Generality
Mucositis is an inflammation of the mucous membrane of the mouth and pharynx .
This disorder is one of the most common side effects of anticancer therapies (in particular, chemotherapy and radiotherapy ), which can alter the integrity of oropharyngeal tissues.
Mucositis causes redness, burning, pain, ulceration and difficulty in eating. The inflammatory process also compromises the barrier function of the oral mucosa and increases the risk of infections of the soft tissues of the mouth.
Mucositis can be very debilitating, so it is important to try to prevent the disorder and recognize the appearance of the first symptoms to intervene as soon as possible. In some cases, in fact, the inflammatory process can extend to the entire mucosa of the gastrointestinal tract (mucositis of the digestive system) and the upper airways.
Causes and risk factors
Mucositis is an inflammation that mainly affects the mucous membranes of the oral cavity and pharyngeal tract .
As a rule, this fabric consists of:
- Paved epithelium (or scaly) multilayered: keratin-free, it reproduces every 7-14 days;
- Submucosa: contains blood vessels, nerve endings and extracellular matrix.
The etiopathogenesis of mucositis is not yet completely clear, but it seems that the inflammatory process of the epithelium is preceded by damage to the vascular component and connective tissue in the submucosa.
The main causes of mucositis are anticancer therapies, but other factors can favor the appearance of the inflammatory process or influence its entity.
These include:
- Malnutrition;
- Dehydration;
- Poor or incorrect oral hygiene;
- Altered saliva secretion for quantity and quality;
- Habit to take foods that are too hot, cold, very spicy or acidic;
- Previous damage to the oral cavity;
- Presence of infections or, in general, impairment of the immune system;
- Smoking habit;
- Genetic predisposition.
Mucositis can be complicated in the presence of local factors that can damage the oral mucous lining, such as periodontal infections, incongruous prostheses and fractured or sharp teeth.
Furthermore, it was found that the risk of developing mucositis in children undergoing cancer treatment is higher than in adults. A greater predisposition to have severe and long-lasting mucositis has also been observed in people over the age of 50; this may depend, in part, on the reduced renal excretion of chemotherapy drugs.
Mucositis and anti-cancer therapies
- Mucositis is one of the most frequent complications associated with chemotherapy and / or radiotherapy treatment of the head, neck, abdomen or pelvic area.
- Chemotherapeutic agents such as methotrexate, fluorouracil (5-FU) and etoposide are particularly stomatotoxic. These medicines inhibit the reproductive capacity of the basal epithelial cells, favoring a thinning of the oral mucosa, which becomes atrophic and predisposed to ulceration.
- The risk of developing the disease is influenced by the therapeutic protocol applied: dosage of the antitumor agent, time interval between administrations, overall duration of treatment, combination of radio- and chemotherapy, irradiated area and possible conditioning regimens in transplant candidates bone marrow.
Signs and symptoms
An early clinical sign of mucositis is the redness ( erythema ) of the oral mucosa, associated with the local burning sensation . Erythema is often localized at the level of the inner surfaces of the cheeks and lips, sides and lower part of the tongue, soft palate and floor of the mouth.
Other early symptoms may be increased sensitivity to hot and cold foods and intolerance to acid substances, such as citrus juice.
As the condition progresses, may appear:
- Sensation of dry mouth (xerostomia);
- Mucous and tongue edema;
- Ache;
- Mucosal ulceration;
- Difficulty swallowing food and liquids (dysphagia);
- Increased salivation;
- Taste changes (dysgeusia);
- Hoarseness or reduction in tone of voice (dysphonia);
- Swallowing pain (odinophagy);
- Gingival bleeding.
Mucositis can be associated with various consequences, such as malnutrition and the risk of soft tissue infections from fungi, viruses and bacteria.
In addition, inflammation can lead to obstruction of the oropharyngeal airways secondary to swelling and bleeding, as well as to predict lower respiratory protection capacity. These manifestations can have a negative impact on patients' quality of life.
Note
The chemotherapy-induced mucositis is a short-term adverse effect: the symptoms appear 4-5 days after the infusion of the antitumor agent and, generally, the appearance of ulcerative lesions is found in the following 7-14 days.
Usually, the condition resolves spontaneously within three weeks of the end of the treatment, when the mucosa slowly regains its normal thickness. However, any complications associated with mucositis may make it necessary to prolong the interval between chemotherapy cycles or a dose reduction.
