ARTICLE IN PRESS

European Journal of Oncology Nursing (2004) 8, 341349

www.elsevier.com/locate/ejon

Childrens acceptance and tolerance of

chlorhexidine and benzydamine oral rinses in the
treatment of chemotherapy-induced
oropharyngeal mucositis$
K.K.F. Cheng*

Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, 804A,
Esther Lee Building, Shatin, New Territories, Hong Kong

KEYWORDS Summary Oral care is of great importance in the prevention of chemotherapy-

Chlorhexidine; induced oropharyngeal mucositis. Although considerable attention has been given in
Benzydamine; improving oral care practices, patients acceptance and tolerance of oral rinses is a
Acceptability; continuing problem in oral care. A randomized crossover design was used to
determine the relative acceptability and tolerability of chlorhexidine and
Tolerability;
benzydamine oral rinse agents in children receiving chemotherapy. At the end of
Children;
the study, each subject was asked to compare these two agents in relation to stinging
Mucositis
and taste, as well as his/her perception in reducing mucositis. Thirty-four children
aged 617 years completed two courses of chemotherapy during which they
alternately practiced oral care using chlorhexidine then benzydamine or benzyda-
mine then chlorhexidine. All of the children tolerated the agents well and continued
with rinsing throughout the study. Only a few children had to resort to diluting the
agents with normal saline or water. Fifty-nine percent of children reported that the
stinging associated with benzydamine was more accepted than chlorhexidine. The
taste of both these agents was accepted by 50% of children. Approximately 60% of
children reported that chlorhexidine was more helpful than benzydamine in reducing
mucositis. About 47% and 50% of them preferred chlorhexidine and benzydamine in
their subsequent chemotherapy, respectively. In conclusion, chlorhexidine and
benzydamine are acceptable and well-tolerated by children over the age 6 years old.
& 2004 Elsevier Ltd. All rights reserved.

Zusammenfassung Akzeptanz und Vertra. glichkeit von Chlorhexidin- und Benzyda-

.
min-Mundspulungen bei Kindern zur Behandlung der Chemotherapie-induzierten
.
oropharyngealen Mukositis (Schleimhautentzundung).
Bei der Verhinderung der oropharyngealen Mukositis wa. hrend der Chemotherapie
spielt die Mundhygiene eine bedeutende Rolle. Obwohl der Verbesserung der
Mundpflegetechnik viel Aufmerksamkeit gewidmet wurde, bleibt bei der Mundpflege
die Akzeptanz und Vertra. glichkeit von Mundspulungen
. often. In einer randomisier-
ten, gekreuzten Studie wurde die Akzeptanz und Vertra. glichkeit von Chlorhexidin
und Benzydamin bei Kindern unter Chemotherapie gepruft.. Bei Studienende sollte

$
Based on a presentation given at the 15th International Symposium of Supportive Care in Cancer, Berlin, Germany, 1822 June,
2003.
*fax: 852-26035935.
E-mail address: kariskwong@cuhk.edu.hk (K.K.F. Cheng).

1462-3889/$ - see front matter & 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejon.2004.04.002
 ARTICLE IN PRESS
342 K.K.F. Cheng

