What is Oral Mucositis?

Oral mucositis is a condition where the lining of the mouth becomes red, swollen, and develops sores or ulcers. This condition is a common side effect of treatments like radiation therapy to the head or neck, chemotherapy, combined chemo and radiation, and stem cell transplant. These treatments can cause so much pain in the mouth that it becomes difficult to eat. In some cases, this can lead to a need for artificial, or ‘parenteral’ nutrition, where nutrients are provided through a vein or a tube inserted through the skin into the stomach.

Furthermore, the sores in the mouth from oral mucositis can weaken the protective lining of the mouth, increasing the risk of local or body-wide infections. In severe cases where oral mucositis has been caused by chemotherapy, it might be necessary to reduce the dose or postpone the next chemotherapy cycle. This can decrease the patient’s quality of life and make the overall treatment less effective.

What Causes Oral Mucositis?

Oral mucositis, a common side effect experienced by patients undergoing certain cancer treatments, is an inflammation of the mouth’s lining. This condition often affects individuals receiving radiation treatment to the head and neck, chemotherapy for solid tumors or lymphoma, and high-dose, intensive chemotherapy before a procedure to replace blood-forming cells called a hematopoietic cell transplantation.

The likelihood of developing oral mucositis varies, depending on the chemotherapy drug used. Drugs that interfere with the building blocks of DNA, such as 5-fluorouracil, methotrexate, and cytarabine, are particularly associated with a high risk of oral mucositis. Other medications, such as anthracyclines, mTOR inhibitors, alkylating agents, and antimetabolites, also carry an increased risk.

The lining of the mouth, known as the oral mucosa, rapidly produces new cells. Because of this fast cell turnover, the cells can be more easily damaged by radiation. When these cells die, and the lining of the mouth can’t heal properly, this can lead to oral mucositis.

Risk Factors and Frequency for Oral Mucositis

Mucositis is a side effect that affects 20% to 40% of patients with solid tumors who are undergoing chemotherapy. This usually starts five to fourteen days after beginning the treatment. The chances and intensity of mucositis can differ based on the type of chemotherapy used, the number of chemotherapy cycles, the dosage, and even from patient to patient. People who receive treatments that prepare them for stem cell transplant face a higher risk of oral mucositis.

Mucositis occurs in 20% to 40% of patients with solid tumors who take chemotherapy.
Mucositis usually starts 5 to 14 days after treatment begins.
The chances and severity of mucositis depend on the chemotherapy type, number of cycles, dosage, and individual patient factors.
People prepared for stem cell transplants face a higher risk of oral mucositis.
Patients receiving high doses of chemotherapy or undergoing bone marrow transplantation have a 76% risk of mucositis.
All patients who undergo a specific type of radiotherapy for head and neck cancer experience radiation-induced oral mucositis.
Patients with poor nutrition and inadequate oral care are more likely to experience mucositis.
Mucositis might be more common in younger patients.

Signs and Symptoms of Oral Mucositis

Oral mucositis caused by radiation therapy is a condition that happens due to the damage radiation causes to tissue. This normally starts around the third week of treatment and can last anywhere from a week to just over three months. The condition begins with inflammation in the tissue covering the inside of the mouth, tongue, and throat. The area that often is affected most is the soft part of the roof of the mouth. This can then be followed by the lower part of the throat, the floor of the mouth, cheeks, tongue, and lips. The pain from this usually severe and in many instances, radiation therapy must be paused. Patients usually find it difficult to eat or talk, and they might notice more bleeding when they brush their teeth.

Mucositis that comes about as a result of chemotherapy generally happens within a range of five to fourteen days after treatment. It usually starts with redness in the mouth lining, which then develops into sores and ulcers. A white layer that resembles a false membrane might cover these sores. Typically, these are only on the non-keratinized areas of the mouth, such as the inner cheeks, the outer and under the tongue, and the soft roof of the mouth.

The condition begins to improve when the number of a type of white blood cell known as neutrophils increases. This is especially true for people with weakened immune systems or those undergoing stem cell transplants for their blood.

