May 14, 2016
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Q: My dad is undergoing chemotherapy and, as a result, has developed a bunch of sores within his mouth. What’s going on and how can I help him?
A: This side effect is known as mucositis and is the most common and frequently debilitating side effect of many of the chemotherapy and radiation treatments used in fighting cancer. It can occur anywhere within the gastro-intestinal tract (which goes from the mouth to the anus) but is most frequently experienced within the mouth which is where we will concentrate the rest of this article.
Our mucosal tissue (also known as our mucous membranes) line all of the body passages that connect with the air that we breathe in, and is roughly composed of epithelial cells and assorted glands that secrete mucous to coat these cells. Many cancer treatments, unfortunately, break down these rapidly-dividing healthy epithelial cells, leaving the underlying tissue open to sores (known as ulcers) and infections.
Not only can this condition be extremely painful but it can also affect a person’s ability to fight cancer by reducing the ability to eat and sleep, subject the person to infections and possibly force the oncologists (the term for doctors who treat cancer) to reduce or delay the dose of these cancer-fighting treatments.
While we know the frequency of mucositis is common, it is hard to get an accurate estimate as many cancer patients do not report this problem to their doctors. Our best guess is that it occurs in roughly 40 per cent of those undergoing chemotherapy.
The signs and symptoms of mucositis can possibly include sores in the mouth or on the gums or tongue; red, shiny or swollen mouth or gums; blood in the mouth; difficulty swallowing or talking; a feeling of dryness; mild burning or pain when eating food; soft white patches or pus in the mouth or tongue; and a thicker saliva in the mouth.
Mucositis is graded in terms of its severity with one indicating that the oral region has general redness and soreness and a grading of four indicating that the patient has an extreme case which we term confluent mucositis. In confluent mucositis, the patient’s entire mouth and tongue can be coated by a white mucus layer up to one millimetre in thickness, and in combination with the extreme soreness of that entire region, can make it close to impossible for the patient to eat.
Factors that can increase the risk of either experiencing mucositis or having a more severe case, include poor oral or dental health, smoking, the consumption of alcohol, gender (females are more likely), dehydration, a low body mass index, other pre-existing disease states (diabetes, kidney disease, HIV), previous cancer treatment, poor fitting dentures, people who previously have a chronically dry mouth, patients who are being treated for cancers that involve the production and function of our blood cells (e.g. bone marrow), and the use of more aggressive treatment regimens.
Younger patients tend to develop this more commonly than older patients but they also tend to heal quicker due to their increased rate of cell turnover. The key to mucositis, as it is with many health-related issues, is prevention. If you wear dentures, make sure they still fit properly and remove them when possible to expose them to air. If any dental work is required, try to get it completed at least one month prior to starting therapy in order to give your mouth time to heal.
Good oral hygiene is, not surprisingly, the cornerstone of any prevention strategy. Mouth rinses are essential and should be before and after meals as well as at bedtime. While there are many commercial products available, none seem to work any better than making your own version of saline (boil one litre of water, allow cooling, and add one-half teaspoon of salt and two tablespoons of baking soda). Warm a small amount of this previously-prepared solution and then rinse your mouth with it before spitting it out.
Use a soft-bristle toothbrush after eating, two to three times per day, and choose a mild-tasting fluoride toothpaste (with no whiteners) such as Biotene’s excellent version. Limit flossing to once a day unless instructed otherwise. Mouthwashes that contain lots of alcohol should be avoided and flossing should be reduced.
Keep your lips moist with a moisturizer but avoid ones that use Vaseline (white petrolatum) as this can promote infection. Increase your fluid intake and try to minimize alcohol as well as foods that are hot, spicy, acidic or coarse. Aim to increase the protein in your diet. Some chemotherapy regimens will have the recipients suck on ice chips while they are being treated in order to decrease the amount of drug that is delivered to the oral region.
With some types of chemotherapy, your oncologist may prescribe specific drugs to help prevent mucositis from starting as well. If you develop mucositis, you may need to increase brushing to every four hours (with the softest brush possible) and at bedtime. Your health care team may switch your mouth rinse to a prescription type that uses assorted combinations of pain relievers, coating agents, antifungals and antibiotics and is generally termed “Magic Mouthwashes”.
Aggressively keeping your mouth moist by chewing ice chips or sugarless gum or sucking on sugar-free candy, is an important step. There are also commercial products available that can aid in this, ranging from mouthwashes and discs you stick to your mouth, to toothpastes and gels that coat it.
There are a number of products that can be applied directly to the sore spot to help control the pain, and there is a drug called Kepivance that mimics the substance in our body that naturally stimulates the growth and repair of the cells that protect the lining of our mouth. As well, all of the pain killers that we normally use for other types of pain may be beneficial depending on the chemotherapy being used and individual patient characteristics.
In general, oral mucositis begins within five to 10 days following the start of chemotherapy and can last anywhere from one week to more than a month. It cannot always be prevented no matter how hard you follow the above recommendations. The key is to recognize its symptoms early and inform your health care team immediately so that treatment can minimize its impact and your discomfort.
For more information about this or any other health-related issues, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination.
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