jeder Proband die beiden Stoffe in Bezug auf Brennen und Geschmack vergleichen,
.
sowie seinen Eindruck bezuglich Wirkung des Pra. parats bei der Verminderung von
Mukositis schildern. Wa. hrend jeweils zwei Chemotherapiebehandlungen benutzten
34 Kinder zwischen 6 und 17 Jahren bei der Mundhygiene abwechselnd zuna. chst
Chlorhexidin und dann Benzydamin oder zuna. chst Benzydamin, dann Chlorhexidin.
.
Alle Kinder vertrugen die Wirkstoffe gut und fuhrten .
die Spulungen wa. hrend der
ganzen Studiendauer durch. Nur wenige Kinder mussten die Spull . o. sungen mit
.
Kochsalzlosung .
oder Wasser verdunnen 59% der Kinder gaben an, dass sie das durch
Benzydamin verursachte Brennen besser vertrugen als das Brennen durch Chlorhex-
idin. Den Geschmack beider Stoffe akzeptierten 50% der Kinder. Etwa 60% der Kinder
berichteten, dass sie Chlorhexidin bei der Verminderung von Mukositis als wirksamer
empfanden. Etwa 47% der Kinder zogen wa. hrend der nachfolgenden Chemotherapie
Chlorhexidin vor, etwa 50% bevorzugten Benzydamin. Abschlieend wird die
Akzeptanz und Vertra. glichkeit von Chlorhexidin und Benzydamin bei Kindern uber .
6 Jahren als gut bezeichnet.
& 2004 Elsevier Ltd. All rights reserved.

