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This disorder is one of the most common side effects of cancer therapies (particularly chemotherapy and radiotherapy), which can alter the integrity of the oropharyngeal tissues. In addition, factors such as nutritional deficiencies, poor oral hygiene and smoking may also influence the onset and/or severity of symptoms.
Mucositis causes redness, burning, pain, ulceration and difficulty in feeding. The inflammatory process also compromises the barrier function of the oral mucosa and increases the risk of infection of the soft tissues of the mouth.
Mucositis can be very debilitating, so it is important to try to prevent its occurrence and to recognize the first symptoms in order to intervene as soon as possible. In some cases, the inflammatory process can extend to the entire mucosa lining the gastrointestinal tract (mucositis of the digestive tract) and to the upper respiratory tract.
What is mucositis
Mucositis is the inflammation of the mucosa of the oral cavity that can extend to the entire mucosa of the gastrointestinal tract and is a complication frequently observed during the treatment of neoplastic diseases (radiotherapy and chemotherapy), which block the reproductive capacity of the basal epithelial cells.
The absence of new cells results in a thinning of the mucosa, which becomes atrophic and prone to ulceration associated with intense erythema, pain, bleeding and increased risk of infection.
The cytotoxic effects of antineoplastic drugs on tissues with high turnover -such as the oral epithelium- and the local effects of radiation on the oral mucosa are responsible for this manifestation that significantly impairs the patient's quality of life. It is a painful and debilitating pathology that affects chewing, swallowing and, sometimes, the ability to speak, as well as being a frequent cause of interruption or delay of cancer treatment.
It increases the risk of hemorrhages and infections, complications that may make it necessary to prolong the interval between chemotherapy cycles or reduce the doses of the drugs.
Mucositis occurs in more than 40 % of people receiving standard-dose chemotherapy and in about 75 % of those receiving high-dose chemotherapy. In addition, the pathology affects almost all patients (90-100 %) undergoing radiotherapy, especially of the head and neck region.
Mucositis appears 4-5 days after chemotherapy administration and usually reaches its peak 7-14 days later with the manifestation of ulcerative lesions.
Causes of mucositis
The etiopathogenesis of mucositis is still not entirely clear, but it seems that the inflammatory process of the epithelium is preceded by damage to the vascular and connective component of the submucosa.
As a general rule, this fabric is composed of:
- Epithelial tissue: devoid of keratin, which reproduces every 7-14 days.
- Submucosal tissue: contains blood vessels, nerve endings and extracellular matrix.
In addition to chemo- and radiotherapy, other factors may favor the appearance of the inflammatory process or influence its extension.
These include:
- Malnutrition.
- Dehydration.
- Deficient or incorrect oral hygiene.
- Alteration of the quantity and quality of saliva.
- Food that is too hot, too cold, too spicy or too acidic.
- Previous damage to the oral mucosa.
- Deterioration of the immune system.
- Smoking habit.
- Genetic predisposition.
Mucositis can be complicated in the presence of local factors that can affect the oral mucosal lining, such as periodontal infections, ill-fitting dentures and fractured or sharp dental elements.
The risk of developing mucositis in children receiving cancer treatment has been found to be higher than in adults. An increased susceptibility to severe and long-lasting mucositis has also been observed in people over 50 years of age; this may be due, in part, to decreased renal excretion of drugs used in chemotherapy.
Oral mucositis and cancer therapies
Oral mucositis is one of the most frequent complications associated with chemotherapy and/or radiotherapy treatment of the head and neck.
Chemotherapeutic agents such as methotrexate, fluorouracil (5-FU) and etoposide are particularly stomatotoxic. These drugs inhibit the reproductive capacity of basal epithelial cells, resulting in a weakening of the oral mucosa, which becomes atrophic and prone to ulceration.
Symptoms of mucositis
In the case of mucositis induced by radiotherapy or chemotherapy, the first sign that should not be underestimated is erythema, often accompanied by local burning. The areas most affected are the inner surfaces of the lips, the inside of the cheeks, the tongue and the floor of the mouth. Ulcers, hemorrhages and intense pain may appear later.
Most patients with mucositis also complain of difficulty speaking or swallowing due to severe pain. In these cases, there is a risk of nutritional deficiencies, and parenteral nutrition is often preferred for these patients.
Although the intensity and duration of symptoms and signs may vary depending on the type, duration and doses of treatment, we can list among the most common ones:
- Redness of the oral mucosa.
- Xerostomia and dry mouth.
- Taste alteration.
- Appearance of ulcers.
- Difficulty in swallowing.
- Pain on swallowing.
Treatment of mucositis
Treatment of mucositis is aimed at relieving symptoms. To control pain, rinses with anti-inflammatory solutions, local anesthetics and antifungal agents are generally recommended to avoid superinfection.
In the case of particularly severe pain that prevents the patient's normal daily activities, the physician may prescribe pharmacological treatment with non-steroidal anti-inflammatory drugs, paracetamol or opiates.
In general, to improve the symptoms of mucositis, it is recommended to have a good oral hygiene at home and, if necessary, increase the frequency of brushing using a soft-bristled toothbrush that should be changed often to avoid infections.
If ulcers are also present, the Mouthwash can help. Gels can also be applied locally to help protect the oral mucosa.
Finally, an excellent rule is:
- Avoid tobacco and alcohol.
- Eat soft and refreshing, but above all nutritious foods.
- Drink small amounts of water frequently to avoid dehydration.
- Avoid acidic, spicy or spicy foods that are irritating to the mucosa.
- Maintain good oral hygiene to minimize the bacterial load in the mouth.
Mucositis after chemo- or radiotherapy is an important pathological condition, which the physician responsible for the treatment should be aware of, in order to have a more complete picture of the patient's response to therapy and also to establish any corrections in the treatment plan.
Prevention of mucositis
Careful cleaning of the teeth with a toothbrush is recommended soft, which should be replaced regularly, asking the dentist for advice from the initial phase through to follow-up.
Dental procedures (from tartar removal to more complex interventions) should be performed prior to chemotherapy, as neutropenia and thrombocytopenia from chemotherapy are considered contraindications.
Mild pain can be counteracted by rinsing with solutions containing an anti-inflammatory or an anesthetic, while moderate or severe pain requires systemic medication. The most commonly used drugs are paracetamol, non-steroidal anti-inflammatory drugs and, in more advanced cases, opiates.
