Mucite : définition, signes, prévention et traitements.

Mucositis: definition, signs, prevention and treatments of these ulcers.

Nov 17, 2022

Mucositis occurs when cancer treatments (chemotherapy or radiation) destroy the rapidly dividing epithelial cells that line the gastrointestinal tract (which runs from the mouth to the anus), leaving the mucosal tissue open to ulceration and infection . . Mucosal tissue, also called mucosa or mucous membrane, lines all passages of the body that communicate with air, such as the respiratory and food passages, and has associated cells and glands that secrete mucus . The part of this lining that covers the mouth, called the oral mucosa, is one of the most sensitive parts of the body and is particularly vulnerable to chemotherapy and radiation . The oral cavity is the most common location of mucositis.

In this article we will see the signs of mucositis and we will talk about its treatments. We will discuss natural treatments for mucositis to prevent it and relieve pain effectively.

What exactly is mucositis?

Oral mucositis is probably the most common and disabling complication of cancer treatments , particularly chemotherapy and radiotherapy . It can lead to several problems, including pain , nutritional problems due to inability to eat, and increased risk of infection due to open sores in the mucosa. It has a significant effect on the patient's quality of life and may be dose-limiting (i.e., requires a reduction in subsequent chemotherapy doses).

What are the signs of mucositis?

Signs and symptoms of mucositis include:
  • A red, shiny, or swollen mouth and gums
  • Blood in the mouth
  • Sores in the mouth, gums or tongue
  • Pain in the mouth or throat.
  • Difficulty swallowing or speaking
  • Sensation of dryness, slight burning or pain when swallowing food.
  • Soft, whitish patches or pus in the mouth or on the tongue.
  • Increased mucus or thicker saliva in the mouth.

An extreme case of this condition is called confluent mucositis. In the worst case, the mucous membrane of the patient's entire mouth and tongue can be covered with white mucus that can be up to a millimeter thick. The combination of mucus, excess saliva, and pain can make eating difficult, if not impossible.

Who has mucositis?

The majority of oral cancer patients receiving chemotherapy combined with radiotherapy have at least some degree of mucositis. When caused by chemotherapy, mucositis is usually due to a low white blood cell count ; When caused by radiotherapy, mucositis is usually due to the necrotic and inflammatory effect of radiation energy on the oral mucosa.

Factors aggravating mucositis

Factors that may increase the likelihood of developing mucositis, or may make it worse if it occurs, include:
  • Poor oral or dental health .
  • Smoking or chewing tobacco and drinking alcohol .
  • Gender (women seem more likely than men to develop mucositis).
  • Dehydration.
  • A low body mass index.
  • Illnesses such as kidney disease , diabetes or HIV/AIDS.
  • Previous cancer treatment.
  • Chronic irritation from poorly fitting dentures or defective restorations may predispose patients to the development of oral mucositis due to local irritation and trauma.
  • In general, patients with hematologic malignancies have a higher rate of oral mucositis than those with solid tumors. This is to some extent related to treatment regimens.
  • Hyposalivation before and during treatment is associated with an increased risk of oral mucositis.
  • The use of methotrexate for chronic GVHD prophylaxis may exacerbate oral mucositis lesions, although this is less of a concern with newer prophylaxis regimens.
  • Oral mucositis occurs independently of infections of the oral mucosa of viral or fungal origin, but it can be exacerbated by these concomitant infections.
  • Young patients tend to develop oral mucositis more often than older patients treated for the same malignancy with the same treatment regimen. This appears to be due to the faster rate of basal cell turnover observed in children. However, recovery from oral mucositis is also faster in the younger age group.

Consequences of mucositis

It is important for cancer patients to be on the lookout for signs of mucositis , which should be treated as quickly as possible once diagnosed. The consequences of mucositis can be mild and require little intervention, but they can also be serious - such as hypovolemia, electrolyte abnormalities and malnutrition - and even lead to death. Oral mucositis can:
  • cause pain
  • Restrict oral intake
  • Act as a gateway for organizations
  • Contribute to the interruption of treatment
  • Increase the use of antibiotics and narcotics
  • Increase the duration of hospitalization
  • Increase the overall cost of treatment.

