Oral Mucositis (Stomatitis) 

TOPIC SEARCH: Radiotherapy and: PubMed 
Cancer Treatment and Mucositis: PubMed

Oral mucositis is an inflammation of the mucous membranes in the mouth. It can range from redness to severe ulceration.  This is a side effect associated with many standard cancer treatments, particularly chemotherapy.  The consequences can range from mild to severe. 

Mucositis "occurs when cancer treatments break down the continually dividing epithelial cells lining the GI tract, particularly in the oral cavity, leaving the mucosal tissue open to ulceration and infection. It can occur anywhere along the digestive tract from the mouth to the anus."

Stomatitis (mouth and oropharynx), oesophagitis (oesophagus), gastritis (stomach), enteritis (small intestine), colitis (colon), proctitis (anus) and vaginitis (vagina) are all examples of mucositis.

Source: GONG Cancer Guidelines

Patients have reported that oral mucositis is a distressing side effect of standard-dose chemotherapy, occurring in approximately one third of patients. Source:  professional.cancerconsultants.com

Mucositis is painful and can affect nutrition, increase your risk of infection, and can delay or limit treatment. It can lead to major complications after or during cancer treatment.

Good oral hygiene practices are thought to reduce pain, bleeding, infection, and dental complications (Rubenstein et al 2004).

Potential complications include:

	Infection, such as herpes simplex virus, candida albicans and other opportunistic agents
	Bleeding from non-intact mucous membranes
	Pain, secondary to lesions
	Decreased dietary intake leading to dehydration and poor nutritional status
	Diarrhea or constipation
	The inability to talk comfortably may lead some patients with severe oral mucositis to suffer from depression Adapted from GONG Cancer Guidelines

Treatment for mucositis should be guided by your doctor.

In general, hydration should be maintained with oral fluid intake and regular care of mucous membranes, such as regular mouth care with a soft brush is recommended to reduce incidence of complications.

In the News

Clinical Oncology: Management of Oral Mucositis in Cancer Patients

Education on Preventive and Management Practices, and Related Services:

Related Services: Dietician for dietary education   Medical Provider education on assessment, management and prevention of mucositis   Dentist for treatment of dental disease before commencement of treatment for cancer

Education on Preventive and Management Practices Ask your health care provider: How to assess and report changes in oral mucous membranes at home including changes to vaginal and rectal mucous membranes   Mouth care regime: Regular cleaning of teeth and gums with a soft toothbrush or swab as tolerated Cleaning dentures daily and leaving out when at rest and whenever a mouthwash is used; Gums and areas under a denture should be brushed on a regular basis Your doctor might recommend rinsing mouth after all meals with a warm salt water or sodium bicarbonate mouth rinse. (Avoid mouthwashes containing irritants, such as alcohol, phenol or chlorhexidine). Sucking on ice cubes may ease discomfort (check that water source is pure)   Avoid hot food and drinks, spicy food, alcohol and smoking   Lubricate lip and mouth as necessary   Discuss use of topical anesthetics and analgesics if necessary.   Discuss strategies to prevent risks associated with sexual activities Avoid trauma to the genital areas such as the use of tampons, suppositories, chemical irritants from deodorants, and vaginal or anal intercourse until areas have recovered.   Discuss need to maintain good hygiene, including encouragement of bathing and cleaning after each urination and bowel movements.   Discuss need to report bleeding from non-intact mucous membranes

Adapted from GONG Cancer Guidelines

Resources on Mucositis

Side Effects > Oral Side Effects Last updated: 03/14/2014
TOPICS   Oral | Resources | Research News Oral Mucositis | Oral Thrush | Loss of Taste | Dry Mouth | Burning Mouth Syndrome  Oral side effects that can result from cancer treatments include oral mucositis, oral thrush and loss of taste sensation or smell. Oral health is important! In addition to being painful, a sore mouth can become easily infected. Every step should be taken to prevent infections, because they can be hard to fight during chemotherapy and can lead to serious problems or the interruption of your treatment. Prevention: Talk you your doctor about seeing a dentist at least two weeks before chemotherapy begins. If you've already started chemotherapy and didn’t go to a dentist, see one as soon as possible, and notify him  or her that you are receiving treatment.  Tip: If brushing becomes too painful due to mouth sores, try a finger toothbrush. Meant for babies, they are very gentle yet are helpful in keeping the teeth and gums clean. They can be found in most drugstores and grocery stores.  See Oral complications of cancer radiotherapy. PMID: 834698  PubMed | Related abstracts
	GONG Cancer Guidelines (very clear and concise recommendations provided here)
	Updated clinical practice guidelines for the prevention and treatment of mucositis. guidelines.gov
	Cancer Treatment-Induced Mucositis Pain: Strategies for Assessment and Management http://www.ncbi.nlm.nih.gov/
	Clinical practice guidelines for the prevention and treatment of cancer therapy–induced oral and gastrointestinal mucositis (Rubenstein et al 2004). http://bit.ly/pwVLVE
	Tips for Getting Through Therapy PAL
	Advances in the Prevention and Management of Oral Mucositis  professional.cancerconsultants.com
	Prevention and evidence-based best practices oralcancerfoundation.org  pdf
	About mucositis  cancerbacup.org.uk | cancersupportivecare.com
	Mucositis Assessment scale  symptomresearch.nih.gov
	Mucosal damage: a major risk factor for severe complications after cytotoxic therapy. Semin Oncol. 2004 Jun;31(3 Suppl 8):35-44. Review. PMID: 15181607
	Preventing Mucositis - discussion of investigational use of  Dehydroascorbic acid DHA  Medscape (free login req.)
	Management of oral mucositis during local radiation and systemic chemotherapy:  a study of 98 patients. J Prosthet Dent. 1991 Sep;66(3):361-9. PMID: 1800734  PubMed | Related abstracts
	FDA Approves Kepivance for Severe Oral Mucositis in Cancer Patients  Undergoing Bone Marrow Transplant; Pivotal Phase 3 Study Published in  This Week's New England Journal of Medicine  cancerconsultants.com Dec 2004 Questions and Answers on Palifermin (Keratinocyte Growth Factor)  FDA.gov
	The cancer patient with severe mucositis. Curr Rev Pain. 2000;4(3):197-202. Review. PMID: 10998733  Abstract
	Complementary Medicine: Oral glutamine to alleviate radiation-induced oral mucositis: a pilot randomized trial. Int J Radiat Oncol Biol Phys. 2000 Feb 1;46(3):535-9. PMID: 10701731 abstract | related abstracts Prospective evaluation of a chamomile mouthwash for prevention of 5-FU-induced oral mucositis. Cancer. 1996 Feb 1;77(3):522-5. PMID: 8630960  PubMed