Testing for Oral Mucositis

To check for oral mucositis, a condition where your mouth is sore and inflamed, your doctor will typically rely on your medical history and a physical examination of your mouth. Tests like blood work or x-rays aren’t usually helpful for this condition. If you have mouth sores on your upper mouth roof (hard palate), gums, or top of your tongue, your doctor might need to take samples from these sores. These will be used to ensure that these sores are not caused by any viruses or fungi.

To understand how serious your case of oral mucositis is, your doctor will use certain scales that have been specifically designed for this. These scales measure the severity of your condition.

One of these scales is the Common Terminology Criteria for Adverse Events (CTCAE). This was created by the National Cancer Institute (NCI) and measures the severity of your condition on a level from 1 to 5. The CTCAE is split into two parts, one is a physical examination and the other one is a functional and symptom-based examination.

For the functional and symptom-based part of the exam:
– Grade 1: You have very mild symptoms or none at all, and no treatment is necessary.
– Grade 2: There is moderate pain or a sore that doesn’t stop you from eating normally. You may need to change your diet a bit.
– Grade 3: There is severe pain that makes it difficult for you to eat.
– Grade 4: The symptoms are dangerously severe to your health and need immediate medical attention.
– Grade 5: In the most extreme cases, it can be life-threatening.

For the physical part of the exam:
– Grade 1: There’s redness of the inside of the mouth.
– Grade 2: There might be patchy sores or tissues that look like membranes covering sores.
– Grade 3: Even a small injury might lead to bleeding. There might be many sores or areas covered by membrane-like tissue.
– Grade 4: There may be tissue death, spontaneous bleeding, or other symptoms that are life-threatening.
– Grade 5: This is the most severe stage and is typically fatal.

Another scale used to measure the severity of oral mucositis is the World Health Organization (WHO) scale. It also grades severity on a level of 0 to 4, and combines both subjective elements (how you feel) and objective elements (what can be measured).

Grade 0: There is no presence of oral mucositis.
Grade 1: There is redness and soreness.
Grade 2: You have mouth ulcers (open sores in your mouth), but you can still eat solid food.
Grade 3: You have mouth ulcers, and you can only consume liquid food due to the mucositis.
Grade 4: You have mouth ulcers and cannot eat at all as a result of the mucositis.

In addition, there is the Oral Mucositis Assessment Scale (OMAS) which specifically measures redness and mouth ulcers. This scale also includes a review of nine specific parts in the mouth.

The Eastern Cooperative Oncology Group (ECOG) common toxicity criteria is another tool that is frequently used in cancer trials to evaluate conditions like oral mucositis.

Treatment Options for Oral Mucositis

If you’re undergoing cancer treatment and experiencing oral mucositis, which is painful mouth sores, your healthcare providers might use several approaches to ease your discomfort.

Basic oral care, including regularly brushing your teeth, using mouth rinses, and keeping the mouth moist, is often recommended to prevent oral infections and soothe discomfort. This care, suggested by groups like the Multinational Association of Supportive Care in Cancer and the International Society of Oral Oncology, also involves frequently checking the mouth before and during cancer treatment to spot early signs of oral mucositis.

Regular oral hygiene can prevent oral mucositis and minimize its duration and severity once it does happen. Uneventful dental procedures before starting cancer treatment, such as extracting unhealthy teeth or fixing cavities, can lessen the risks of oral mucositis.

You should be encouraged to enhance your routine tooth cleaning, which means brushing your teeth more frequently using a soft toothbrush, replacing the toothbrush regularly, and cleaning between your teeth.

It might be suggested to rinse your mouth with saline or sodium bicarbonate solution every four hours to maintain oral hygiene and comfort. Chlorhexidine is not recommended as it does not have known benefits in preventing oral mucositis caused by radiation therapy.

Benzydamine mouthwash, a kind of anti-inflammatory agent, is also recommended for preventing oral mucositis in patients receiving moderate doses of radiation or both radiation and chemotherapy.

Stay hydrated, avoid irritants such as tobacco and alcohol, and use barrier gels or mousses to keep the surfaces of your mouth lubricated. Your diet should avoid foods that could irritate or damage your mouth, like spicy, crunchy, or hard foods.