Patients with oral mucositis and neutropenia (a type of white blood cell deficiency) have a relative risk of sepsis (a systemic, toxic disease caused by invasion of the bloodstream by virulent bacteria from a local infection) more than 4 times higher than in patients with neutropenia alone.

Nausea and vomiting

Mucositis is further complicated by the nausea and vomiting that often accompany treatment. Chemotherapy and radiation therapy can affect the ability of cells to reproduce, slowing the healing of the oral mucosa and often prolonging the duration of the current mucositis. Patients with damaged oral mucosa and reduced immunity are also prone to oral infections .

Maintain your diet

The loss of taste tends to increase in proportion to the aggressiveness of the treatment. Nausea, pain, vomiting, diarrhea, a sore or dry mouth can make eating difficult. Maintaining adequate nutrition is the first natural treatment for mucositis and therefore an important challenge for oral cancer patients. Reducing calorie intake can lead to weight loss , loss of muscle mass strength, and other complications, including decreased immunity and longer healing time from treatments.

Physical problems can interfere with food intake and proper nutrition. Patients with head and neck tumors may experience pain in the mouth or throat that can interfere with chewing and worsen swallowing difficulties . Tooth and gum disease can also exacerbate problems. Chemotherapy can suppress appetite by the same mechanisms as radiation. This phenomenon is often aggravated by the nausea that accompanies it.

Decreased food intake is common for a short time around the time of treatment. It is important to try to compensate for weight loss during this time by making a conscious effort to eat more or, if this is not possible, by using feeding tubes or food pumps. If you have any of these problems, talk to your doctor, nurse or dietician on your healthcare team first. With their help and the suggestions below, you should be able to plan a diet designed to minimize these problems. Prescription medication may be needed. Your dentist, dental hygienist, nurse, dietitian and pharmacist can also help you.

How long does mucositis last?

Oral mucositis usually begins 5 to 10 days after starting chemotherapy and lasts for a week to six weeks or longer . Recovery coincides with recovery of white blood cell count , specifically when the absolute neutrophil count becomes greater than 500 cells/µL. In patients treated for solid tumors, the duration of oral mucositis depends on the type, dose and duration of treatment.

Natural preventive measures against mucositis

You may not be able to prevent mucositis from occurring, but there are steps you can take before starting radiation or chemotherapy treatment to help reduce the side effects and symptoms. The first step is to see if your doctor can recommend a dentist who treats cancer patients . If you wear dentures , you'll need to make sure they fit properly. If work is necessary (tooth extractions or readjustment of dentures), it must be carried out at least one month before treatment begins, to ensure that your mouth is completely healed and to avoid damage to your teeth , your existing gums or jaw bones.

Oral hygiene

It is known that a good oral hygiene regimen can help prevent or reduce the severity of mucositis and, just as importantly, prevent the development of infection through open mouth sores. The mainstay of an effective oral care regimen is mouth rinsing , and numerous studies have determined that plain salt water is one of the best and most cost-effective mouth rinses available. A mouthwash helps remove debris and keep oral tissues moist and clean.

A foam toothbrush

Brushing techniques (electric toothbrush) and oral hygiene are another important aspect of oral care. To treat mucositis naturally, you should also avoid alcohol and irritating foods , such as those that are spicy, hot, or acidic. You should use a soft-bristled toothbrush and brush your teeth after eating, 2-3 times a day. If you suffer from sensitivity or mouth sores , you may need to use foam toothbrushes with an antibacterial rinse . You should use mild-tasting toothpastes that contain fluoride , such as Biotene enzyme-based products, because certain flavors and foaming agents like SLS in toothpastes can irritate the mouth. You can supplement these toothpastes with Rx-type fluoride toothpastes, such as Colgate's Prevident. If your toothpaste is still too irritating, you can use a solution made by dissolving one teaspoon of salt in 4 cups of water, or mixing one teaspoon of baking soda in 2 cups of water. You should also floss once a day.

three different colored toothbrushes on blue background

How to treat mucositis naturally?

