Oral Mucositis – the disease, the symptoms, prevention and treatment

 Our mouth is an important organ and an integral part of our digestive system. Oral health is fundamental to systemic-well being of our body. However, Mucositis is a common condition that affect cancer patients receiving radiation or chemotherapy. Mucositis treatment is a big challenge for doctors and caregivers. 

What is Mucositis?

Mucositis is commonly described as the inflammation of the mucosal layer of the lining of the gastro-intestinal tract.  Mucositis condition occurs as oral mucositis and esophagitis. There are many treatments of Oral Mucositis and Esophagitis for temporary and long-term relief, but depending upon the severity of the Oral Mucositis a treatment is followed. 

What is a Mucosal layer?

Mucosa is the outer layer of membrane that lines our gastro-intestinal tract including mouth, throat, oesophagus, and stomach. The mucosal membrane lining our mouth, or the oral cavity is called Oral Mucosa. Oral Mucosal layer performs several functions for our body:

1. Protection – It protects tissue and glands in our mouth

2. Secretion – It secretes saliva through salivary glands which play an important part in digestion

3. Sensation – It receives sensation of pain or discomfort in oral cavity

What is Oral Mucositis?

Oral Mucositis is commonly described as the acute inflammation of oral mucosal layer of oral cavity, tongue, and pharynx. It is also designated as Stomatitis. It is characterized by the presence of erythematous areas on the lining of your mouth, tongue, and oesophagus.

What are the symptoms of Oral Mucositis?

As described Oral Mucositis is concerned with the deterioration of the mucous membrane lining of the gastrointestinal tract and oral cavity. The adverse effects can be seen and felt in the oral cavity and gastro-intestinal tract. The general symptoms or Oral Mucositis are

• swollen gums

• soreness in mouth and throat

• sores in mouth and on tongue

• difficulty in swallowing 

• soft whitish patches in mouth or on tongue

• mild burning, or pain when eating food

• dryness in mouth and throat

• increased mucous or thicker saliva

What causes Oral Mucositis?
It is generally occurs among cancer patients who undergo radio-chemotherapy for malignant diseases especially person with low white cell blood count. Apart from chemo-radiotherapy, mucositis is also observed to occur in people receiving bone marrow transplants (BMTs). So, the condition of Oral Mucositis induced by radiation is also called Radiation Induced Oral Mucositis (RIOM). When caused by radiation, mucositis is usually due to the necrotic and inflammatory effect of radiation on oral mucosal membrane.

So, Oral Mucositis occurs primarily as the negative effect of chemotherapy (CT) and radiotherapy (RT) on the oral cavity. As discussed, it also occurs in patients receiving BMT treatments, stem cell transplants and on consumption of chemotherapy medication. You must always ask your doctor if the chemotherapy you receive causes mucositis. Even total body irradiation causes mucositis.  

What factors increases the chances of getting Oral Mucositis?

Besides Chemotherapy or Radiation Therapy, there are several factors that increases your chances of getting mucositis.

• Poor oral health

• Poor dental care. 

• Smoking or chewing tobacco. 

• Drinking alcohol. 

• Dehydration. 

• Diseases such as kidney disease, diabetes, or HIV/AIDS.

• Women are more likely to get it than their male counterparts

• Low Body Mass Index

• Patient with hematologic malignancies

WHO - Oral Toxicity Scale

World Health Organization Oral Toxicity Scale measures the anatomical, symptomatic, and functional elements of Oral Mucositis.

The toxicity is graded on a scale of 1-4, whereby grade 3 and 4 are categorized as severe cases of Oral Mucositis. Below is the standard scale to grade the toxicity of Oral Mucositis.

Grade 0 = No oral mucositis

Grade 1 = Erythema and Soreness

Grade 2 = Ulcers, able to eat solids

Grade 3 = Ulcers, requires liquid diet (due to mucositis)

Grade 4 = Ulcers, alimentation not possible (due to mucositis)

Treatment of Mucositis depends upon the severity of the Mucositis. Once the severity of Mucositis is determined, the treatment of mucositis is planned.  

What preventive steps you can take?

When you undergo a chemotherapy or radiation therapy regimen, it is hard to stop or avoid the onset of Oral Mucositis, but you can take a few steps to lessen the severity of it.     

Here is what you can do:

• Consult a dentist dealing with cancer patients

• If you wear denture, please make sure they fit well.

• Follow a good oral care regimen

• Rinse your mouth with salt water. Rinse your mouth before and after the meal with normal saline or salt and soda

• Avoid alcohol-based mouthwash

• Quit smoking

• Keep lips moist. Avoid Vaseline.

• Keep a tab on your platelet count. If below 40,000 avoid using dental floss.

• Do include high protein foods in your diet such as eggs, peanut butter, meat, fish, and dairy products, such as milk, cheese, and yogurt (Greek yogurt is recommended as it is high in protein).

• Do not eat spicy of acidic food

• Do not take painkillers without consulting your doctor

• Do not take tobacco

• Increase your intake of fluids especially if your intake is less than 12 cups of water a day.

• Avoid carbonated beverages.

• Eat smaller, more frequent meals throughout the day, rather than three large meals.

• Take Cryotherapy - sucking on ice chips during chemotherapy administration is effective

Suggestions for Oral Care
Simple steps can be big steps in easing the discomfort of mucositis and ease the condition.

You must check the entire mouth twice a day. If you wear dentures, report if they loosen or if notice any change to your dentist.

Rinse your mouth (swish, lightly gargle and spit) before and after meals and at bedtime with Salt water. You can also use salt and soda and mix it with water for mouth rinses.

Use a soft-bristle toothbrush. Make the brush bristles softer by soaking your toothbrush in hot water.

Avoid toothpastes with whiteners or other additives.

Avoid products that irritate mouth and gums 

Suggestions for topical treatment and pain relief from Mucositis

You may take the below actions to treat mucositis to reduce the pain and the discomfort arising from it:

• Use ice pops, or ice chips. It may numb the area and provide temporary relief.

• Topical pain relivers as prescribed by doctors

• Lozenges are also known to effective treat mucositis providing much needed relief. Medicated lozenges including Cepacal lozenges or Cholraseptic spray and lozenges may also offer relief are used as treatment regimen for Oral Mucositis.

• You may use gentle mouthwash

• Swishing mouth with diluted milk magnesia.

• A popular topical treatment for oral mucositis is "Magic Mouthwash,” a mix of lidocaine, diphenhydramine, and Maalox. It is best to use lidocaine alone in a swish and spit method.   

Why Mucositis is a bigger problem

In addition to sores, the pain and difficulty in eating and drinking, Oral Mucositis imposes significantly serious dangers.

Mucositis also due to severe pain leads to interruption or dose reduction of cancer therapy, adversely impacting the effect of the chemo-radiation therapy on tumour. Patients with multicycle chemo-radiation therapy have been known to have increase possibility of cancer recurrence and decreased survival rates. Not to mention the increased cost of care and cure.  

It is always best to consult your doctor every kind of treatment and care for your Oral Mucositis. You could also try an online forum like:

Cancer Research UK: cancer chat

Macmillan Cancer Support: online community