Overview

Mucositis is a painful inflammatory condition affecting the mucous membranes lining the digestive tract, most commonly seen in individuals undergoing cancer treatments such as chemotherapy and radiation therapy. It results in redness, swelling, and ulceration of the mucosa, particularly in the mouth and throat. Mucositis can severely impact a patient's quality of life by causing difficulty in eating, drinking, and speaking, and it increases the risk of infections due to mucosal barrier damage. Prompt recognition and appropriate management are crucial to minimize complications and improve treatment outcomes.

Causes

The primary cause of mucositis is damage to rapidly dividing epithelial cells of the mucosa, most often due to cancer therapies. Other contributing factors include:

• Chemotherapy: Certain chemotherapy drugs, especially those targeting rapidly dividing cells, can damage mucosal lining cells, leading to mucositis.
• Radiation Therapy: Radiation targeting the head, neck, or gastrointestinal region can cause localized mucositis, particularly in the oral cavity and esophagus.
• Stem Cell Transplantation: High-dose chemotherapy and radiation before bone marrow or stem cell transplants are strongly associated with severe mucositis.
• Infections: Viral, bacterial, or fungal infections can worsen mucosal damage, particularly in immunocompromised patients.
• Poor Oral Hygiene: Pre-existing dental problems or poor oral care can increase the risk and severity of mucositis.
• Other Medications: Some non-cancer medications, like bisphosphonates or certain antibiotics, may rarely contribute to mucosal irritation.

Symptoms

Mucositis symptoms typically develop within a few days of starting chemotherapy or radiation therapy and can vary in severity:

• Redness and Swelling: Initial signs include inflammation and redness of the mucous membranes, especially inside the mouth.
• Mouth Sores or Ulcers: Painful open sores or ulcers can form, making eating and speaking difficult.
• Pain or Burning Sensation: Ongoing pain or a burning feeling in the mouth or throat.
• Dry Mouth: Reduced saliva production (xerostomia) is common, exacerbating discomfort.
• Difficulty Swallowing (Dysphagia): Pain while swallowing, especially in cases involving the throat or esophagus.
• Bleeding: Fragile mucosa may bleed easily with minor irritation or brushing.
• Altered Taste: Changes in taste perception or complete loss of taste (ageusia).
• Increased Risk of Infections: Open sores provide a portal of entry for bacteria, viruses, and fungi.

Diagnosis

Mucositis is primarily diagnosed through clinical evaluation based on symptoms and physical examination:

• Clinical History: History of recent chemotherapy, radiation therapy, or immunosuppressive treatments.
• Physical Examination: Visual inspection of the mouth, throat, and other affected mucous membranes for redness, swelling, and ulcerations.
• Grading Severity: Severity is often graded using standardized scales such as the World Health Organization (WHO) Oral Toxicity Scale or the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE).
• Swab Cultures: In cases with suspected infection, cultures may be taken from ulcers to guide antibiotic or antifungal therapy.

Treatment

Treatment for mucositis focuses on symptom relief, preventing infections, and facilitating healing while continuing essential cancer treatments whenever possible.

Supportive Care

• Oral Hygiene: Gentle oral care with soft toothbrushes and non-alcoholic mouthwashes to prevent secondary infections.
• Pain Management: Topical anesthetics like lidocaine, oral rinses, and systemic analgesics (e.g., acetaminophen, opioids for severe pain).
• Hydration and Nutrition: Maintaining adequate fluid and nutritional intake, with dietary modifications to avoid irritants like spicy or acidic foods.
• Cryotherapy: Sucking on ice chips during certain chemotherapy infusions may reduce the risk and severity of mucositis.

Medical Treatments

• Coating Agents: Mouth rinses or gels that form protective barriers (e.g., sucralfate) to soothe the mucosa.
• Growth Factors: Palifermin, a keratinocyte growth factor, may be used in selected high-risk cases to reduce mucositis severity.
• Antimicrobial Therapy: Topical or systemic antibiotics, antifungals, or antivirals if secondary infections are present.

Advanced Therapies

• Low-Level Laser Therapy (LLLT): Also called photobiomodulation therapy, used to reduce pain and promote mucosal healing in some centers.

Prognosis

The prognosis for mucositis is generally good, with most cases resolving within two to four weeks after completing cancer therapy. Mild cases may resolve within a few days, while severe cases can persist longer and may require temporary adjustments in cancer treatment schedules.

Early recognition and proactive management can significantly reduce the duration and severity of symptoms. Preventive measures, such as good oral hygiene, cryotherapy, and the use of protective agents, can lower the risk of mucositis. Long-term complications are rare but may include persistent taste changes or increased susceptibility to oral infections. With appropriate care, most patients recover fully without lasting effects.