- What is oral mucositis?
- Statistics on oral mucositis
- Risk factors for oral mucositis
- Progression of oral mucositis
- Symptoms of oral mucositis
- Clinical examination of oral mucositis
- How is oral mucositis diagnosed?
- Prognosis of oral mucositis
- Treatment of oral mucositis
What is oral mucositis?
OM can cause severe pain and difficulty eating, and can severely impact on a person’s quality of life, nutritional intake, and treatment for cancer. The severity of this impact on quality of life may result in depression in some individuals.
OM presents a significant burden because symptoms are often of such a severity that they can require an interruption, or may lead to dose reduction of cancer therapy. Thus, OM is a major factor in determining the maximum dose possible of radiation and chemotherapy to the head and neck region.
The outlook for OM in the long-term is reasonably good as most lesions resolve within 2-4 weeks of stopping chemotherapy or radiation. However, it is critical to manage this condition when present to avoid interruption to cancer therapy. Treatment includes pain medication, proper oral and nutritional care and barrier membranes.
OM is an important complication of head and neck cancer therapy and can significantly complicate treatment, extend hospitalisation, decrease quality of life, and increase costs.
Statistics on oral mucositis
In general, the risk of OM increases depending on the type of treatment performed, with the lowest risk occurring with “gentler” chemotherapeutics and the higher risk occurring with more aggressive agents and/or radiation therapy.
People being treated with the chemotherapeutic medications fluorouracil and cisplatin are most likely to develop OM (90% of cases), whereas OM is uncommon with asparaginase and carmustine. At least 40% and up to 70% of individuals treated with standard chemotherapy regimens can have OM.
People who have cancer of the head and neck and receive radiotherapy are particularly at risk – approximately 80% will develop OM. In those who receive only chemotherapy, the incidence of OM is around 22%.
Risk factors for oral mucositis
OM is essentially seen in two different types of people:
- Those with head and neck cancer who are having radiation therapy to fields involving the oral cavity; and
- Those receiving strong chemotherapy for cancer, including those receiving conditioning for stem cell transplantation.
Progression of oral mucositis
When will I get OM?
OM that is caused by chemotherapy is typically seen between 7 to 14 days after the initiation of drug therapy.
The accumulated of dose of radiation in cancer therapy is also important in determining if someone gets OM. The higher the dose of radiation, the greater the severity of OM.
Symptoms of oral mucositis
OM typically begins as a red and inflamed oral mucosa (e.g. on the inside of the lips or the inside walls of the cheeks), which may or may not be painful for the person suffering from OM. In some people, the inside of the mouth may break out in ulcers, and the risk of this happening depends on the type of treatment. Ulcerations will most likely cause severe pain for the individual. There may or may not be a whitish appearance on the oral mucosa too.
Clinical examination of oral mucositis
OM caused by chemotherapy generally affects the back of the palate (soft palate), the top of the tongue, and the inside of the cheek.
Radiation-induced OM for head and neck cancer affects whatever area has experienced toxic radiation doses.
How is oral mucositis diagnosed?
OM is typically diagnosed based on the appearance, location, and timing of oral lesions, as well as the medical history, which may show a medication or treatment form that is highly linked with OM.
Some medications also appear to cause lesions in a particular part of the mouth, and knowing these medications makes the diagnosis easier to reach.
What other conditions look like OM?
Other common conditions can have a similar clinical presentation to OM and may make it difficult to determine the exact problem:
Candidiasis occurs in response to treatment for cancer and is treated with anti-fungal medications. In individuals undergoing treatment for head and neck cancer, the fungal infection starts mainly due to a dry mouth, which is caused by an impaired saliva flow.
HSV is frequently seen in people receiving chemotherapy,with cold cores appearing near or in the mouth. HSV infection in people receiving cancer therapy is often much worse than those who are healthy, and are not receiving chemotherapy or radiation. Anti-viral therapy is very effective in controlling the symptoms of HSV.
Some people who get a transplant of blood may develop GVHD. The clinical appearance of GVHD is similar to OM as there is ulceration and inflammation inside the mouth. Steroids are usually the main choice in terms of medication.
Prognosis of oral mucositis
The outlook for OM in the long-term is reasonably good as most lesions resolve within 2-4 weeks of stopping chemotherapy or radiation.
OM can cause severe pain and trouble eating, resulting in depression in some people. These problems are further complicated by the associated dry mouth and alterations in taste that can lead to anorexia, weight loss, and weakness due to poor nutrition.
Severe inflammation and injury to the oral mucosa also increases the chance of other infections in the mouth and body. The symptoms of OM are often so bad that they can cause a reduction in dose of treatment, or even postponing treatment till the OM is better controlled.
