口腔黏膜炎

对于正在接受骨髓毒性治疗、需要造血支持的血液系统恶性肿瘤患者，重组人角质细胞生长因子- 1（帕利夫明）可减少严重口腔黏膜炎的发生率和持续时间。[11]Spielberger R, Stiff P, Bensinger W, et al. Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med. 2004;351:2590-2598.http://www.nejm.org/doi/full/10.1056/NEJMoa040125#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/15602019?tool=bestpractice.com

在接受化疗前3天和化疗后3天连续给药。[25]Saunders DP, Epstein JB, Elad S, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3191-3207.http://www.ncbi.nlm.nih.gov/pubmed/23832272?tool=bestpractice.com[29]Spielberger R, Emmanouilides C, Stiff P, et al. Use of recombinant human keratinocyte growth factor (rHuKGF) can reduce severe oral mucositis in patients (pts) with hematologic malignancies undergoing autologous peripheral blood progenitor cell transplantation (auto-PBPCT) after radiation-based conditioning - results of a phase 3 trial. Proc Am Soc Clin Oncol. 2003;22:abstr 3642.

对于接受自体干细胞移植，进行高剂量化疗和全身放疗的血液系统恶性肿瘤患者，建议使用帕利夫明。[27]Raber-Durlacher JE, von Bültzingslöwen I, Logan RM, et al. Systematic review of cytokines and growth factors for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:343-355.http://www.ncbi.nlm.nih.gov/pubmed/2298709?tool=bestpractice.com接受同种异体移植的患者可以考虑使用这种药物。[16]Hensley ML, Hagerty KL, Kewalramani T, et al. American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol. 2009;27:127-145.http://jco.ascopubs.org/cgi/content/full/27/1/127http://www.ncbi.nlm.nih.gov/pubmed/19018081?tool=bestpractice.com对于在未使用全身放疗、非干细胞移植的情况下或者实体瘤治疗时的用药，目前尚无充足的数据。[16]Hensley ML, Hagerty KL, Kewalramani T, et al. American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol. 2009;27:127-145.http://jco.ascopubs.org/cgi/content/full/27/1/127http://www.ncbi.nlm.nih.gov/pubmed/19018081?tool=bestpractice.com

对于接受高剂量美法仑治疗作为血液系统恶性肿瘤清髓治疗方案一部分的患者，以及静脉推注氟尿嘧啶的患者，推荐在化疗药物输注前、输注期间及输注刚完成后口含冰块或冰水。[10]Peterson DE, Ohrn K, Bowen J, et al. Systematic review of oral cryotherapy for management of oral mucositis caused by cancer therapy. Support Care Cancer. 2013;21:327-332.http://www.ncbi.nlm.nih.gov/pubmed/22993025?tool=bestpractice.com[28]Riley P, Glenny AM, Worthington HV, et al. Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy. Cochrane Database Syst Rev. 2015;(12):CD011552.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011552.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26695736?tool=bestpractice.com [ ]Can oral cryotherapy help to prevent chemotherapy-induced oral mucositis?http://cochraneclinicalanswers.com/doi/10.1002/cca.1255/full显示答案

对于在造血干细胞移植前接受高剂量化疗或放化疗的患者和接受头颈部放疗而未同时接受化疗的患者来说，弱激光治疗可减轻口腔黏膜炎的严重程度。[17]Migliorati C, Hewson I, Lalla RV, et al. Systematic review of laser and other light therapy for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:333-341.http://www.ncbi.nlm.nih.gov/pubmed/23001179?tool=bestpractice.com其作用机制尚不明确，但可能是通过促进愈合和抗炎来发挥作用。[18]Lopes NN, Plapler H, Chavantes MC, et al. Cyclooxygenase-2 and vascular endothelial growth factor expression in 5-fluorouracil-induced oral mucositis in hamsters: evaluation of two low-intensity laser protocols. Support Care Cancer. 2009;17:1409-1415.http://www.ncbi.nlm.nih.gov/pubmed/19234862?tool=bestpractice.com[19]Lopes NN, Plapler H, Lalla RV, et al. Effects of low-level laser therapy on collagen expression and neutrophil infiltrate in 5-fluorouracil-induced oral mucositis in hamsters. Lasers Surg Med. 2010;42:546-552.http://www.ncbi.nlm.nih.gov/pubmed/20662031?tool=bestpractice.com很多肿瘤中心不具备弱激光治疗的条件。

