Oral mucositis (OM)

• 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
• References

What is oral mucositis?

Oral mucositis (OM) refers to an inflammatory, erosive, and/or ulcerative process inside the mouth, which is usually caused by radiation or chemotherapy.

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:

1. Those with head and neck cancer who are having radiation therapy to fields involving the oral cavity; and
2. 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 (oral thrush);
• Herpes simplex virus (HSV);
• Graft-versus-host disease (GVHD).

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.

Complications

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.

Clinical management

Pain control

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.

Regular pain medication such as paracetamol and ibuprofen can be used as well to provide pain relief, and can be combined with opioids such as morphine and hydromorphone when pain is severe.

Barrier methods

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

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

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.

Other

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.

More information

For more information on oral mucositis, including treatments and some useful videos, see Mucositis.

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