Treatment of oral mucositis
Prevention of oral mucositis
Education for individuals suffering from OM is highly important so they understand what to expect, and also that it is manageable. Those at high risk of developing OM need to learn about proper oral hygiene, and this is often the case anyway with people undergoing treatment for head and neck cancers.
Those people that receive radiation can have a block placed in the mouth that can reduce the amount of radiation absorbed by the tissues surrounding the mouth.
For those with advanced head and neck cancer, careful control of the radiation dose and volume are critical, and this is possible with new-age techniques that do not reduce the success rate of treatment, but do reduce the amount of radiation on the rest of the tissues.
The main symptom encountered in OM is pain. This pain can significantly affect nutritional intake, ability to maintain oral hygiene and quality of life. Management of pain is essential for any person suffering from OM.
Discomfort from OM can be reduced in some of the following ways:
- Avoiding things that may irritate the mouth (smoking, alcohol, mouthwashes, or rough, acidic or spicy foods e.g. tomatoes, lemons);
- Maintaining good oral hygiene;
- Cooling the mouth down with ice chips or salt water rinses and topical mouth rinses; and
- Pain control medications that help with pain control and trouble eating such as:
- Lidocaine (or lignocaine), which will provide help with pain management. It is similar to what is given in many dental injections;
- Benzydamine provides pain relief in the mouth and has been shown to reduce the pain, as well as reduce the severity of OM in people receiving radiation therapy;
- Doxepin rinse has been shown recently to provide pain relief.
Barrier agents may reduce pain in the mouth. These work by providing a protective barrier over the surface of the mouth and throat, shielding and soothing the exposed and sensitised nerves which are causing most of the pain. They are usually used one hour before meals.
Barrier medications include Gelclair, Orabase and sulfacrate (Pluronic).
Oral hygiene makes a big difference to the severity of OM. Good oral hygiene also reduces the chance of getting candidiasis as well as other systemic infections. This is especially true in people who are immunosuppressed e.g. from chemotherapy. Those undergoing radiotherapy will most likely not suffer from systemic infections following treatment.
Oral health care during head and neck cancer consists of the following;
- Scale and cleaning before cancer therapy, if possible;
- Toothbrushing twice daily with a soft-bristled toothbrush and fluoride containing toothpaste;
- High-fluoride toothpastes may be used in people at increased risk for dental caries due to a dry mouth;
- Flossing, this may not be recommended in some cases due to a low platelet count. In such patients, the use of a regular toothbrush may be replaced by an ultrasoft toothbrush;
- Rinsing with a non-irritating solution e.g. salt water or 2 tablespoons of baking soda in warm water; rinsing may help improve the quality of saliva;
- Very meticulous diet control consisting of minimal sugar and acidic food and drinks, no smoking, no alcohol etc;
- Use of agents by your dentist such as CPP-ACP, which are beneficial to tooth repair following an acidic attack; and
- Limiting the use of dentures as far as possible to minimise trauma to the oral tissues and decrease risk of infection.
For more information, see Dental Hygiene.
Nutritional intake can be severely compromised by the pain associated with severe OM and there are recommended options to ensure proper nutrition is maintained:
- Nutritional intake and weight will be monitored regularly by a dietitian or your doctor;
- A soft diet and liquid diet supplements are more easily tolerated than a normal diet when OM is present;
- In individuals expected to develop severe OM, a tube can be inserted prior to the onset of OM, although this can be discussed with your doctor; and
- In people undergoing a blood stem cell transplant, nutrition is essentially given completely via a tube.
For more information, see Oral Mucositis and Nutrition.
Ice chips are useful in the management of OM when undergoing certain forms of chemotherapy. Beginning 5 minutes before chemotherapy is given, ice chips are provided to the patient and replenished as needed for up to 30 minutes. Using ice chips is only effective if the chemotherapy is given in a short period, otherwise the individual is likely to not wish to continue with treatment.
|For more information on oral mucositis, including treatments and some useful videos, see Mucositis.|
- Woo SB, Sonis ST, Monopoli MM, Sonis AL. A longitudinal study of oral ulcerative mucositis in bone marrow transplant recipients. Cancer. 1993; 72(5): 1612-7.
- Lalla RV, Peterson DE. Oral mucositis. Dent Clin North Am. 2005; 49(1): 167-84.
- Scully C, Epstein J, Sonis S. Oral mucositis: A challenging complication of radiotherapy, chemotherapy, and radiochemotherapy. Part 2: Diagnosis and management of mucositis. Head Neck. 2004; 26(1): 77-84.
- Trotti A, Bellm LA, Epstein JB, Frame D, Fuchs HJ, Gwede CK, et al. Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: A systematic literature review. Radiother Oncol. 2003; 66(3): 253-62.