Introduction Dodd et al., 1999). Children in particular are prone

Oropharyngeal mucositis characterized by general-
ized inflammation and extensive ulceration is
common to many chemotherapeutic agents and
radiation therapy. While rarely life threatening,
mucositis can elicit multiple debilitating symptoms
and functional impairment including pain, dyspha-
gia and reduction in oral intake, with consequent
weight loss and poor nutritional status. Recent
studies revealed that severe inflammation and
ulceration are strongly correlated with an in-
creased risk of sepsis and bleeding, poor treatment
results, high hospital costs, and excess resource
utilization including antibiotic therapy, supplemen-
tal analgesia and nutrition (Eltng et al., 2003; Sonis
et al., 2001). Patients can also become socially
withdrawn and even clinically depressed because
of functional impairment (Bellm et al., 2000;
Rose-Ped et al., 2002).
The pathogenesis of oropharyngeal mucositis
is not fully understood, yet it is thought to be
multifaceted involving direct and indirect cytotoxi-
city, inflammatory response elicited by epithelial
and connective tissue cytokines, bacterial coloni-
zation of ulcerative lesion (Sonis, 1998), and
apoptotic damage to the basal epithelium (Peterson,
1999). Accumulating data suggests that the major
reason for aggravation of mucositis leading to
severe clinical symptoms is not the morphological
changes of the mucosal membrane associated with
cytotoxic cancer therapies, but the subsequent
bacterial superinfection (Folwaczny and Hickel,
2002). Literature also indicates that mucositis can
be a dose-limiting toxic effect, in which the
frequency is dependent on type, dose, or schedule
of cancer therapies, age, myelosuppressive status,
and the oral hygiene level (Bolwell et al., 2002,
to this morbid condition, afflicting from 52% to 80%
of paediatric patients receiving chemotherapy
(Bonnaure-Mallet et al., 1998, Childers et al.,
1993).
Considerable effort has been expended during
the past decade to identify the molecular biological
basis, and develop strategies to alleviate orophar-
yngeal mucositis. A multitude of interventions
directed at altering the exposure of oral mucosa
to antineoplastic insult, providing the protection of
mucosal proliferating cells, enhancing mucosal
epithelial maturation and healing, as well as
reducing inflammatory response and oral bacterial
load have been investigated with different types of
cancer patients. Unfortunately, no approach or
intervention has scientifically demonstrated clin-
ical efficacy in controlling oropharyngeal mucositis
and its sequelae. In nearly all of the approaches,
the outcomes for paediatric patients remain un-
known. Research is proceeding currently on re-
combinant human keratinocyte growth factor, with
a pre-clinical study showing a moderate reduction
of mucositis severity after growth factor use
(Meropol et al., 2003), but these will be too
expensive to support their routine use in future
clinical practice. In practice, the only acceptable
forms of treatments are the prophylactic elimina-
tion of dental and periodontal problems prior to the
commencement of cancer therapy, systematic oral
hygiene care, and pain relief. Rijt and Zuijlen
(2001) suggested that given the simplicity and low
cost of oral care, protocols on oral hygiene should
be the standard intervention in addition to which
special therapies will be developed. Oncology nurse
researchers have repeatedly highlighted that oral
hygiene care is one of the most vital nursing duties
in everyday oncology practice (Graham et al.,
 ARTICLE IN PRESS
Childrens acceptance and tolerance of chlorhexidine and benzydamine
1993, Holmes, 1991). Although considerable atten-
tion has been given in improving oral care practices
in recent years, stinging sensation and taste
acceptability and tolerability of oral rinse agents
is a continuing problem in oral care. (Bellm et al.,
2000, Foote et al., 1994). Some patients may
discontinue the oral care regimens prematurely
and will not derive its full benefit, making many
