All About Mucositis
What is the mucosa?
The mucosa is the thin outer layer that lines most organs including your mouth, throat, esophagus, stomach, and bowel. The mucosa is made up of epithelial cells that make mucous. Epithelial cells divide and replicate rapidly. Imagine this: if you bite your lip, the tissue is often able to heal by the next day because of this rapid growth.
What is mucositis?
Mucositis is inflammation of the mucosa that can cause mouth sores, oral mucositis, or esophagitis. It can range from a red, sore mouth and/or gums to open sores that can cause you to be unable to eat. Chemotherapy and radiation therapy kill not only cancer cells, but other rapidly dividing cells as well, including the lining of the entire gastrointestinal (GI) tract. These treatments can lead to mucositis.
Oral mucositis can lead to several problems:
- Nutritional issues as a result of not eating enough.
- Increased risk of infection due to open sores in the mucosa.
Mucositis can affect your quality of life and can be dose-limiting (meaning the dose of chemotherapy may be lowered).
What are the signs and symptoms of mucositis?
The signs and symptoms of mucositis can vary but can include:
- Red, shiny, or swollen mouth and gums.
- Blood in the mouth.
- Sores in the mouth, including on the gums or tongue.
- Soreness or pain in the mouth or throat.
- Trouble swallowing or talking.
- Feeling of dryness, mild burning, or pain when eating food.
- Soft, whitish patches or pus in the mouth or on the tongue.
- Increased mucus or thicker saliva in the mouth.
Who gets mucositis?
Certain treatments can lead to mucositis.
- Radiation to the head, neck, or chest areas.
- Bone marrow or stem cell transplant.
- Certain chemotherapy medications. Ask your provider if the chemotherapy you receive causes mucositis.
- Total body irradiation.
Factors that can increase your chance of getting mucositis, or that can make it worse if it does occur, include:
- Poor oral or dental health.
- Smoking or using chewing tobacco.
- Drinking alcohol.
- Diseases such as kidney disease, diabetes, or HIV/AIDS.
It can be hard to manage mucositis and to determine how bad a case is because each person is different. The World Health Organization (WHO) oral toxicity scale is one of a number of grading systems that is used to stage the severity of mucositis:
Examples of mucositis:
Mucositis with candida infection (thrush)
Prevention and Treatment
There have been studies trying many different medications and interventions to reduce the incidence and severity of oral mucositis. Only a few of these interventions have shown much success.
A good oral care regimen can help in preventing or decreasing the severity of mucositis and can help prevent infection through open mouth sores. Mouth rinses are an important part of mouth hygiene. Many studies have shown that salt water is the best and most cost-effective mouth rinse available. A mouth rinse aides in removing debris and keeping the oral tissue moist and clean. Other parts of good oral hygiene are using mouth and lip moisturizers, using a soft-bristle toothbrush, maintaining adequate intake of fluids and protein, and avoiding irritating foods, alcohol, and tobacco.
Example of oral care protocol:
- Rinse mouth (swish and spit) before and after meals and at bedtime with either:
- Normal saline (1 tsp of table salt to 1 quart (32 oz.) of water).
- Salt and soda (1 tsp of salt and 1 tsp of baking soda in 1 quart of water).
- Use a soft-bristle toothbrush after meals and at bedtime. If the brush causes pain, toothettes may be used.
- Use a non-abrasive toothpaste (or mix 1 tsp baking soda in 2 cups water). Avoid toothpastes with whiteners.
- Keep lips moist with moisturizers.
- Avoid products that irritate the mouth and gums:
- Avoid commercial mouthwashes and those with alcohol.
- Limit the use of dental floss.
- Do not use lemon or glycerin swabs. Use only a soft bristle toothbrush.
- Increase your fluid intake (how much fluid you drink).
- Try to include foods high in protein in your diet.
- Avoid hot, spicy, or acidic foods, alcohol, hard or coarse foods (crusty bread, chips, crackers).
- If you wear dentures:
- Remove whenever possible to expose gums to air.
- Loose-fitting dentures can irritate the mouth and gums and should not be worn.
- Do not wear dentures if mouth sores are severe.
Do not smoke cigarettes, cigars, or pipes. Do not use smokeless tobacco (chewing tobacco, snuff).
Cryotherapy, which is when you suck on ice chips while getting your chemotherapy, has shown some effect in preventing mucositis caused by certain chemotherapies.
Gelclair® and Zilactin® work by coating the mucosa to form a barrier for exposed nerve endings. They help control pain and increased the ability to eat and speak in clinical trials. Amifostine (Ethyol®), a drug that protects against the damage to the mucosa caused by radiation, is approved by the FDA for patients receiving radiation therapy for cancers of the head and neck. Studies have shown that amifostine can reduce dry mouth and may prevent mouth sores; however, more research is needed. Other agents that have been studied include: capsaicin (derived from chili peppers), glutamine, prostaglandin E2, Vitamin E, sucralfate, and allopurinol mouthwash.
Keratinocyte growth factor (KGF) is a substance made in the body that promotes the growth, repair, and survival of cells that protect the lining of the mouth and GI tract. A manmade version of human KGF has been developed as the drug palifermin. It is currently used for patients with hematologic malignancies or blood cancers (leukemias, lymphomas, and myelomas) who are undergoing bone marrow or stem cell transplant. Palifermin was found to decrease the length and severity of mucositis in these patients.
Pain can be a challenge for people with mucositis. In mild cases, ice pops, water ice, or ice chips may help numb the area, but you may need more intervention for relief or pain.
Topical pain relievers (that you apply to the mucosa) include lidocaine, benzocaine, dyclonine hydrochloride (HCl), and Ulcerease® (0.6% Phenol). One of the issues of using topical agents is that you can't always coat all areas and that the pain relief is brief. If you don't achieve pain relief with topical agents, oral or intravenous (IV) medications are needed. In some cases, if you need IV pain medications, you may need to stay in the hospital until the mucosa begins to heal, particularly if you are unable to swallow. This side effect is temporary and the use of medications for pain relief will be temporary as well. You should not "suffer through it" to avoid using medications. You will not become addicted to them when used for this very real pain.
One popular topical treatment is "magic mouthwash,” a mix of lidocaine, diphenhydramine, and Maalox. This has not been proven effective and Maalox further dries the tissue, which can add to the problem. It is best to use lidocaine alone in a swish and spit method.
If you are receiving radiation therapy to the chest/head/neck area or chemotherapy you should examine your mouth at least once a day for redness, sores, or signs of infection. You should notify your healthcare team if you notice worsening sores, white patches, pus, a "hairy" or thick feeling tongue, bleeding in the mouth, or a fever (temperature greater than 100.4°F [38°C]).
Research continues into many new agents to prevent or treat mucositis, but at this point, it remains a challenging, costly, and distressing side effect.
Mucositis Tip Sheet: Here you will find helpful tips about oral mucositis (mouth sores). You will find information that explains what oral mucositis is, why it happens, how it is treated, and what you can do to prevent yourself from developing it.
Materials and photos adapted from Amgen Inc., 2006 teaching materials on Palifermin (Kepivance™)
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