Mucositis
Mucositis is a painful condition characterized by ulceration in the mouth and gastrointestinal tract, often occurring as a side effect of cancer treatments such as radiation and chemotherapy. It can manifest as oral mucositis, affecting the mouth, or gastrointestinal mucositis, impacting the esophagus, intestines, and anus. The risk of developing mucositis is closely tied to the intensity of cancer therapies, with up to 100% of patients receiving high-dose radiation experiencing some degree of this condition. Symptoms typically arise one week after chemotherapy or two weeks post-radiotherapy, beginning with redness and swelling, and escalating to painful ulcers that can interfere with eating and lead to complications like infections and malnutrition. Diagnosis is based on clinical observation, with severity classified into grades by the World Health Organization. Treatment focuses on pain management and infection control, as mucositis often resolves naturally after therapy concludes. Preventative measures, such as maintaining good oral hygiene and addressing dental issues before treatment, can significantly reduce the risk and severity of mucositis. Ongoing research aims to enhance treatment options, with certain FDA-approved medications showing promise in prevention and management.
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Subject Terms
Mucositis
ALSO KNOWN AS: Oral mucositis, gastrointestinal mucositis
RELATED CONDITIONS: In extreme cases, bacteremia and sepsis, radiation-induced oral mucositis (RIOM)
DEFINITION: Mucositis is ulceration in the mouth (oral mucositis) and esophagus, intestines, and anus (gastrointestinal mucositis) as a side effect of radiation or chemotherapy for cancer.
Risk factors: Mucositis is directly related to therapeutic radiation and chemotherapy. Genetic factors may cause some people to be more sensitive or resistant to cellular damage following therapy.
Etiology and the disease process: Radiation and chemotherapy kill cancer cells but can also damage normal tissue in the gastrointestinal tract. Endothelial cells, which make up the capillaries under the skin, and fibroblast cells, which build connective tissue, are the most sensitive to therapeutic damage. These cells produce important growth factors that maintain the epithelial cells on the surface lining of the gastrointestinal tract. Because of cell death and inflammation, ulcers form along the gastrointestinal tract.
Incidence: Up to 100 percent of patients who receive high-dose radiation treatment will develop some level of mucositis. Between 20 and 40 percent of chemotherapy patients with solid tumors and more than 90 percent of patients undergoing radiotherapy for head and neck cancers develop mucositis. Patients can lower their risk by up to 25 percent by visiting the dentist before treatment begins to address any outstanding oral issues.
Symptoms: Symptoms often begin one week after chemotherapy and two weeks after radiotherapy. Redness of the skin resulting from capillary congestion (erythema) and swelling are early symptoms. More advanced cases develop ulcers in the mouth and intestines a few days following cancer treatment. Patients may also experience diarrhea, nausea and vomiting, a drop in blood volume (hypovolemia), dry mouth, fungal mouth infection, change of taste, and loss of appetite. Ulcers can become infected, and infection can spread to the blood (bacteremia). Patients often stop eating because of the pain. Severe complications may lead to death due to blood infection (sepsis), electrolyte imbalances, and malnutrition.
Screening and diagnosis: Mucositis is diagnosed by clinical observation of symptoms according to different grades established by the World Health Organization:
- Grade 0: No symptoms
- Grade 1: Erythema
- Grade 2: Erythema, ulcers, can eat solid food
- Grade 3: Ulcers, liquid-only diet
- Grade 4: Ulcers, assisted (parenteral) feeding necessary
Treatment and therapy: After therapy ends, mucositis will resolve without treatment. While mucositis persists, palliative treatment is given, including narcotics for pain, antibiotics for infections, and assisted feeding.
Research on drugs and other interventions to prevent and treat mucositis is ongoing. The Food and Drug Administration approves Palifermin (Kepivance) and Amifostine (Ethyol) for treating oral mucositis. Palifermin, a keratinocyte growth factor, is related to a hormone that stimulates epithelial cells. Before radiation therapy, palifermin strengthens and protects the oral epithelium, making it much more resistant to developing mucositis. Amifostine is prescribed to patients undergoing radiation of the head or neck to prevent mucositis. It is also used in patients with oral cancer. Low-level laser therapy can also help prevent or lessen oral mucositis.
Prognosis, prevention, and outcomes: Most patients recover from mucositis, though a small percentage die from complications. Cancer therapy is often reduced or stopped because of mucositis, which may compromise cancer care. To prevent mucositis or limit its severity, good oral hygiene is essential. Brushing and flossing teeth twice daily, chewing sugar-free gum, and using lip balm must be prioritized. Rinsing with warm salt water, staying hydrated, and avoiding spicy, hot, alcohol-based, or crunchy foods also help keep patients comfortable.
Bibliography
Bell, Andrea, and Anup Kasi. "Oral Mucositis." National Library of Medicine, 29 May 2023, www.ncbi.nlm.nih.gov/books/NBK565848. Accessed 20 June 2024.
Gersten, Todd. "Oral Mucositis." MedlinePlus, 25 Jan. 2022, medlineplus.gov/ency/patientinstructions/000047.htm. Accessed 20 June 2024.
"Mouth Sores and Pain." American Cancer Society, 24 Sept. 2021, www.cancer.org/cancer/managing-cancer/side-effects/eating-problems/mouth-sores.html. Accessed 20 June 2024.
"Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ(R))." National Cancer Institute, 21 Oct. 2022, www.ncbi.nlm.nih.gov/books/NBK65881.5/?report=printable. Accessed 20 June 2024.
Singh, Vibha, and Akhilesh Kumar Singh. “Oral Mucositis.” National Journal of Maxillofacial Surgery, vol. 11, no. 2, 2020, pp. 159-168. doi:10.4103/njms.NJMS‗10‗20.
Worthington, H. V., et al. "Interventions for Preventing Oral Mucositis for Patients with Cancer Receiving Treatment." Cochrane Database of Systematic Reviews, vol. 4, 13 Apr. 2011, doi.org/10.1002/14651858.CD000978.pub5.