- Peterson DE. New strategies for management of oral mucositis in cancer patients. J Support Oncol. 2006; 4(2 Suppl 1): 9-13.
- Chi KH, Chen CH, Chan WK, Chow KC, Chen SY, Yen SH, et al. Effect of granulocyte-macrophage colony-stimulating factor on oral mucositis in head and neck cancer patients after cisplatin, fluorouracil, and leucovorin chemotherapy. J Clin Oncol. 1995; 13(10): 2620-8.
- Symonds RP. Treatment-induced mucositis: An old problem with new remedies. Br J Cancer. 1998; 77(10): 1689-95.
- Scully C, Epstein J, Sonis S. Oral mucositis: A challenging complication of radiotherapy, chemotherapy, and radiochemotherapy. Part 1: Pathogenesis and prophylaxis of mucositis. Head Neck. 2003; 25(12): 1057-70.
- Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin North Am. 2008; 52(1): 61-77.
- Elting LS, Cooksley C, Chambers M, Cantor SB, Manzullo E, Rubenstein EB. The burdens of cancer therapy. Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer. 2003; 98(7): 1531-9.
- Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys. 2007; 68(4): 1110-20.
- Silverman S Jr. Diagnosis and management of oral mucositis. J Support Oncol. 2007; 5(2 Suppl 1): 13-21.
- Duncan M, Grant G. Oral and intestinal mucositis – causes and possible treatments. Aliment Pharmacol Ther. 2003; 18(9): 853-74.
- Jansma J, Vissink A, Bouma J, Vermey A, Panders AK, Gravenmade EJ. A survey of prevention and treatment regimens for oral sequelae resulting from head and neck radiotherapy used in Dutch radiotherapy institutes. Int J Radiat Oncol Biol Phys. 1992; 24(2): 359-67.
- Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M, Hauer-Jensen M, et al. Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer. 2004; 100(9 Suppl): 1995-2025.
- Epstein JB, Gorsky M, Guglietta A, Le N, Sonis ST. The correlation between epidermal growth factor levels in saliva and the severity of oral mucositis during oropharyngeal radiation therapy. Cancer. 2000; 89(11): 2258-65.
- Tang IT, Shepp DH. Herpes simplex virus infection in cancer patients: Prevention and treatment. Oncology (Williston Park). 1992; 6(7): 101-6.
- Khan SA, Wingard JR. Infection and mucosal injury in cancer treatment. J Natl Cancer Inst Monogr. 2001; (29): 31-6.
- Perch SJ, Machtay M, Markiewicz DA, Kligerman MM. Decreased acute toxicity by using midline mucosa-sparing blocks during radiation therapy for carcinoma of the oral cavity, oropharynx, and nasopharynx. Radiology. 1995; 197(3): 863-6.
- Mantini G, Manfrida S, Cellini F, Giammarino D, Petrone A, Vitucci P, et al. Impact of dose and volume on radiation-induced mucositis. Rays. 2005; 30(2): 137-44.
- Samaranayake LP, Robertson AG, MacFarlane TW, Hunter IP, MacFarlane G, Soutar DS, et al. The effect of chlorhexidine and benzydamine mouthwashes on mucositis induced by therapeutic irradiation. Clin Radiol. 1988; 39(3): 291-4.
- Epstein JB, Stevenson-Moore P, Jackson S, Mohamed JH, Spinelli JJ. Prevention of oral mucositis in radiation therapy: A controlled study with benzydamine hydrochloride rinse. Int J Radiat Oncol Biol Phys. 1989; 16(6): 1571-5.
- Kim JH, Chu FC, Lakshmi V, Houde R. Benzydamine HCl, a new agent for the treatment of radiation mucositis of the oropharynx. Am J Clin Oncol. 1986; 9(2): 132-4.
- Epstein JB, Epstein JD, Epstein MS, Oien H, Truelove EL. Oral doxepin rinse: The analgesic effect and duration of pain reduction in patients with oral mucositis due to cancer therapy. Anesth Analg. 2006; 103(2): 465-70.
- Buchsel PC. Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair): A bioadherent oral gel for the treatment of oral mucositis and other painful oral lesions. Expert Opin Drug Metab Toxicol. 2008; 4(11): 1449-54.
- Cawley MM, Benson LM. Current trends in managing oral mucositis. Clin J Oncol Nurs. 2005; 9(5): 584-92.
- The clinical effectiveness of Gelclair in the management of oral mucositis. Aust Nurs J. 2009; 16(9): 30-3.
- Innocenti M, Moscatelli G, Lopez S. Efficacy of gelclair in reducing pain in palliative care patients with oral lesions: preliminary findings from an open pilot study. J Pain Symptom Manage. 2002; 24(5): 456-7.