oral rinse agents an impractical choice for muco-
sitis in oncology setting. Such problems which will
affect patients compliance with oral hygiene
regimens have also been an impediment to re-
search in this area, particularly in paediatric
oncology setting. Currently, information on the
patients acceptance and tolerance of oral rinse
agents that can be of assistance to clinical staff
nurses in deciding on the most appropriate protocol
is limited. McGuire (2002) pointed out that a
challenge for nurse researchers and health care
providers is how to implement the oral care
standards or protocols in various clinical settings
and achieve compliance with them. Outcomes
including patients acceptance and tolerance of
oral hygiene measures, which are important in
determining the feasibility and effectiveness of
mucositis intervention should receive adequate
attention.
Chlorhexidine gluconate, a bis-biguanide com-
pound with potent antimicrobial activity, has been
used in a variety of clinical studies to control
plaque, treat periodontal disease and oral infec-
tions (Ferretti et al., 1990b). Several studies have
evaluated the use of chlorhexidine to modify the
course and sequelae of mucositis (Cheng et al.,
2001; Dodd et al., 1996; Foote et al., 1994; Levy-
Polack et al., 1998; Rutkauskas and Davis, 1993).
However, the relative efficacy of chlorhexidine has
varied in different studies. While chlorhexidine
rinse has beneficial effects on mucositis in some
studies with adult and paediatric populations
(Cheng et al., 2001; Levy-Polack et al., 1998;
Rutkauskas and Davis 1993), others report negative
findings (Dodd et al., 1996; Foote et al., 1994).
Since chlorhexidine has been shown to reduce
bacterial and fungal colonization in the mouth of
myelosuppressed patients, some literature sup-
ports the prophylactic use of chlorhexidine in
children receiving intensive myelosuppressive ther-
apy to obtain optimum oral health (Levy-Polack
et al., 1998; Shaw et al., 2000).
Benzydamine hydrochloride, which contains anti-
inflammatory, pain relieving and antimicrobial
properties, has been suggested to be more effec-
tive when used prophylactically to prevent muco-
sitis rather than therapeutically once mucositis is
present. Positive responses to benzydamine on
343
reducing mucositis frequency and improving the
oral symptoms were reported in several studies of
adult and paediatric patients undergoing radio-
therapy (Epstein et al., 1989; 2001; Lever et al.,
1987). Epsteins et al., (2001) study also showed a
diminished incidence of oral candidiasis with the
use of benzydamine rinses compared with placebo,
suggesting that benzydamine has an antifungal
effect. Currently, no studies have been traced
assessing the acceptability and tolerability of
chlorhexidine versus benzydamine oral rinses. In
addition, there are no published studies concerning
childrens perception of these two agents in
alleviating chemotherapy-induced oropharyngeal
mucositis. The purpose of this study was therefore
to determine the relative acceptability and toler-
ability of 0.2% w/v chlorhexidine gluconate and
0.15% w/v benzydamine hydrochloride, and to
determine the effects of these two agents on
mucositis from the perspective of children.
Patients and methods
Setting and sample
The study was conducted in a childrens cancer
center of a university-affiliated hospital in Hong
Kong after approval from the ethics committee.
Enrolled in the study were children between the
ages of 617 who had received two consecutive
cycles of high-dose or combination chemotherapy
for hematological malignancies or solid tumors.
They were also capable of demonstrating the
ability of tooth brushing and mouth rinsing as
judged by the investigator. Subjects and their
parents were informed of the aim of the study
and were included only after signing a written
consent for participation in this randomized study.
Study design
This study was a prospective randomized crossover
study. The study was conducted over 12 months.
Subjects were randomly assigned according to the