Possible complications
If not adequately treated, the inflammatory process can extend to the entire mucosa of the gastrointestinal tract, up to the anal area ( mucositis of the digestive system ).
In this case, they can occur:
- Gastric pyrosis;
- Esophagitis;
- Nausea and vomit;
- Abdominal swelling;
- Diarrhea;
- Rectal bleeding;
- Pain in the abdomen;
- flatulence;
- Malabsorption.
In the most serious cases, it may be necessary to resort to injecting nutrition .
In neutropenic patients, the radiation-induced and / or chemotherapy-induced mucositis can cause localized infections that can spread and cause septicemia .
Diagnosis
When changes are noted at the level of the oral mucosa, it is important to report them to your doctor, who can assess the situation and recommend the most appropriate therapeutic interventions for the case.
The diagnosis of mucositis examines the symptoms and alterations found during inspection of the oral cavity .
In clinical practice, the assessment can make use of different criteria, organized in scales, which take into consideration the macroscopic lesions at the level of the oral cavity and the degree of functional impairment of swallowing and feeding.
To define the severity of mucositis, the World Health Organization distinguishes five stages:
- Grade 0 : no sign and symptom.
- Grade 1 : presence of redness and / or irritation (slight discomfort).
- Grade 2 : erythema and mild ulceration; the person still manages to eat solid food.
- Grade 3 : ulceration and redness are widespread; the patient is unable to swallow solid food (liquid diet only).
- Grade 4 : ulcerations are so extensive and painful that the person cannot feed himself orally.
Treatment and recommendations
The treatment of mucositis is aimed at resolving the symptoms.
In general, however, it is recommended that the patient always maintain good oral hygiene to reduce the risk of infections by brushing his teeth with gentle movements after each meal, upon awakening and before going to sleep.
If small wounds form inside the mouth, it is useful to gargle and rinse with disinfectant solutions : it is also possible to use water and sodium bicarbonate or saline solution at 0.9%.
Furthermore, in the presence of mucositis it can be useful:
- Always moisturize your lips using softening and protective sticks;
- Avoid cigarette smoking and alcohol;
- Consume food at room temperature or warm (on inflamed tissues, heat causes pain);
- Choose soft, creamy and refreshing foods, such as baby food, ice cream, milkshakes, yogurt and puddings (alternatively, you can blend foods).
- Avoid spicy, acidic or spicy foods, which can irritate and traumatize the mucosa (such as garlic, spices, citrus fruits and pineapple);
- Drink frequently, even taking small amounts of water at a time, to maintain mucosal integrity.
Pain control interventions may include rinses with solutions containing an anti-inflammatory (eg benzydamine hydrochloride mouthwash) or an anesthetic (such as lidocaine). Furthermore, it is possible to resort to the local application of gel to coat and protect ulcers from minor traumas and to alleviate their discomfort.
Depending on the severity of the pain, the doctor may prescribe a systemic analgesic therapy based on paracetamol, non-steroidal anti-inflammatory drugs (for radiotherapy), opiates or tramadol.
Prevention
The indications for the prevention of mucositis vary according to the cause. In general, however, accurate and constant oral hygiene is recommended; this habit helps to maintain the integrity of the mucous membranes and counteracts the formation of bacterial plaque.
Teeth cleaning should be carried out after each meal, with a soft toothbrush, to be replaced regularly. It is also advisable to brush the tongue to remove bacteria and freshen the breath. The use of chlorhexidine-based mouthwashes is not recommended.
Who uses the denture must clean it by immersing it in solutions based on water and disinfectant after each meal and with the toothbrush must gently clean the gums. In the case of ulcerative lesions of the mucosa, it is recommended to use the denture only for meals.
If dental procedures need to be performed, such as a dental extraction or an implant, it is advisable to consult the dentist before starting a chemotherapy and / or radiotherapy treatment, to plan and complete them at least one month before the start of anticancer therapy.
In people undergoing chemotherapy, cooling with oral cryotherapy is recommended to prevent mucositis. It seems, in fact, that melting ice cubes in the mouth during the infusion of some chemotherapeutic agents (such as 5-fluorouracil) has a preventive action: the cold induces a vasoconstriction, limiting the amount of drug that reaches the mucous membranes of the mouth and the responsible effect of inflammation.
