Oral mucositis, also called stomatitis, is a common, debilitating complication of cancer chemotherapy and radiotherapy, occurring in about 40% of patients. It results from the systemic effects of cytotoxic chemotherapy agents and from the local effects of radiation to the oral mucosa. Oral mucositis is inflammation of the mucosa of the mouth which ranges from redness to severe ulceration. Symptoms of mucositis vary from pain and discomfort to an inability to tolerate food or fluids. Mucositis may also limit the patient’s ability to tolerate either chemotherapy or radiotherapy. Mucositis may be so severe as to delay treatment and so limit the effectiveness of cancer therapy. Patients with damaged oral mucosa and reduced immunity resulting from chemotherapy and radiotherapy are also prone to opportunistic infections in the mouth. The mucositis may affect patients’ gum and dental condition, speech and self esteem are reduced, further compromising patients’ response to treatment and/or palliative care. It is therefore extremely important that mucositis be prevented whenever possible, or at least treated to reduce its severity and possible complications.
High dose chemotherapy, and localized high dose radiation therapy to the head and neck region (e.g. for treatment of head and neck cancer and lymphoma), are the main risk factors for developing oral mucositis. These treatments effectively target the rapidly dividing cancer cells, but also inadvertently affect normal healthy tissues that rapidly turnover, such as the lining of the inside of the mouth (oral mucosa). A complicated series of biological events are triggered that ultimately compromises the integrity of the oral mucosa. Minor trauma to the mouth from speaking, chewing, and swallowing is sufficient to breakdown the mucosa, resulting in the formation of painful ulcerations. Individuals undergoing chemotherapy or radiation therapy are often advised to eat a soft or liquid diet.
Impact of Oral Mucositis
Symptoms of discomfort and pain often precede the visible tissue changes in the mouth and throat. In the earliest stages, there may be distinct areas of redness (erythema). The red areas soon progress to form painful ulcerations, which usually appear as round or linear yellow/white plaques. The insides of the cheeks and lips and the sides and underside of the tongue are the most commonly affected sites (see images below). The ulcers can vary in size and shape, ranging from very small to extensive. Small ulcerations may only be mildly discomforting, while more extensive ulcerations may cause pain so severe as to interfere or prevent with eating and drinking. When such severe cases occur, the use of feeding tubes may be required to ensure the patient obtains adequate nutrition and hydration.
Recommendations – Oral Care Protocol
All patients at risk of developing mucositis should receive a standardised oral care regime as an ongoing component of their care. The aim of this regimen is to achieve and maintain a clean mouth and to limit opportunistic infection via the damaged mucosa.