order of receiving the particular oral rinse agents.
One group received an oral care protocol with
chlorhexidine for 3 weeks in the initial chemother-
apy cycle followed by another 3 weeks with
benzydamine in the subsequent chemotherapy
cycle (CHD/BZD group). The other group received
an oral care protocol with benzydamine for the first
cycle and then chlorhexidine (BZD/CHD group) for
the second cycle. Subjects in each study cycle were
instructed to maintain strict oral hygiene according
 ARTICLE IN PRESS
344
to the protocol on the first day of chemotherapy
and to continue to do so for three weeks. The
protocol consisted of tooth brushing, mouth clean-
ing with the allocated oral rinse agent twice a day,
and with normal saline after each meal and every
24 h thereafter. Both the chlorhexidine and ben-
zydamine oral rinses were applied using the same
technique with 30 s contact time. Subjects who
complained of oral stinging or burning with the use
of agents were advised to dilute the oral rinses with
one part of normal saline or water (1:1) (Epstein
et al., 2001; Ernst et al., 1998; Kim and Lakshmi,
1986)
Compliance of subjects in performing oral care
rested on the patients self-reports. Each subject
was given an oral care practice diary where the
child (or parent) recorded every oral hygiene
procedure that was performed. Compliance was
assessed based on the frequency of mouth rinsing
with oral rinse agents recorded in the diary. The
amount of oral rinse used was counterchecked by
comparing with what had been recorded in the
diary and left in returned bottles. The compliance
rate was computed mainly based on the sum of the
average percentage of mouth rinsing with oral rinse
agents performed each day during the study period
divided by 21. The level for adequate compliance
was set at 80%.
Assessment
Demographic and clinical data such as gender, age,
education level, usual oral care practice, under-
lying disease and chemotherapy regimens were
recorded for each subject. An oral rinse evaluation
form designed by the investigators was employed at
the end of the study to assess each subjects
acceptability of oral rinse agents in terms of
stinging and taste. Each subject was also asked to
state the preference for chlorhexidine and benzy-
damine oral rinses, and the reasons for his/her
preferences. In addition, each subject was asked to
compare the two oral rinses in relation to their
perception of the reduction in mucositis and
palliation of oral discomfort. Tolerability was based
on the demand of dilution of oral rinses with normal
saline or water, as well as the occurrence of
adverse events.
Data analysis
The Statistical Package for Social Sciences (SPSS)
software, version 11.0 for windows, was used for
summarizing and analyzing data. Demographic and
clinical data were summarized using frequency
K.K.F. Cheng
distributions for categorical data, and means and
standard deviations for continuous data. Fishers
exact tests were used to examine the differences in
preference for oral rinse agents between subjects
in the two oral care protocol treatment orders. The
criterion for statistical significance was set at P p
0.05.
Results
Study population
Between April 2000 and April 2001, a total of 34
paediatric patients with cancer were enrolled and
randomly allocated to receive one of the oral care
protocol treatment orders. The subjects consisted
of 21 boys and 13 girls, ranging from 6 to 16 years of
age. The mean age of the subjects was 10.32 years
(SD 3.33). The years of schooling ranged from 0 to
11 years (Mean 4.53, SD 3.01). Mothers were
the caregivers of most of the children during cancer
treatment (f 28, 82%). Before the study, 7
subjects (21%) performed oral care using a com-
mercial mouthwash. The most common diagnoses
were acute lymphoblastic leukemia (f 19, 56%),
osteosarcoma (f 6, 18%), and acute myeloblastic
leukemia (f 5, 15%). The more commonly used
chemotherapy regimens included antitumor anti-
biotics/plant alkaloids (f 13, 38%) and antimeta-
bolities (f 9, 26%). Sixteen subjects (47%) had
received chemotherapy previously.
