Oral Mucositis: Preventing the Side Effect Before Undergoing Cancer Treatment

Oral mucositis can be painful and, in some cases, require hospitalization of patients being treated for cancer with chemotherapy and other radiation therapies. However, along with your care team, you can take steps to prevent this uncomfortable side effect.

In an interview CURE®, Dr. Alessandro Villa, assistant professor in oral medicine and dentistry at the Harvard School of Dental Medicine, Brigham and Women's Hospital in Boston, spotlighted the number of patients with cancer who are affected by oral mucositis, explained the benefits of an agent approved by the Federal Drug Administration (FDA) for intervention and explored how patients can control the side effect from the comfort of their homes.

CURE®: Can you explain what types of cancer treatment cause oral mucositis?

Villa: Oral mucositis is an iconic toxicity of cancer therapy and remains one of the most painful and disrupting side effects of radiation therapy and chemotherapy. When I talk about radiation therapy, I talk about patients with head and neck cancer. In these patients, usually 100% receiving radiation therapy develop oral mucositis. We also see mucositis in approximately 60% to 80% of patients who undergo bone marrow transplants. And finally, we see it in 20% to 40% of patients who receive conventional chemotherapy for any cancer.

What are the consequences of oral mucositis?

Oral mucositis is one of the most painful toxicities in patients receiving radiation therapy to the head and neck. It’s the number one cause of hospitalization in these patients. It can sometimes be so severe and painful that patients can’t speak, swallow or eat. It’s a very debilitating toxicity. If they are not able to eat, they may end up receiving a feeding tube. The cost associated with oral mucositis is higher than $17,000 per patient. There is still a huge unmet need out there for patients.

What questions should patients and/or caregivers ask their health care team about oral mucositis?

The first question I would have them ask is, what can I expect? Because it can be different between radiation and chemotherapy. And as we have discussed, they can also ask: What can I do at home to minimize this risk? And what are the preventative measures?

How can oral mucositis be prevented?

The FDA has approved an agent for mucositis intervention called palifermin, which is approved for the prevention of severe oral mucositis in patients who receive certain treatment in preparation for bone marrow transplant. The second agent, benzydamine hydrochloride, is approved in Europe, Canada and Australia, as well as some countries in Asia and South America but not in the United States. This rinse represents a potential intervention for some patients.

Cryotherapy is recommended by the American Society of Clinical Oncology in patients who receive a specific chemotherapy, 5-fluorouracil or more commonly 5FU. Patients can swish on ice chips for about 30 minutes starting about five minutes before the drug is administered. And to control mucositis pain, morphine may be used in patients who undergo stem cell transplantation.

What can patients do at home to help avoid the side effect or reduce its severity?

There are specific recommendations that patients should follow to minimize oral mucositis. One of them is maintaining good oral hygiene using a soft toothbrush. Patients can also use a saline solution 3-4 times a day, then rinse and spit. Cleansing of the mouth and good lubrication of the inside of the cheeks and lips can help with the pain and inflammation. The reason behind it is that, from a scientific standpoint, the microbiome (the bacteria and all the bugs that we have in the mouth) can contribute in the development and worsening of the mucositis. The cleaner the mouth, the better it is. Of course, patients may be sensitive to certain toothpastes, so it’s important to use mild-flavored fluoridated toothpaste when brushing. In some cases, patients should avoid spicy, acidic or hot foods because these may trigger symptoms for the patient.

How is the side effect monitored?

This depends on the type of treatment they are receiving. If they are receiving radiation, they come in the hospital Monday through Friday, so they are monitored daily.

For those with chemotherapy, most of these drugs are administered through IV in the hospital. However, there are some new chemotherapies given by mouth and patients take these at home, but they can give different side effects.

Is there anything else that you would like to add about oral mucositis?

Right now, this is a huge unmet clinical problem for patients and a devastating toxicity, but the development for oral mucositis is pretty robust with a wide range of new agents. This is promising, and there are some good results in current clinical trials with some of these new agents in progress. If I’m being optimistic, I think that there should be new options ready for approval in the next 5-10 years. There is a lot in the pipeline.