Topical morphine 0.2% mouth rinse might be recommended for managing pain, especially for patients receiving radiation and chemotherapy.

For some patients, low-level light or laser therapy might be recommended. It’s used to encourage healing of affected tissue and prevent inflammation.

During chemotherapy, keeping your mouth cold could help prevent oral mucositis. The cold causes the blood vessels in your mouth to constrict, preventing the cancer-killing drugs from getting to your oral tissues. This measure is usually used in conjunction with short chemotherapy treatments or when the drugs used don’t stay long in the body.

Palifermin, a medication known to promote growth and survival of certain cells in the body, is recommended for severe oral mucositis for patients undergoing certain stem cell transplant procedures.

Though zinc supplements were once suggested to preventive oral mucositis in oral cancer patients undergoing radiation, these are no longer recommended according to the most recent guidelines.

When doctors are trying to figure out what’s causing mouth sores or ulcers, they need to consider several possibilities:

Infections: While infections don’t directly cause these sores (known as oral mucositis), they can make the condition more complicated. For example, viral infections like herpes or fungal infections like candidiasis can occur at the same time.
Skin symptoms of other diseases: Some systemic inflammatory diseases, like systemic lupus erythematosus or rheumatoid arthritis, can also cause oral ulcers.
Oral cancer: Oral squamous cell carcinoma, a type of mouth cancer, can also present with mouth sores or ulcers.
Nutritional deficiencies: A lack of certain nutrients, like zinc, can cause oral lesions. In such cases, nutritionists often prescribe zinc supplements.

In each case, it’s crucial for doctors to accurately identify the cause so they can recommend the most effective treatment.

What to expect with Oral Mucositis

Treatment that focuses on relieving symptoms and improving quality of life (also known as palliative care) can sometimes be enough to manage simpler cases of mucositis. Mucositis is generally a condition that gets better on its own. However, almost 20% of patients with head and neck cancer who are undergoing chemotherapy and radiotherapy need to be admitted to the hospital and experience a delay in their cancer treatment because of severe mucositis. This can negatively affect patients’ quality of life, make their overall health outlook worse, and lead to increased use of medical resources.

Possible Complications When Diagnosed with Oral Mucositis

Oral mucositis, or the inflammation of the mouth’s mucous membranes, can cause severe pain and reduce the patient’s willingness to eat. This can severely impact the quality of life and nutritional health of the patient. It can also disrupt the patient’s course of chemotherapy treatment, potentially leading to worsened cancer outcomes. In addition, mucositis can weaken the protective lining of the mouth, making the patient more vulnerable to infections. To counteract this, chemotherapy protocols that increase the risk of mucositis often include prophylactic (preventative) oral care and antibiotics. This helps to prevent the onset of mucositis and septicemia – a serious bloodstream infection.

Common Issues Related to Oral Mucositis:

Severe pain in the mouth
Lessened oral intake
Deterioration of the patient’s quality of life
Worsening of the patient’s nutritional health
Interrupted chemotherapy treatment cycle
Potential worsening of cancer outcomes
Weakened protective lining of the mouth, leading to higher risk of infections
The need for preventative oral care and antibiotics in chemotherapy protocols
Possible development of septicemia – a serious bloodstream infection.

Preventing Oral Mucositis

Before starting chemotherapy or radiotherapy treatments that might contribute to oral mucositis, patients need to be informed about the signs and symptoms. Oral mucositis is a painful condition that causes inflammation and ulcers in the mouth. Identifying and treating this condition early can lead to better outcomes. Additionally, patients need to know when certain serious symptoms require immediate medical attention, such as having difficulty eating or drinking or concern for an infection.

Patients should also understand how crucial basic oral care is for their health, as well as how to avoid things that could irritate their mouth and the right diet to follow. Basic oral care includes brushing teeth regularly, using a soft toothbrush, and rinsing with a gentle mouthwash. Avoiding irritants could mean not eating spicy or hard food and not smoking. A healthy diet might involve avoiding acidic or spicy food and drinks, which can worsen the mouth’s condition. These strategies are explained in depth throughout your treatment plan.