Oral rinse preference
There were a total of 33 subjects (20 boys and 13
girls) who indicated their preference for oral rinse
agent: 16 subjects (47%) preferred chlorhexidine,
17 subjects (50%) preferred benzydamine. The
proportion of preferences for subjects preferring
chlorhexidine was 8 out of 16 (50%, 1 missing case)
in the CHD/BZD group, and 8 out of 17 (47%) in the
BZD/CHD group. Eight out of 16 subjects (50%, 1
missing case) and 9 out of 17 subjects (51%) of the
CHD/BZD and BZD/CHD groups, respectively, pre-
ferred benzydamine. No significant difference was
found between the subjects in CHD/BZD and BZD/
CHD groups with respect to the oral rinse pre-
ference (P40.05). This finding indicates that the
order of administration of oral rinse agents had no
effect on the patients preference.
In this study, more than half of the boys preferred
chlorhexidine (f 11, 55%), whereas about two-
third of girls preferred benzydamine (f 8, 62%).
No significant difference was found between boys
 ARTICLE IN PRESS
Childrens acceptance and tolerance of chlorhexidine and benzydamine
Fig. 1 Mouthwash preference according to the age of children (chlorhexidine, n 16; benzydamine, n 17). CHD
chlorhexidine; BZD benzydamine.
and girls in oral rinse preference (P40.05). Fig. 1
shows the frequency distribution of oral rinse
preference according to the age of subjects. The
mean age of subjects who preferred chlorhexidine
and benzydamine oral rinses was 10.75 (median
11.5) and 9.88 (median 9), respectively. No
specific pattern was noted according to the age of
subjects in relation to oral rinse preference.
However, it is interesting to note that among the
subjects preferring chlorhexidine, the majority
were either the youngest (19%) or oldest children
(19%). Among subjects preferring benzydamine, the
majority were seven (18%) and nine years (18%)
of age.
Among the 33 subjects who had indicated their
preferences, 31 subjects also stated the reason for
preferring chlorhexidine or benzydamine oral
rinses. The frequency distribution for reasons
related to oral rinse preference is presented in
Fig. 2. The most common reasons for subjects
preferring chlorhexidine included better soothing
effect (f 14, 93%) and pleasant taste (f 9, 60%).
For subjects preferring benzydamine, pleasant
taste (f 11, 69%), better soothing effect (f 10,
63%), and less stinging when rinsing (f 10, 63%)
were the major reasons for their preference.
Oral rinse evaluation
As shown in Fig. 3, chlorhexidine was reported by
subjects to be more helpful in reducing mucositis
(f 19, 59%) and for palliating discomfort asso-
345
ciated with mucositis (f 19, 59%) than benzyda-
mine (f 13, 41%; f 13, 41%, respectively). In
comparison to stinging associated with rinsing,
more subjects reported acceptance of the stinging
level associated with benzydamine (f 19, 59%)
than with chlorhexidine. The taste of both the oral
rinses was accepted by 50% of subjects.
Oral rinse tolerance
Overall, the paediatric patients using both
oral rinse agents achieved acceptable compliance
(4 80%) throughout the 6-week study. The mean
compliance with chlorhexidine and benzydamine
oral rinses was 91% (SD 4.2) and 94% (SD 4.8),
respectively. None of the subjects discontinued use
of chlorhexidine, and only two subjects required
dilution of the chlorhexidine with normal saline or
water at 1:1 for the initial stinging in the first few
days of the study. All of the subjects using
benzydamine also tolerated the oral rinse well
and continued with rinsing throughout the course of
study. Only one subject had to resort to diluting
benzydamine with normal saline or water (1:1) for
the first few days of the study. When oral ulcers
developed, the number of subjects who required
dilution of chlorhexidine and benzydamine with
normal saline or water for the relief of oral stinging
was 33% (3 out of 9) and 20% (3 out of 15),
respectively. In this study, minor reversible dis-
coloration of teeth and soft tissue was observed in
three (9%) subjects rinsing with chlorhexidine.
 ARTICLE IN PRESS
346 K.K.F. Cheng