- Castagna L, Benhamou E, Pedraza E, Luboinski M, Forni M, Brandes I, et al. Prevention of mucositis in bone marrow transplantation: A double blind randomised controlled trial of sucralfate. Ann Oncol. 2001; 12(7): 953-5.
- McGinnis WL, Loprinzi CL, Buskirk SJ, Sloan JA, Drummond RG, Frank AR, et al. Placebo-controlled trial of sucralfate for inhibiting radiation-induced esophagitis. J Clin Oncol. 1997; 15(3): 1239-43.
- Cheng KK. Oral mucositis, dysfunction, and distress in patients undergoing cancer therapy. J Clin Nurs. 2007; 16(11): 2114-21.
- Levy-Polack MP, Sebelli P, Polack NL. Incidence of oral complications and application of a preventive protocol in children with acute leukemia. Spec Care Dentist. 1998; 18(5): 189-93.
- Borowski B, Benhamou E, Pico JL, Laplanche A, Margainaud JP, Hayat M. Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: A randomised controlled trial comparing two protocols of dental care. Eur J Cancer B Oral Oncol. 1994; 30B(2): 93-7.
- Yoneda S, Imai S, Hanada N, Yamazaki T, Senpuku H, Ota Y, et al. Effects of oral care on development of oral mucositis and microorganisms in patients with esophageal cancer. Jpn J Infect Dis. 2007; 60(1): 23-8.
- Ruescher TJ, Sodeifi A, Scrivani SJ, Kaban LB, Sonis ST. The impact of mucositis on alpha-hemolytic streptococcal infection in patients undergoing autologous bone marrow transplantation for hematologic malignancies. Cancer. 1998; 82(11): 2275-81.
- Spielberger R, Emmanouilides C, Stiff P, Bensinger W, Gentile T, Weisdorf D, et al. Use of recombinant human keratinocyte growth factor (rHuKGF) can reduce severe oral mucositisin patients (pts) with hematologic malignancies undergoing autologous peripheral blood progenitor cell transplantation (auto-PBPCT) after radiation-based conditioning: Results of a phase 3 trial [abstract 3642]. Proceedings of the American Society of Clinical Oncology 2003.
- Reddy GK, Jain VK. Palifermin is efficacious in reducing oral mucositis induced by intensive cancer therapy. Support Cancer Ther. 2005; 2(2): 84-5.
- Bussolino F, Wang JM, Defilippi P, Turrini F, Sanavio F, Edgell CJ, et al. Granulocyte- and granulocyte-macrophage-colony stimulating factors induce human endothelial cells to migrate and proliferate. Nature. 1989; 337(6206): 471-3.
- Kannan V, Bapsy PP, Anantha N, Doval DC, Vaithianathan H, Banumathy G, et al. Efficacy and safety of granulocyte macrophage-colony stimulating factor (GM-CSF) on the frequency and severity of radiation mucositis in patients with head and neck carcinoma. Int J Radiat Oncol Biol Phys. 1997; 37(5): 1005-10.
- Foncuberta MC, Cagnoni PJ, Brandts CH, Mandanas R, Fields K, Derigs HG, et al. Topical transforming growth factor-beta3 in the prevention or alleviation of chemotherapy-induced oral mucositis in patients with lymphomas or solid tumors. J Immunother. 2001; 24(4): 384-8.
- Epstein JB, Silverman S Jr, Paggiarino DA, Crockett S, Schubert MM, Senzer NN, et al. Benzydamine HCl for prophylaxis of radiation-induced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial. Cancer. 2001; 92(4): 875-85.
- Evans ME, Jones DP, Ziegler TR. Glutamine prevents cytokine-induced apoptosis in human colonic epithelial cells. J Nutr. 2003; 133(10): 3065-71.
- Peterson DE, Jones JB, Petit RG 2nd. Randomized, placebo-controlled trial of Saforis for prevention and treatment of oral mucositis in breast cancer patients receiving anthracycline-based chemotherapy. Cancer. 2007; 109(2): 322-31.
- Grdina DJ, Kataoka Y, Murley JS. Amifostine: Mechanisms of action underlying cytoprotection and chemoprevention. Drug Metabol Drug Interact. 2000; 16(4): 237-79.
- Cascinu S, Fedeli A, Fedeli SL, Catalano G. Oral cooling (cryotherapy), an effective treatment for the prevention of 5-fluorouracil-induced stomatitis. Eur J Cancer B Oral Oncol. 1994; 30B(4): 234-6.
- Migliorati CA, Oberle-Edwards L, Schubert M. The role of alternative and natural agents, cryotherapy, and/or laser for management of alimentary mucositis. Support Care Cancer. 2006; 14(6): 533-40.