Oral Mucositis
WebMagic Patient Tips:

	It is called magic mouthwash but to tell you the truth, I used frozen things like popsicles. I was advised to even start with ice chips during my treatment and continue with very cold things.
	This is the recipe for "Magic Mouthwash" that the onc nurse gave me.... Equal parts of hydrogen peroxide and water, mixed together. Swish around in mouth, DO NOT GARGLE OR SWALLOW. ALWAYS ASK YOUR ONCOLOGIST BEFORE TRYING THIS OR ANYTHING NEW.
	I used CAPHOSOL®. It tasted almost like a salt water rinse. I found it worked longer than the magic mouthwash and didn't have any aftertastes which I was sensitive to at the time.
	Much sympathy to your friend. I got nailed with sores pretty hard after the first round of chemo and the doctor gave me a life-time supply of CAPHOSOL®. It did help, and it had some cool geek cred because its two liquid components come in separate plastic ampules which have to be mixed. It did not, however, represent a dramatic improvement over the saline/baking soda solution. I found that being really diligent about rinsing regularly, regardless of whether I felt any sores oncoming or not, was the best routine for me.

Oral Mucositis
Research News and Resources

	Chlorhexidine prophylaxis for chemotherapy- and radiotherapy-induced stomatitis:  a randomized double-blind trial. Oral Surg Oral Med Oral Pathol. 1990 Mar;69(3):331-8. PMID: 2179802  PubMed
	A controlled evaluation of chamomile for preventing stomatitis in patients receiving 5-fluorouracil based chemotherapy asco.org
	Mayo Clinic on chemo mouth sores: what causes, which days are worst, how to help prevent, how to cope. http://bit.ly/78jiYn
	Preventing / managing oral mucositis (resources) - common and serious side effect related to high dose therapy and stem cell transplantation  Abstract
	A prospective, randomized study of cryotherapy ... [ice chips and ice-cold water shortly before, during, and for additional 90 min after completion of treatment]  ... during administration of high-dose melphalan to decrease the severity and duration of oral mucositis in patients with multiple myeloma undergoing autologous peripheral blood stem cell transplantation. Bone Marrow Transplant. 2006 Jun;37(11):1031-5. PMID: 16633359 Compared to the normal saline group, patients using cryotherapy experienced less grade 3-4 mucositis, 14 vs 74%, P=0.0005. Patients receiving cryotherapy also had statistically  lower uses of narcotics and TPN, although there were no differences in length of  hospitalization or weight loss. Patient-reported pain was significantly lower and  activities were significantly better in the cryotherapy group.

Oral thrush

Oral thrush presents as distinctive lesions of the mouth, tongue, or cheeks -- caused by infection of the mouth with the fungus (yeast) Candida albicans.. Lesions are easily brushed away revealing a reddened, tender area that may bleed slightly."  MedlinePlus 

About oral thrush  CDC

• Information from Merck Manual
  
  "Depending on the cause of the taste disorder, a doctor may recommend changing or stopping  a suspected drug, keeping the mouth wet by sucking on candy, or just waiting several weeks to see if the problem disappears. Zinc supplements, which can be purchased without a prescription, are claimed to speed recovery, especially from taste disorders that follow a bout of the flu. The effect, however, has not been scientifically confirmed."

• Taste and smell impairment  CancerSupportiveCare  
  
  "The cells comprising taste buds usually  will regenerate within four months after treatment. However, the degree of long-term  impairment of taste is quite variable from patient to patient."

• Impaired taste info   MedlinePlus 
   
  "Vitamin (Vitamin B-12) or mineral (Zinc in diet) deficiency"

• Disorders of taste and smell  eMedicine.com

Support for mucositis  cancersupportivecare.com  

Review these sections in Cancer Treatment Support for additional recommendations: 
Avoiding Infections | Diet Guidelines | Diet for Immunosuppressed | Oral Health

Complimentary Medicine: Chemo-protection  PAL | Radio-protection  PAL

Low blood counts  PAL

Chemotherapy side effects  PAL