Oral mucositis in cancer patients: the effect of oral supplementation

shutterstock_74662099 zinc

Oral mucositis is a common side effect in patients undergoing cancer treatment being seen is around 40% of those undergoing chemotherapy and 100% of patient have radiotherapy for head and neck cancer. Oral mucositis has a negative effect on treatment outcomes and survival and management is based on reduction of symptoms and prevention of complications.

The aim of this review was to evaluate the evidence of the effects of oral supplementation on the prevention and/or treatment of oral mucositis in patients with cancer undergoing chemotherapy and/or radiotherapy.


Searches were conducted in the CINHAL Cochrane Central Register of Controlled Trials (CENTRAL), LILACS, PubMed, Scopus, Web of Science, Google Scholar, Open Grey, and ProQuest Dissertation & Theses databases. There was no restriction on date of publication, but non-roman languages were excluded.

Randomised controlled trials (RCTs) evaluating oral supplementation against an alternative treatment or no treatment were considered. Two reviewers independently screened and selected studies extracted data and assesses risk of bias using the Cochrane risk of bias tool. Disagreements were resolved by discussion with a third reviewer. The primary outcome was the occurrence of oral mucositis or reduction in the severity. Secondary outcomes included reduction in pain intensity, presence of erythema, ulceration, dysphasia, and healing.  Meta-analysis was carried out when appropriate and the overall certainty of evidence was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument


  • 12 studies were included
  • 8 studies involved patients with head and neck cancer, 2 studies patients with oesophageal cancer, 1 study patients with leukaemia and 1 study patients with multiple types of cancer.
  • 2 studies were considered to be at low risk of bias, 7 at unclear risk and 3 at high risk.
  • 3 different oral supplementations were reported with meta-analysis being conducted for Zinc and glutamine.
  • Meta-analysis showed that:-
    • the risk of oral mucositis in the zinc group was slightly lower than in the control, relative risk (RR) = 0.71 (95%CI; 0.53-0.96) [6 studies].
    • the glutamine group presented the same risk as the control, RR = 0.91 (95%CI; 0.78-1.05) [3 studies].


The authors concluded: –

Zinc is a promising strategy in the management of oral mucositis since it delayed the occurrence and reduced its severity. Glutamine and Elental, on the other hand, had no strong evidence in the prevention and/or treatment of oral mucositis in patients with cancer.


A broad range of interventions for the prevention and treatment of oral mucositis have been proposed and we have previously looked at two Cochrane reviews (Dental Elf – 4th Dec 2017, Dental Elf – 11th Jan 2016) that have assessed cryotherapy and cytokines and growth factors. These two reviews are part of a series being developed by Cochrane in liaison with the Mucositis Study Group (MSG) of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The reviews will cover the following areas.

  • basic oral care/good clinical practice;
  • growth factors and cytokines;
  • anti-inflammatory agents;
  • antimicrobials, mucosal coating agents, anaesthetics, and analgesics;
  • laser and other light therapy;
  • cryotherapy;
  • natural and miscellaneous agents;
  • amifostine.

This new review of oral supplementation has searched a broad range of databases, but the exclusion of non-roman languages means that some relevant studies may have been omitted. While the review suggests a benefit from zinc supplementation the authors highlight the small sample sizes of the included studies and the variation in the assessment of oral mucositis and the dosages and period of administration.  There is a clear need for well designed, conducted and reported studies of with larger sample sizes to help clarify the best interventions for the management of this distressing condition.


Primary Paper

de Menêses AG, Normando AGC, Porto de Toledo I, Reis PED, Guerra ENS. Effects of oral supplementation in the management of oral mucositis in cancer patients: A meta-analysis of randomized clinical trials. J Oral Pathol Med. 2019 Jun 7. doi: 10.1111/jop.12901. [Epub ahead of print] Review. PubMed PMID: 31172573.

 Review protocol on PROSPERO

Other references

Dental Elf – 4th Dec 2017

Mucositis in adult cancer patients reduced with keratinocyte growth factor

Dental Elf – 11th Jan 2016

Oral cryotherapy reduces oral mucositis in patients receiving 5FU-based treatment for solid cancers


Dental Elf – Oral mucositis blogs



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