Basic oral care is recommended for cancer patients to prevent OM caused by anti-tumor therapies [7, 8, 12]. In this study, we retrospectively review three methods of mouthwashes, nystatin, aloe vera, or plain water, in OM prevention in patients treated with HSCT. Our result suggested that plain water mouthwash could efficiently prevent OM occurrence in patients secondary to HSCT, and reduce the OM severity. Rinse mouth with plain water is easy, costless and well-tolerated, all of which may promote patient’s adherence to routine mouse care. Plain water rinse also reduces bacterial load in oral cavity and provide comfort. The mechanism of plain water rinse in OM prevention is still not fully demonstrated. One previous study suggested that plain water mouth rinse might promote oral cleanness, therefore reduce oral infection [13]. Roopashri’s study showed that distilled water and other mouthwashes, such as benzydamine hydrochloride, chlorhexidine, and povidone iodine, had the same preventive effect on oral mucositis in cancer patients [14].
Compared with water, nystatin mouthwash could hardly prevent OM in our study. Nystatin belongs to polyene anti-fungal agent[15]. Oral candidiasis is the most common opportunistic fungal infection of oral mucosa, and nystatin is considered as the first-line agent to treat oral candidiasis[16]. In Cidon’ study, nystatin mouthwash showed effective in oral candidiasis prevention [17]. However, another study also suggested that nystatin mouthwash, either alone or in combination with chlorhexidine, could not prevent OM in cancer patients [18]. Furthermore, an adverse effect of nystatin mouthwash was taste of the agent. Epstein et al.[15] found that the taste of nystatin during mouthwash might cause patient nausea and vomiting, thus decreasing the therapeutic compliance.
Aloe vera is a perennial plant which has ingredient of hydroxyanthraquinone derivatives that shows active in sterilizing, inflammation relieving, toxins breaking down, pain alleviating, wound healing and immune promoting[19, 20]. According to our result, aloe vera mouthwash showed effective in OM prevention. There were no severe OM (grade III or above) occurred in aloe vera group. Most patients with OM in this group healed within a week. Literature search returned controversial findings of aloe vera in OM prevention. A previous study showed that aloe vera had healing activity to different mucocutaneous problems[21]. While a meta-analysis found aloe vera mouthwash showed no superior effect on OM prevention, compared with other natural products, such as honey, chlorhexidine and curcumin. Further studies might be required to address the function of aloe vera in OM prevention.
The latest ESMO clinical practice guideline does not recommend any specific types of mouthwash in OM prevention, probably because of inadequate and/or conflicting clinical evidences[7]. The results of this study suggested that under the current medical conditions, hematological cancer patients who underwent HSCT could gain a benefit from plain water mouthwash in OM prevention.