Chemotherapy-induced Stomatitis/Mucositis

Chemotherapy-induced stomatitis/mucositis is a common side effect of myeloma patients undergoing an autologous stem cell transplant. According to research,

“Approximately 75% to 80% of myeloma patients undergoing an autologous stem cell transplant (ASCT) develop stomatitis, with some studies reporting even higher rates. Of these, a significant portion, around 21%, experience severe (Grade 3 or 4) stomatitis. The incidence and severity can be influenced by factors like the dose of melphalan, a patient’s renal function before the transplant, and pre-existing oral conditions.”

While the usual therapy is for the MM patient to chew ice (cryotherapy), leading up to melphalan infusion, consider undergoing more than a single therapy in an effort to hedge your bets. After all, mucositis, aka stomatitis, is advanced (grade 3 or 4) in more than 20% of patients.

Say Goodbye to Mouth Sores: How to Protect Your Mouth During Stem Cell Transplant| #myeloma

What are some of the non-conventional therapies to prevent mucositis in myeloma patients undergoing an autologous stem cell transplant

🔹 1. Cryotherapy (Oral Cooling)

Mechanism: Vasoconstriction reduces melphalan delivery to oral mucosa.
Evidence:

Strongest non-drug evidence for ASCT mucositis prevention.
RCTs and meta-analyses show ~50–70% reduction in grade ≥2 mucositis with 30–60 min of ice-chip cooling during and immediately after melphalan infusion.
Protocol:
Hold ice chips or frozen water for 30 min before, during, and 30 min after melphalan.
Note: Very safe and inexpensive; standard in many centers.

🔹 2. Honey and Manuka Honey Rinses

Mechanism: Antibacterial, anti-inflammatory, and tissue-healing properties.
Evidence:

Several small RCTs (mostly hematologic malignancies) show reduced ulceration severity and shorter healing times.
Manuka honey (with high methylglyoxal content) may outperform standard oral rinses.
Use:
Swish 5–10 mL honey for 1–2 min, 3–4 ×/day during mucotoxic chemotherapy.
Caution: Avoid if neutropenic and local center discourages unsterilized products (rare).

🔹 3. Glutamine (Oral or Swish-and-Spit)

Mechanism: Fuel for rapidly dividing mucosal cells; supports repair and barrier integrity.
Evidence:

Meta-analyses suggest oral glutamine (10–30 g/day) may reduce duration/severity of mucositis after high-dose chemotherapy and ASCT.
However, results are mixed; benefits more consistent with “swish and swallow” protocols.
Typical regimen: 10 g in water, 2–3×/day starting before transplant.

🔹 4. Probiotics

Mechanism: Modulate gut–oral microbiome and immune responses.
Evidence:

Limited direct oral data, but some RCTs (esp. Lactobacillus rhamnosus GG) show reduced gastrointestinal mucositis and infections in transplant recipients.
May help stabilize mucosal immunity, though safety during profound neutropenia must be monitored carefully.
Note: Only use medically approved, sterile strains under supervision.

🔹 5. Low-Level Laser Therapy (Photobiomodulation)

Mechanism: Promotes healing, reduces inflammation, improves microcirculation.
Evidence:

Strong supportive evidence (MASCC/ISOO guidelines recommend it for mucositis prevention).
Wavelengths: 630–685 nm or 780–830 nm, 2–3 J/cm².
Limitation: Requires trained dental/oncology staff and specific equipment.

🔹 6. Herbal and Nutraceutical Options

Agent	Mechanism	Key Data
Curcumin mouthwash	Anti-inflammatory, NF-κB inhibition	Small studies show decreased mucositis severity
Aloe vera gel/rinse	Soothing, mucosal healing	Mixed results; safe, mild benefit
Chamomile mouthwash	Anti-inflammatory, antimicrobial	Some RCTs positive in head & neck cancer mucositis
Vitamin E topical oil	Antioxidant	Small trials show faster healing

🔹 7. Omega-3 Fatty Acids

Mechanism: Anti-inflammatory and membrane-protective.
Evidence:

Pilot studies show less mucosal damage and shorter recovery when omega-3s (EPA/DHA) are started before conditioning.

🔹 8. Zinc or Selenium Supplementation

Mechanism: Support mucosal repair and antioxidant defense.
Evidence:

Some evidence for zinc sulfate (220 mg TID) reducing mucositis in head-neck radiation; limited ASCT data, but plausible biological rationale.

🔹 9. Acupuncture and Auricular Therapy

Mechanism: Anti-inflammatory and pain-modulating effects.
Evidence:

Early-phase trials show possible reductions in oral pain and opioid use during ASCT mucositis, though larger data are limited.

🔹 10. Maintaining Oral Microbiome and Hygiene

Non-conventional in its intensity but essential:

Daily salt-baking soda rinses (4–6×/day)
Avoid alcohol-based mouthwashes
Gentle brushing with soft brush + chlorhexidine only if directed

When I had my ASCT, I developed a tiny bit of mucositis. I got off easy. But I think it makes more sense to prepare for the worst and hope for the best.

Scroll down the page and post your mucositis/stomatitis experience.

Thanks,

David Emerson

MM Survivor
MM Cancer Coach
Director PeopleBeatingCancer

The effect of Malva sylvestris mouthwash on chemotherapy-induced stomatitis and associated pain in patients with cancer

Abstract

Background and objectives

Stomatitis is among the most debilitating complications of cancer treatment, particularly chemotherapy. The use of medicinal plants has been suggested as a potential therapeutic approach to mitigate this condition. This study aimed to evaluate the effect of Malva sylvestris(mallow) mouthwash on chemotherapy-induced stomatitis in cancer patients.

Materials and methods

This triple-blind randomized clinical trial was conducted in 2024 on 70 cancer patients with chemotherapy-induced stomatitis who attended medical centers in an urban area of Iran. Participants were randomly allocated to two groups using the minimization method. The intervention group received 15 ml of Malva sylvestris mouthwash three times daily for 14 days, while the control group received standard chlorhexidine mouthwash. The severity of stomatitis and associated pain were assessed at baseline and on days 3, 7, and 14 using the World Health Organization (WHO) Mucositis Scale and the Visual Analog Scale (VAS) for pain, respectively. Data were analyzed using SPSS version 22.

Results

Before the intervention, no statistically significant differences were observed in mean stomatitis or pain scores between the two groups. By day 7, the intervention group demonstrated significantly lower mean scores for both stomatitis and pain compared with the control group (P < 0.001). Moreover, the reduction in stomatitis severity over time was greater in the intervention group than in the control group (P < 0.05). On day 14, although the intervention group maintained lower mean stomatitis scores, the difference between the two groups was not statistically significant (P = 0.08).

Conclusion

The findings suggest that Malva sylvestris mouthwash has a beneficial effect in reducing the severity of stomatitis and associated pain in patients undergoing chemotherapy. Therefore, its use may be recommended as a supportive intervention for patients, caregivers, and healthcare professionals involved in cancer care.

Chemotherapy-induced stomatitis/mucositis Chemotherapy-induced stomatitis/mucositis Chemotherapy-induced stomatitis/mucositis

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