在接受这些药物治疗的患者中，建议在化疗药物输注前、输注期间和输注刚完成后口含冰块和/或冰水。[10]Peterson DE, Ohrn K, Bowen J, et al. Systematic review of oral cryotherapy for management of oral mucositis caused by cancer therapy. Support Care Cancer. 2013;21:327-332.http://www.ncbi.nlm.nih.gov/pubmed/22993025?tool=bestpractice.com[28]Riley P, Glenny AM, Worthington HV, et al. Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral cryotherapy. Cochrane Database Syst Rev. 2015;(12):CD011552.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011552.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/26695736?tool=bestpractice.com [ ]Can oral cryotherapy help to prevent chemotherapy-induced oral mucositis?http://cochraneclinicalanswers.com/doi/10.1002/cca.1255/full显示答案

对于有金属牙修复体的患者，可用牙齿保护套、棉卷、或石蜡等使黏膜和金属隔离，从而防止射线接触金属后发生反向散射，引起相邻部位的黏膜炎。[16]Hensley ML, Hagerty KL, Kewalramani T, et al. American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. J Clin Oncol. 2009;27:127-145.http://jco.ascopubs.org/cgi/content/full/27/1/127http://www.ncbi.nlm.nih.gov/pubmed/19018081?tool=bestpractice.com

所有患者应进行口腔护理。[15]McGuire DB, Fulton JS, Park J, et al. Systematic review of basic oral care for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3165-3177.http://www.ncbi.nlm.nih.gov/pubmed/24018908?tool=bestpractice.com包括保持良好的口腔卫生，如使用软毛牙刷刷牙、使用牙线，以及避免口腔组织的损伤。对牙体表面进行专业的灌洗和清创并对口腔黏膜进行无创性的清洁可能是合适的。

每日多次使用简单的漱口水（半茶匙小苏打溶于一杯温水）可改善口腔湿润度。也可考虑使用其他漱口液，例如羧乙基纤维素溶液。

针对经选择患者组全部患者的治疗推荐

简单的口腔镇痛剂，例如对乙酰氨基酚和布洛芬，可用于减轻疼痛。

局部利多卡因凝胶或含利多卡因的含漱液可有效止痛。

其他能够减轻疼痛的局部药物包括吗啡漱口水或多虑平漱口水。这些药物需要药剂师来配制。[25]Saunders DP, Epstein JB, Elad S, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3191-3207.http://www.ncbi.nlm.nih.gov/pubmed/23832272?tool=bestpractice.com[26]Leenstra JL, Miller RC, Qin R, et al. Doxepin rinse versus placebo in the treatment of acute oral mucositis pain in patients receiving head and neck radiotherapy with or without chemotherapy: a phase III, randomized, double-blind trial (NCCTG-N09C6 [Alliance]). J Clin Oncol. 2014;32:1571-1577.http://www.ncbi.nlm.nih.gov/pubmed/24733799?tool=bestpractice.com

对于严重溃疡性黏膜炎，可能需要阿片类镇痛剂用以充分地控制疼痛。这类药物包括曲马多、羟考酮或吗啡。对于接受传统剂量或高剂量化疗的患者，芬太尼经皮贴剂可以用于治疗口腔黏膜炎。对于正在进行造血干细胞移植的患者，使用吗啡进行患者自控镇痛可减少阿片类药物的每小时用量、缩短疼痛持续时间。[25]Saunders DP, Epstein JB, Elad S, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3191-3207.http://www.ncbi.nlm.nih.gov/pubmed/23832272?tool=bestpractice.com