Oral Mucositis - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

A universal complication that most cancer patients encounter during treatment is oral mucositis. It is a painful condition that interrupts cancer treatment, prolongs hospitalization, and affects the patients' overall health by compromising food intake. It is treatable and resolves over weeks to months following the completion of cancer therapy.

What Is Oral Mucositis?

The mucosa is a thin lining that outlines most organs, including the mouth, stomach, esophagus, etc. Oral mucositis is an inflammation in the mucosa lining the mouth, presenting as redness, swelling, bleeding, and ulcers in the mouth, tongue, and throat. It is an acute reaction that starts anywhere between the fifth and the tenth day after the recent dose of chemotherapy and resolves in a few weeks or months.

What Are the Causes of Oral Mucositis?

• Oral mucositis could be a complication to different modes of cancer treatments like radiotherapy or chemotherapy.

• In patients undergoing chemotherapy, mucositis results from low white blood cell levels, whereas in radiotherapy, it occurs as an adverse effect of radiation.

• The severity of mucositis varies with the treatment type (chemotherapy or radiotherapy), the type of drug used in chemotherapy, the number of treatment cycles, the dosage of drug intake, and individual susceptibility.

What Are the Symptoms of Oral Mucositis?

The symptoms of oral mucositis are similar to any other oral infection, making it difficult to distinguish. The common symptoms of oral mucositis include;

• Swollen mouth, gums, tongue, etc.

• Dryness of mouth.

• Thick and ropey saliva.

• Generalized pain and burning sensation in the mouth and sometimes even in the throat, which results in eating difficulty.

• Bleeding.

• Whitish patches and deposits in the mouth.

• Difficulty in oral hygiene maintenance.

• Difficulty in speaking.

What Are the Phases of Oral Mucositis?

There are five phases in oral mucositis, which includes;

1. Initiation - This is the first stage, wherein the cancer therapies cause cell damage, but the mucosa remains undisturbed.

2. Signaling - In response to the cell damage experienced, inflammation and tissue damage occur.

3. Amplification - Progression in inflammation and tissue damage occurred previously.

4. Ulceration - The damage to the cells starts showing up externally as ulcers.

5. Healing - The healing process begins after discontinuing the treatment temporarily or after the treatment is completed.

Various scales are used to grade mucositis based on its severity. World Health Organization (WHO) grading scale for oral mucositis is the simplest, and it goes as follows;

Grade 0- No oral mucositis.

Grade 1- Erythema and soreness occur.

Grade 2- Ulcers start appearing, but patients can consume a solid diet.

Grade 3- Ulcers are still present, and this stage requires consuming a liquid diet.

Grade 4- Ulcers, difficulty in food intake; feeding tubes are used in this stage.

The other standard grading scales include - The Eastern Cooperative Oncology Group (ECOG) scale, Radiation Therapy Oncology Group (RTOG) scale, National Cancer Institute Common Toxicity Criteria (NCI-CTC), etc.

Who Can Get Oral Mucositis?

Although the incidence of oral mucositis does not follow a pattern, certain factors influence the occurrence of oral mucositis;

• Patients who have undergone head and neck radiotherapy.

• As per studies, oral mucositis is higher in females than males.

• Though young people show higher oral mucositis incidence than older people, they recover from it quickly.

• Habits such as smoking, chewing tobacco, and alcohol intake increase the risk of oral mucositis.

• People with diabetes, kidney problems, immunocompromised individuals, etc.

• People with blood-related disorders carry a higher risk.

• Wearing an ill-fitting denture that keeps pricking the tissues in the mouth.

• Dehydration (loss of fluid from the body).

• Decreased saliva production due to radiation therapy.

What Are the Complications of Oral Mucositis?

• The incidence of superinfections is high in patients with oral mucositis.

• Chronic and late reactions could also occur due to changes in the blood supply, fibrosis (thickening of the connective tissue), alterations in the body cells, etc.

• An increase in the period of hospitalization, interrupting and prolonging the cancer treatment, hike in the hospital expenses, etc.

• Availability of adequate nutrition for the body becomes impossible due to difficulty eating and chewing. In severe cases, the use of feeding tubes becomes a necessity.

• The overall immunity of the individual keeps declining.

How to Prevent Oral Mucositis?

It is not possible to stop oral mucositis from occurring altogether, but its symptoms and severity can be minimized to an extent by following the below steps;

• Before starting your cancer treatment, consult a dentist and undergo all the treatments required at least a month before the first session.

• Ensure that you wear a comfortable fit denture, check for broken dental fillings, and get them corrected.

• Take proper care of your mouth by following necessary oral hygiene protocols like;

-Brushing twice a day using a soft-bristled toothbrush.

-Using a mild toothpaste free of harsh chemicals that might irritate the mucosa.

-Using antimicrobial mouthwashes and warm salt water rinsing two to three times a day.

• Avoid consuming hot and spicy foods and follow a soft and liquid-based diet.

• Frequent fluid intake to prevent dehydration.

• Chewing sugar-free gums to stimulate saliva production.

• Avoid unhealthy habits like alcohol consumption, smoking, doing drugs, etc.

• Moisturize the lips to protect them from drying.

What Is the Pharmacological Approach for Oral Mucositis?

• Cryotherapy (sucking onto the ice while undergoing radiotherapy).

• Topical analgesics (painkillers) or anesthetics (numbing agents) such as Lidocaine, Benzocaine are used to relieve pain in the inflamed areas, but the relief is temporary.

• Mucosal protectants create a barrier upon the mucosa, thus protecting it from radiation.

• The doctors usually minimize the dosage of the causative drug.

• Low-dose steroids such as Prednisone are effective.

• Research shows that low-level laser therapy decreases after radiation effects and the severity of mucositis in chemotherapy patients.

• Intra-oral bleeding is controlled using hemostatic (anti-bleeding agents) such as fibrin glue.

Conclusion:

Though it is common, oral mucositis is self-limiting with a good prognosis. Avoiding panic and following the recommended guidelines promotes faster healing and control severity based on the stage at which it is diagnosed.