Mucositis

Background

[1]

  • One of the most common side effects of cancer treatment with chemotherapy or radiation
  • Occurs in almost all cases of head or neck radiation
  • 20-80% of people who receive chemotherapy
  • Major dose limiting toxicity of chemotherapy and head and neck radiation therapy

Clinical features

  • Erythema and ulcerations of the mucosal lining of the gastrointestinal tract
  • Causes dysphagia, changes in taste, secondary infections, weight loss
    • Oral mucositis is associated with increased inpatient hospitalization duration, bacteremia and higher 100‐day mortality.
    • GI mucositis is associated with nausea, vomiting, bloating, diarrhea, intestinal cramping and anal pain.

Differential Diagnosis

  • Oral candidiasis
  • Herpes simplex virus infection
  • Acute Graft-versus-Host disease

Evaluation

Grading system: National Cancer Institute Common Terminology Criteria for Adverse Events(CTCAE)[2]

  • Grade 1 - Aysymptomatic or mild symptoms, no intervention needed
  • Grade 2 - Moderate pain or ulcer that does not interfere with oral intake, modified diet indicated
  • Grade 3 - Severe pain, interfering with oral intake
  • Grade 4 - Life threatening consequences; urgent intervention indicated
  • Grade 5 - Death

Workup

No specific requirements, base on patients clinical presentation

Diagnosis

Clinical history and exam

  • Stomatotoxic effect begins approximately 7 days after therapy
  • Erythema of the soft tissue of buccal mucosa or soft palate and burning sensation in mouth->elevated, white desquamative patches->epithelial sloughing leading to shallow ulcerations with pseudomembranous look->coalesce into large, painful ulcerations

Management

2020 guidelines from Multinational Association of Supportive Care in Cancer and International Society for Oral Oncology (MASCC/ISOO):

  • Prevention with multi agent, combination oral care[3]
    • Tooth brushing, flossing, mouthwashes (bland rinses, reduce bacterial build‐up) and applying moisturizing agents to the oral mucosal surfaces
  • benzydamine mouthwash for prevention
  • Topical morphine 0.2% mouthwash
  • Honey
  • Mucosal-protective agents(oral antacids, Gelcair, Orabase, Episil, topical kaolin/pectin) without any concrete evidence showing effectiveness
  • Saline and sodium bicarb rinses
    • No strong evidence but relatively harmless, expert opinion level of recommendation

Chewing gum was NOT effective in preventing oral mucositis in pediatrics

Disposition

  • Will require admission if PO intolerance, significant weight loss

See Also

External Links

References

  1. Daugėlaitė G, Užkuraitytė K, Jagelavičienė E, Filipauskas A. Prevention and Treatment of Chemotherapy and Radiotherapy Induced Oral Mucositis. Medicina (Kaunas). 2019;55(2):25. Published 2019 Jan 22. doi:10.3390/medicina55020025
  2. Common Terminology Criteria for Adverse Events (CTCAE), Version 5.0, November 2017, National Institutes of Health, National Cancer Institute. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf (Accessed January 6th, 2020)
  3. Elad S, Cheng KKF, Lalla RV, et al. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431. doi:10.1002/cncr.33100
  • Epstein JB, Schubert MM. Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology (Williston Park). 2003;17(12):1767-1792.
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