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Oral Mucositis
Oral mucositis refers to erythematous (reddened) and ulcerative lesions of the oral mucosa
observed in patients with cancer being treated with chemotherapy and / or with radiation
therapy to areas involving the oral cavity.

Oral mucositis is often very painful and can result in odynodysphagia (painful swallowing),
dysgeusia
(bad taste in mouth) & subsequent dehydration & malnutrition, compromising
nutrition and oral hygiene as well as increase risk for local and systemic infection.
What is Oral Mucositis?

Oral mucositis (also called stomatitis, though in this context, it is the diffuse inflammatory, ulcerative condition
affecting the mucous membranes lining the mouth), is a common, debilitating complication of cancer chemotherapy
& radiotherapy.  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
oral mucositis vary from pain & discomfort to an inability to tolerate food or fluids.

Oral mucositis may also limit the patient’s ability to tolerate either chemotherapy or radiotherapy.  Oral mucositis
may be so severe as to delay treatment and so limit the effectiveness of cancer therapy.

Patients with
oral mucositis are also prone to opportunistic infections in the mouth.  The mucositis may affect
patients'
gingival (gums) & dental condition, speech & 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.

Oral mucositis typically occurs 7 - 14 days after chemotherapy or radiotherapy and may last for 2-3 weeks after
the completion of treatment.

It is important to take preventative measures against
oral mucositis and to recognise and treat it promptly and
effectively if it occurs.
Last Updated 5th April 2020
Useful Websites:

The Oral Cancer Foundation

Wikipedia

NHS Choices

MedLine Plus

OncoLink

Medscape / Emedicine

American Academy of Oral Medicine

Head & Neck Cancer Alliance

NICE

Cochrane Review - Interventions for preventing oral mucositis in patients with cancer receiving treatment: oral
cryotherapy

Cochrane Review - Interventions for treating oral mucositis for patients with cancer receiving treatment

Cochrane Review - Can oral cryotherapy help to prevent chemotherapy‐induced oral mucositis?

Cochrane Review - Can keratinocyte growth factor (KGF) help to prevent oral mucositis in people receiving cancer
treatment?

Cancer Care

Mouth Cancer Foundation

Emedicine.com

BMJ Best Practice


Useful Articles:

Best Practice 1998.  Prevention & Treatment of Oral Mucositis in Cancer Patients

CA Cancer J Clin 2001.  Oral Mucositis Complicating Chemotherapy and or Radiotherapy - Options for Prevention
and Treatment

Brit J Cancer 2003.  Oral Mucositis & Selective Elimination of Oral Flora in Head & Neck Cancer Patients receiving
Radiotherapy - A Double-Blind Randomised Clinical Trial

Cancer 2004.  Clinical Practice Guidelines for the Prevention & Treatment of Cancer Therapy–Induced Oral &
Gastrointestinal Mucositis

Neoplasia 2004.  Chemotherapy-Induced and  or Radiation Therapy-Induced Oral Mucositis - Complicating the
Treatment of Cancer

Summary of 2004 MASCC Guidelines for the Treatment of Oral and GI Mucositis

Clinical J Oncology Nursing 2005. Current Trends in Managing Oral Mucositis

Dent Clin North Am 2008. The effectiveness of strategies for preventing and treating chemotherapy & radiation
induced oral mucositis in patients with cancer

Dent Clin North Am 2008.  Management of Oral Mucositis in Patients with Cancer

Malaysian J Med Sci 2008.  Current Trends in the Management of Oral Mucositis related to Cancer Treatment

Cochrane Collaboration 2010.  Interventions for treating oral mucositis for patients with cancer receiving treatment
(Review)

Int J Head & Neck Surg 2010.  Strategies in Management of Oral Mucositis

Int Dent J Student’s Res 2012.  Oral Mucositis – Management Protocol By Oral Physician

Cochrane Collaboration 2013.  Interventions for preventing oral mucositis for patients with cancer receiving
treatment (Review)

Pharmacovigilance 2013.  Oral Mucositis and Stomatitis Associated with Conventional & Targeted Anticancer
Therapy

Cancer 2014.  MASCC  ISOO Clinical Practice Guidelines for the Management of Mucositis Secondary to Cancer
Therapy

J Clin Exp Dent. 2014.  Prevention & Treatment of Oral Mucositis in Patients receiving Chemotherapy

Ann Oncol 2015.  Management of Oral & Gastrointestinal Mucosal Injury.  ESMO Clinical Practice Guidelines for
Diagnosis, Treatment & Follow-Up

Integrative Cancer Therapies 2016.  Natural Products for Management of Oral Mucositis Induced by Radiotherapy
& Chemotherapy

BMJ Supportive & Palliative Care 2017.  Guideline for the Prevention of Oral & Oropharyngeal Mucositis in Children
receiving Treatment for Cancer or undergoing Haematopoietic Stem Cell Transplantation

Front Oncol 2017.  Radiation-induced Oral Mucositis

Int J Mol Sci 2017.  Oral Mucositis - Melatonin Gel an Effective New Treatment

Stomatological Dis Sci 2017.  Chemotherapy - Oral Side Effects & Dental Interventions.  A Review of the Literature

Integrative Cancer Therapies 2018.  Adjunctive Treatments for the Prevention of Chemotherapy & Radiotherapy-
Induced Mucositis

J Clin Oncol Oncology Practice 2020.  Evidence-Based Management of Oral Mucositis



European Oral Care in Cancer Group Oral Care Guidance & Support.  1st Edition

UK Oral Mucositis in Cancer Group.  2nd Edition.  Mouth Care Guidance & Support in Cancer & Palliative Care

UK Oral Mucositis in Cancer Group.  3rd Edition.  Mouth Care Guidance & Support in Cancer & Palliative Care
Photos of Oral Mucositis
What are the signs & symptoms & how is it diagnosed?