Fig. 2 Frequency distribution for reasons of subjects preferring chlorhexidine (n 15) and benzydamine (n 16) oral
rinses. CHD chlorhexidine; BZD benzydamine.

Fig. 3 Patients evaluation of the use of chlorhexidine and benzydamine oral rinses (n 32) CHD chlorhexidine;
BZD benzydamine.

Diminished taste acuity was reported by two (6%)
and three (9%) subjects when using chlorhexidine
and benzydamine, respectively.
Discussion
When developing a protocol about oral hygiene for
patients in cancer therapy, particularly in paedia-
trics, it is important that the regimen be not only
effective but also feasible. This study represents
the first evaluation of patients acceptance and
tolerance of chlorhexidine and benzydamine oral
rinses. Such information can be of assistance to
clinical staff in deciding on the most appropriate
oral care protocol for patients with oropharyngeal
mucositis. At present, although many researchers
do not regard the acceptability and tolerability of
oral hygiene measures or agents as significant
 ARTICLE IN PRESS
Childrens acceptance and tolerance of chlorhexidine and benzydamine
clinical outcomes, attention to this type of evalua-
tion is important and meaningful to patients, their
families and health care providers. Even if oral care
protocols are well supported by research they are
worthless if the oral hygiene regimens are unac-
ceptable and/or intolerable to patients. The
literature has emphasized that an oral care proto-
cols success depends on patient compliance (Dodd
et al., 1996; NIH, 1989). Patient acceptability,
tolerability, and preferences are integral compo-
nents in achieving therapeutic compliance.
Both the chlorhexidine and benzydamine oral
rinses were acceptable and tolerable to the
children in this study. The level of compliance with
these two agents was very high. This is despite the
fact that using chlorhexidine and benzydamine oral
rinses have led to a poor acceptance and compli-
ance in adult patients because of their stinging and
astringent taste. The results obtained in this study
indicated that the degree of stinging associated
with benzydamine was more acceptable than
chlorhexidine. In contrast to the situation in adults,
patients often reported the degree of stinging when
rinsing the mouth with chlorhexidine was more
acceptable than benzydamine (Matthews et al.,
1987; Samaranayake et al., 1988). Although some
degree of stinging was reported during the mouth
rinsing procedure particularly when ulcerative
lesions developed, the 1:1 dilution recommended
when stinging was evident was such that topical
contact with chlorhexidine and benzydamine still
sufficient to comply with the required length of
time throughout the study. In agreement with the
observations by Lang et al. (1982) and Cheng et al.
(2001), chlorhexidine oral rinse was considered
tolerable to children. This has also been supported
by OSullivan et al. (1993), who reported that there
was 100% compliance in children who had received
prophylactic chlorhexidine oral rinses four times a
day for the whole duration of the study. In a recent
study testing chlorhexidine in adult patients re-
ceiving chemotherapy, noticeable stinging sensa-
tion was not reported and patients had over 90%
compliance with chlorhexidine (Dodd et al., 2000).
However, the use of chlorhexidine has been
reported to induce a level of stinging that
compromised adult radiotherapy patient compli-
ance with the oral hygiene regimen (Foote et al.,
1994). Epstein et al. (2001) reported that 87%
subjects experienced mild adverse events when
rinsing with benzydamine, and about half of them
were associated with stinging, numbness, and taste
alteration. In Lever et al.s (1987) study, one third
of paediatric patients did not comply with benzy-
damine because of the stinging. In another study,
Samaranayake et al.s (1988) reported that more
347
than half of the adult patients discontinued using
benzydamine and dropped out of the study because
of the stinging. The reason for the difference in
stinging tolerance is not clear, but it may be related
to the variations in the alcohol content and
formulation of oral rinses among the studies. We
also believe that the better tolerance of stinging by
our study subjects who experienced stinging was
due to the dilution of oral rinses. Thus, if stinging
occurred with the use of oral rinses, nurses can
advise the children to dilute the oral rinses with
normal saline or water at 1:1. Nevertheless, further
studies are warranted to determine whether the
dilution of oral rinses will modulate oral rinse
efficacy.
Discoloration of teeth and soft tissue is a concern
with the use of chlorhexidine. In the present study,
with the exception of few children, discoloration
was not observed in those rinsing with chlorhex-
idine. The discolorations that were observed in
those few children were very mild. Indeed, the
amount of staining depends on the frequency and
duration of use, as well as the patient diet (Ferretti
et al., 1990a). Three elements in the current study
may explain the mild discolorations. First, the 3-
week rinsing period was short, and the patients
were therefore not at risk of developing high
degree of discoloration. Second, twice-daily tooth
brushing as performed by children may also have
contributed to the continuous removal of any
developing stain. Third, children had no intake of
tea or other tannin-containing substances. Earlier
studies of dietary factors which might affect tooth
staining associated with the use of chlorhexidine
demonstrated that consuming tannin-containing
substances such as tea, red wine, and port wine
will increase the level of chlorhexidine discolora-
tions (Prayitno et al., 1979). Another issue with the
use of oral rinse agents is taste alteration. A few of
children when using chlorhexidine and benzyda-
mine experienced diminished taste acuity. This may
be related to the use of chemotherapy, especially
doxorubicin and cisplatin, in the treatment of
cancer for these children. It has been documented
that taste changes occur frequently in patients
undergoing carboplatin, cisplatin, cyclophospha-
mide, doxorubicin, and methotrexate therapy (Pai
et al., 2001).
In this study, soothing and taste were the major
factors that influenced patient preference for oral
rinses. The majority of children liked the soothing
effects of chlorhexidine, whereas most of the
children liked the taste of benzydamine. A clinical
study of adult patients with radiation-associated
mucositis also reported similar findings for patients
using benzydamine oral rinse (Epstein et al., 1989).
 ARTICLE IN PRESS
348
However, it is interesting to note that some
patients in the current study had complained of
the unpleasant taste of benzydamine oral rinse.
This serendipitous finding therefore implies that
taste sensation and the acceptability of the oral
rinse is a subjective experience, and can vary
significantly from patient to patient.
From the patients perspective, chlorhexidine is
more helpful than benzydamine in reducing muco-
sitis and palliating oral discomfort. Although this
study provides some insights into the children
perception of chlorhexidine and benzydamine on
oropharyngeal mucositis, it does not reveal specific
information about the efficacy of these two agents
in reducing the incidence and severity of mucositis.
Further studies are needed to evaluate prospec-
tively the use of chlorhexidine and benzydamine
oral rinses to determine whether these two agents
will help paediatric patients to alleviate che-
motherapy-induced oropharyngeal mucositis.
In conclusion, the oral hygiene measure of mouth
rinsing with chlorhexidine and benzydamine is
acceptable and well-tolerated by children over
the age of 6 years. However, the small sample size
available for the study limits the generalizability of
the results. In addition, this study could not fully
assess the impact of stinging sensation and taste on
acceptability and tolerability, and the role of
parents in achieving compliance with these oral
rinse agents. Future studies using numeric rating
scales with a larger sample size, together with
qualitative methods are needed to obtain in-depth
information about the patients perception on
stinging sensation and taste, and thus acceptability
and tolerability with using chlorhexidine and
benzydamine. Factors that may influence oral rinse
acceptance, and comply with oral hygiene regimen
such as the support of parents also merit further
investigation.
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