The Management of Oral Mucositis in Oncology

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One of the most uncomfortable consequences of anticancer therapy is the development of oral mucositis. This painful condition develops in approximately 40% of patients treated with standard chemotherapy, 30%—60% of patients receiving radiation therapy for cancer of the head and neck, 70% of patients who undergo bone marrow transplantation and receive high-dose chemotherapy, and over 90% of patients receiving concomitant chemotherapy and localized radiation.¹

Oral mucositis is characterized by erythema, swelling, and ulceration of the mucous membranes. The consequences of this inflammation can greatly affect a patient’s health, quality of life, and anticancer therapy outcome. The disruption of the natural mucosal barrier can increase the risk of systemic infections. Furthermore, the intense pain associated with oral mucositis may impede the patient’s eating and oral hygiene activities which in turn can disrupt the efficacy of cancer therapy.

The economic consequences of oral mucositis are substantial. In patients receiving high-dose chemotherapy for stem-cell transplant, Sonis and colleagues² observed that the increased infections, disruption of therapy, and increased need for hospitalization caused by oral mucositis added $43,000 per patient. Costs were also dependent on the level of oral mucositis. The authors estimated that for each 1 point rise in the oral mucositis assessment scale (OMAS), there was an additional $25,000 in costs. Similarly, in patients treated with standarddose chemotherapy, a large portion of the extra costs of mucositis arise from the increased need for hospitalization.³

Management of Oral Mucositis

The best management option for oral mucositis however, is preventive therapy—a key component of which is recognizing which patients are at risk (see table 1).

Once it is established that the patient will likely develop oral mucositis, it is imperative that preventive/ educational measures be given to reduce the risk of developing mucositis or to reduce the severity of mucositis. Key educational material should include the importance of oral hygiene to reduce the risk of inflammation and nutritional advice to help the patient get the calories needed during therapy while reducing the discomfort of mucositis.

If the patient does develop oral mucositis, most treatment options are symptomatic to reduce pain (analgesic), swelling (cryotherapy), and/or inflammation (anti-inflammatory). One treatment option that has proven to be safe and effective at reducing the incidence, severity, and duration of oral mucositis is Caphosol^® (Supersaturated Calcium Phosphate Rinse).

Risk factors for mucositis include⁴

Patient Related

Age (children and patients over 50 yr of age)

Female sex

Tumor location (e.g., oral cavity, throat)

Pre-existing mouth damage

Periodontal status

Tobacco and alcohol consumption

Genetic predisposition

Treatment Related

Chemotherapy (type of drug, dose and intensity,

induced neuropenia)

Radiotherapy (location, fractioning,

combined with chemotherapy)

Bone marrow transplantation

CaphosolCaphosol is a super-saturated Ca²⁺/PO₄ ²- solution and is believed to promote healing of the mucosal lesions while helping to cleanse the oral cavity. In this manner, it reduces both the intensity and duration of mucositis in patients given high-dose chemotherapy. This was observed in a prospective, double-blind, randomized clinical trial by Papas and colleagues⁵ who compared Caphosol used at the initiation of cancer therapy in conjunction with proper oral hygiene with standard fluoride rinse in 95 patients undergoing hematopoietic stem-cell transplantation. During the course of treatment, oral mucositis was scored on a 6 point scale (0-no change; 1-erythema; 2-single ulcer < 1 cm; 3-a few ulcers approximately 1 cm; 4-multiple ulcers < 1 cm; 5-slough) and pain on a 0—100 visual analog scale (VAS). Inflammation (absolute neutrophil counts) and morphine intake were also measured during the study.

One interesting aspect of this study was that it acknowledged the importance of oral hygiene before beginning bone marrow transplant. Before transplant, patients in the Caphosol group received Caphosol and four topical fluoride treatments. After the transplant they received Caphosol at least four times daily. The comparator group was given a placebo gel with fluoride rinse prior to transplant and the fluoride rinse continued after transplant (at least 4 times daily).

The results of this study were very encouraging. As shown in Figure 1, the mean number of days patients experienced mucositis (days with score > 1) or ulcerations were significantly lower in patients receiving Caphosol compared with standard fluoride care. Patients given Caphosol also had significantly fewer days of pain and fewer days that required morphine (Figure 2). Further analysis showed the patients receiving Caphosol had fewer days of neutrophil engraftment, lower peak levels of mucositis and lower peak levels of pain.

The authors of this study concluded that Caphosol “should be considered in the treatment of of patients undergoing hematopeoitic stem-cell transplantation at high risk for mucositis.” The authors also noted that the encouraging results seen in this study with bone marrow transplant patients were similar to results reported at conferences with patients undergoing radiation and/or chemotherapy.

Concluding Remarks

Oral mucositis is a costly consequence of cancer therapy that can impede the efficacy of anticancer therapy. Even small reductions in OMAS scores can reduce medical costs by the thousands while improving the patient’s quality of life. Therefore, every effort to reduce the severity and/or risk of getting mucositis should be undertaken by the patient as well as the patient’s oncologist, general practitioner, dentist, and other medical professionals.

Since most patients undergoing high-dose chemotherapies for solid tumors, bone marrow transplant, and radiation for head and neck cancer will develop oral mucositis, it is advised that these patients be part of an oral hygiene plan that cleans the oral cavity and promotes healing of the mucosal lesions. Using these simple preventive measures, the patient’s outcome and quality of life can greatly improve.

References1. Naidu MUR, Ramana GV, Rani PU, et al: Chemotherapyinduced and/or radiation therapy—induced oral mucositis—

Neoplasia

Complicating the treatment of cancer. 2004;6:423-431.

2. Sonis ST, Oster G, Fuchs H, et al: Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell

J Clin Oncol

transplantation. 2001;19:2201-2205.

3. Elting LS, Cooksley C, Chambers M, et al: The burdens of cancer therapy: Clinical and economic outcomes of

Cancer

chemotherapy- induced mucositis. 2003;98:1531-1539.

4. D’Hondt L, Lonchay C, Andre M, et al: Oral mucositis induced by anticancer treatments: Physiopathology and

Ther Clin Risk Manag

treatments. 2006;2:159-168.

5. Papas AS, Clark RE, Martuscelli G, et al: A prospective, randomized trial for the prevention of mucositis in patients

Bone Marrow Transplant

undergoing hematopoietic stem cell transplantation. 2003;31:705-712.