The diagnosis of oral mucositis is based on the symptoms the patient is experiencing and the appearance of the
tissues in the mouth following chemotherapy or radiotherapy.  The severity of
oral mucositis can be evaluated
according to several different assessment tools.

A number of scales are available, including those developed by the WHO, the Radiation Therapy Oncology Group,
the Western Consortium for Cancer Nursing Research & the National Cancer Institute (NCI), amongst others.

Two of the most commonly used scales are the
WHO Oral Toxicity Scale and the NCI Common Toxicity Criteria
for oral mucositis
.

While the
NCI system has separate scores for appearance (erythema & ulceration) and function (pain & ability to
eat solids, liquids or nothing by mouth), the
WHO score combines both elements into a single score that grades the
severity of the condition from 0 (no
oral mucositis) to 4 (swallowing not possible, such that patient needs
supplementary nutrition).
What are the causes of Oral Mucositis?

Treatments most commonly associated with oral mucositis include:

  • Anti-metabolites e.g. 5-FU, capecitabine, methotrexate
  • Anthracyclines e.g. epirubicin, doxorubicin
  • All lymphoma or leukæmia patients who have recently had treatment
  • Tyrosine Kinase Inhibitors (such as sunitinib, pazopanib, afatinib) and everolimus
  • Radiotherapy to the head & neck region

It is important to take preventative measures against mucositis and to recognise and treat it promptly & effectively
if it occurs.
How is it treated?

Many different treatments are used to mitigate, possibly prevent or ameliorate the oral mucositis.

Treatment of
mucositis is mainly supportive, with both non-pharmacological and pharmacological options.
Non-pharmacological methods include:

  • Preventive strategies involving a pre-treatment dental examination and improved dental hygiene, since good
    oral hygiene is the mainstay of treatment.  Patients should be encouraged to clean the mouth every 4 hours
    and at bedtime, and more often if the mucositis worsens.  Patients should have the mouth checked regularly,
    brush the teeth with a gentle toothbrush two or three times daily, use a non-detergent toothpaste, floss
    between the teeth & use an alcohol-free mouthwash

  • The use of artificial saliva & water-soluble jellies to lubricate the mouth.  Dry-mouth lozenges & dry-mouth gum
    also may be used (see below)

  • The use of saline / baking soda mouthwash to soothe the pain & remove food particles to avoid infection

  • Drinking plenty of liquids - at least 3 litres per day - & avoiding alcohol

  • Avoiding citrus fruits, tomatoes, acidic foods, alcohol & hot foods that can aggravate mucositis lesions.  
    Ingested food should be soft, non-spicy, pureed or in liquid form.  Harder foods should be treated to make
    them soft and easy to eat

  • Refraining from smoking

  • Sucking ice cubes.  This is a simple, but often effective, method of relieving the symptoms of oral mucositis
Pharmacological options include:


  • Interventions to reduce the mucosal toxicity of chemotherapy drugs (eg allopurinol M/W 4 – 6 x daily &
    cryotherapy)

  • Mouthwashes with mixed action (eg benzydamine hydrochloride, corticosteroids & chamomile)

  • Immunomodulatory agents (eg Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF) & Granulocyte
    Colony Stimulating Factor (G-CSF))

  • Topical anaesthetics (eg dyclonine HCl, viscous lignocaine with 1.0 % cocaine & a solution containing kaolin-
    pectin, diphenhydramine & saline)

  • Antiseptics (eg Chlorhexidine, Povidone Iodine & Hydrogen Peroxide)

  • Antibacterial, antifungal & antiviral agents (eg Nystatin, Clotrimazole & PTA lozenges (polymixin E, tobramycin
    and amphotericin B); Clotrimazole alone, or in combination with Polymixin B & Tobramycin; Acyclovir)

  • Mucosal barriers and coating agents (eg Sucralfate, sodium alginate, kaolin-pectin, plastic wrap film, radiation
    guards & antacids)

  • Cytoprotectants (eg β-carotene (pro-vitamin A), Vitamin E, Oxpentifylline, Azelastine, Prostaglandins E1 & E2)

  • Mucosal cell stimulants (low energy laser treatment, Silver nitrate, glutamine)

  • Psychotherapy (Cognitive Behaviour Training, Relaxation & Imagery Training, Hypnosis & Therapist Support)

  • Analgesics (Patient Controlled Analgesia, Alfentanil, Morphine, Capsaicin)

  • Drugs for dry mouth & artificial saliva