Mucosal cells replicate rapidly and so like cancer cells they are destroyed as a consequence of cytotoxic therapy. Mucositis can occur with or without neutropenia. Mucositis usually starts five - seven days after cytotoxic chemotherapy treatment and can lead to a delay in the next course of treatment or a reduction in dose, depending on the severity of toxicity experienced by the patient. Drugs more likely to cause mucositis are Anthracyclines (e.g. Daunorubicin, Doxorubicin),Methotrexate, including oral Methotrexate in some patients.
Much attention is focused on the mouth as this is the most visible mucosa, but oral mucositis should trigger an assessment of the whole gastro intestinal tract as symptoms may affect the gut from top to bottom and include bleeding or cracked lips, sore mouth, dry mouth, sore throat, difficulty in swallowing (including difficulty in swallowing saliva), desquamation (shedding) of mucosa, retrosternal (pain behind the big central chest bone) discomfort, epigastric (Around the stomach / upper abdomen / lower ribs area) pain, lower abdominal pain, diarrhoea or constipation [1].
Stomatitis is the term specifically used to describe inflammation of the mouth, however, it should be noted that both mucositis and stomatitis may be used interchangeably [2]. Mucositis can make the tongue and inside of the mouth look pale and white and the tongue may have a scalloped appearance. On examination, patients may also have lip and / or mouth ulcers; therefore it is important to check all around the inside of the mouth, under the tongue, inside the cheeks and inside of lips when assessing toxicities. Many oral assessment tools are used but the most commonly used in Paediatric Oncology is Eilers oral assessment guide (OAG) [4]
Taken from- Mucositis (18 slides) - Centers for Disease Control and Prevention www.cdc.gov/nchs/ppt/icd9/att_mucosit s sept05.ppt
Consequences of stomatitis
All of these areas can be very painful and often limit the patient’s ability to maintain an adequate fluid and nutritional intake [3]
The discomfort experienced from stomatitis or mucositis can be so severe, a morphine infusion (PCA) may be required in order to control the pain.
Oral candidiasis may occur at the same time with flakes of white material attached to tongue and insides of mouth. Candida oesophagitis rarely occurs but if it does, it should be treated with systemic antifungals such as fluconazole or ambisome.
Herpes Simplex virus (HSV) may cause extensive ulceration and requires treatment with aciclovir. Further advice should then be sought from the haematology/oncology consultant.
Treatment for mucositis
This will usually be initiated by the patient’s treatment centre following a toxicity assessment. Community professionals should seek advice from the centre on management and dosing.
Action most likely to be taken:
Mouth
- Swabs for bacteriology and virology
- Regular pain relief as appropriate.
- Other useful agents to consider are:
- Difflam mouthwash or spray
- Gelclair is very effective
- Omeprazole can be given for epigastric pain
- Gaviscon and sucralfate may be tried. Fluconazole can be given for oral candidiasis but check if Vincristine has been given within the last five days as there is an interaction between both drugs.
- Generally Buscopan is not prescribed for colicky lower abdominal pain, partly as it is rarely effective and also to avoid the rare complication of toxic megacolon if the patient has colitis.
- Fluid management should be carefully considered. Feeding via a naso-gastric or gastrostomy tube may continue if tolerated, although a rate reduction may be required.
- Vomiting commonly accompanies mucositis and standard antiemetics may not be effective. Domperidone or Metoclopramide are more likely to be effective than Ondansetron if chemotherapy is more than three days past.
- TPN can be used in severe mucositis.
- Surgical review should be obtained for significant lower abdominal pain, especially right iliac fossa pain which could be typhlitis, and to rule out appendicitis. Typhlitis, or neutropenic enterocolitis, is well recognised in immunosuppressed and neutropenic patients.
- Surgical review should be obtained for bile-stained vomiting i.e. green vomitus
- Anti-diarrhoeal preparations, e.g. loperamide are not recommended.
Practical considerations
Mouth care
Mucositis during cancer treatment cannot be avoided; however, in order to reduce the risk, good oral hygiene should be encouraged to keep the mouth clean, moist and free from infection.
Assessment of the mouth should be systematic and carried out as part of routine care throughout the entire treatment. Each cancer centre has a mouthcare policy that includes an oral assessment tool to ensure the risk of stomatitis is minimised or identified as soon as possible. [1]
Following diagnosis, each patient will be reviewed by the dental team in their treatment centre to discuss a mouthcare plan, promote good oral hygiene and give advice on the importance of good dietary intake. It should be stressed that good oral hygiene should be encouraged even when the child or young person is not eating, due to nausea and vomiting, for example.
Parents/carers are advised that sugary snacks should be limited to mealtimes and milk and water should be the preferred drinks offered. However, it must be recognised that this may be very difficult for parents/carers if the only food or drink their child craves during treatment is sweet, especially if they are struggling to maintain their weight. Support and advice regarding nutrition is available from the dietitian and ward staff to help parents/carers be creative when encouraging their child to eat or drink healthier options.
Helpful tips
- Soft multi-tufted toothbrushes are recommended, which should be replaced when bristles begin to splay, following a mouth infection or when at home after three months of use
- If toothbrushing becomes intolerable or spontaneous bleeding occurs before or during mouthcare, other options should be explored, e.g. a soft gauze swab wrapped round a finger. Parents/carers can seek advice from their Paediatric Oncology Outreach Nurse Specialist (POONS) or ward staff
- Fluoride toothpaste should be used. The correct amount of fluoride will be advised by the dental team
- When used, dummies should be changed frequently, especially following a mouth infection. These should be sterilised frequently, ensuring there are replacements to hand. If possible, parents/carers should be encouraged to wean their child off a dummy.
Taste alteration
Children and young people receiving cytotoxic chemotherapy may experience taste alterations due to damage to the taste buds and salivary glands, which in turn can affect their dietary intake. [2] Some patients report a metallic taste in their mouth or an inability to taste anything, whilst others crave spicy or strong-tasting food, e.g. salt and vinegar crisps.
Sweets, such as mints, can be given during chemotherapy administration, which may help alleviate or lessen the symptoms.
Taste alteration can result in a loss of appetite leading to reduced nutritional status. It is important that parents/carers are pre- warned this may happen so they can manage the situation, understanding that it is not the child or young person being fussy [2]. A dietitian will be available if parents/carers and patients need further advice or support.
References
[1] McCulloch R, Hemsley J, Kelly P (2013) Symptom management during chemotherapy. Paediatrics and Child Health 24:4 pp166-177
[2] Gibson F, Soanes L (2008) Cancer in Children and young People. Wiley and sons Ltd
[3] Cheung K, Lee V, Li CH, Yueng HL, Ip WY, He GH, Epstein JB (2013) Impact of oral mucositis on short-term clinical outcomes in paediatric and adolescent patients undergoing chemotherapy. Support care Cancer 21: pp2145-2152
[4] . Eilers J, Berger AM, Petersen MC. Development, testing, and application of the oral assessment guide. Oncol Nurs Forum. 1988;15(3):325-330.