night and can be flavoured to please each patient. Keeping the mucosal membranes moist can improve comfort for the patient and minimise irritation and the risk of infection.

Int'l J Pharm Compounding. May/June 2000; 4(3):215
Saliva Substitute for Dry Mouth/Throat
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Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):340
Saliva Substitute
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Pilocarpine Troches for Xerostomia

Pilocarpine is indicated for the treatment of xerostomia secondary to radiation therapy of the head and neck. Pilocarpine is a cholinergic agent that stimulates residual-functioning exocrine glands. In a study by Vivino et al., pilocarpine at oral doses of 2.5mg and 5mg four times daily significantly increased saliva production and alleviated symptoms of dry mouth when compared to placebo. The higher dose produced the most improvement but also the highest incidence of adverse effects, such as sweating, diarrhoea, and urinary frequency.

Arch Intern Med. 1999; 159:174-181
Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren syndrome: a randomised, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group.
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Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):381
Pilocarpine HCl 2-mg Troches
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Treatment for Dry Mouth, Stomatitis, and Mucositis

Loss of saliva (xerostomia) is one of the most common complaints among patients who have received radiation therapy of the head and neck. Xerostomia contributes to radiation-induced periodontal infection, dental caries, osteoradionecrosis, and poor digestion of carbohydrates. Ask us about sialogogues (saliva stimulants) in customized dosage forms.

Aust Dent J 2002 Sep;47(3):249-53
An investigation into the use of pilocarpine as a sialagogue in patients with radiation induced xerostomia.
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