Here are other ways to maintain a healthy oral care protocol to naturally treat mucositis:
  • Rinse your mouth (rinse and spit) before and after meals and at bedtime with either saline (1 teaspoon of table salt to 1 pint of water) or salt and baking soda (half a teaspoon of salt and 2 tablespoons of baking soda in 1 pint of hot water).
  • If you smoke, it is extremely important that you quit. Your doctor can help you find smoking cessation products and programs.
  • Avoid toothpastes containing whitening agents.
  • Avoid products that irritate the mouth and gums, such as commercial mouthwashes with strong flavors and those containing alcohol.
  • Keep lips moist with moisturizers. Avoid using petroleum jelly (the oily base can promote infection).
  • Limit the use of dental floss. Do not use if your platelet count is below 40,000.
  • Do not use lemon or glycerin cotton swabs or toothbrushes without soft bristles.
  • Increase your fluid intake.
  • Try to include protein-rich foods in your diet.

If you wear dentures, remove them as much as possible to expose the gums to air . Poorly fitted dentures can irritate the mouth and gums and should not be worn. Do not wear dentures if the mouth sores are severe. Another natural treatment for mucositis is cryotherapy , which involves sucking on pieces of ice while chemotherapy is administered. It has shown some efficacy in preventing mucositis caused by 5-FU (fluorouracil) chemotherapy treatments.

Oral cancer patients receiving radiation therapy should examine their mouth at least once a day for redness, sores, or signs of infection. The healthcare team should be informed if you notice worsening sores, white spots, pus, a "hairy" or thick tongue , bleeding in the mouth or the onset of a fever. Additionally, two agents, Gelclair® and Zilactin®, are mucosal protectants that work by coating the mucosa, forming a protective barrier for exposed nerve endings. In clinical trials, these agents improved pain control and the ability to eat and speak. Amifostine (Ethyol®), a drug that provides some protection against mucosal damage from radiation, is approved by the FDA for patients receiving radiation therapy for head and neck cancers.

Studies have shown that Amifostine can reduce dry mouth and prevent or reduce the degree of mucositis. Amifostine is frequently prescribed to oral cancer patients as a chemoprotective agent to spare salivary gland damage during radiation treatments. Although it has a significant negative side effect in many patients, namely nausea, it is certainly worth seeing if a patient is able to tolerate it for the many positive effects it can have. Other agents have been studied, including capsaicin (derived from chili peppers), glutamine, prostaglandin E2, vitamin E, sucralfate, and allopurinol mouthwash, with varying degrees of success. OROSOL (Medical Device) is the only solution for the natural treatment of mucositis which has clinical evidence of effectiveness. Based on glycerol and natural polymers, OROSOL helps moisturize and clean the wound and prevents the appearance of new mucositis. This French innovation received the prize from the Academy of Sciences in 2006. In March 2007, the study group on mucositis of the Multinational Association of Supportive Cancer Care and the International Society of Oral Oncology published its latest guidelines for mucositis prevention:

  • To prevent radiotherapy-induced mucositis , they recommend the use of midline radiation blocks and 3D radiotherapy. They recommend the use of benzydamine to prevent mucositis in head and neck cancer patients receiving moderate-dose radiation therapy.
  • To prevent standard-dose and high-dose chemotherapy-induced mucositis , they recommend using either ranitidine or omeprazole (a gastric ascension reducer/proton pump inhibitor ) to prevent epigastric pain after chemotherapy with cyclophosphamide, methotrexate and 5-fluorouracil or 5-fluorouracil with or without folinic acid.
  • They advocate against using chlorhexidine in patients with solid head and neck tumors who are undergoing radiation therapy. They also say that you should not use antimicrobial lozenges or systemic glutamine to prevent mucositis.

In late 2008, palifermin, a recombinant keratinocyte growth factor, was approved by the American Society for Clinical Oncology for protection against severe mucositis associated with hematopoietic stem cell transplantation in hematological malignancies. This represents "a breakthrough for the field," write the guideline authors, co-chaired by Martee L Hensley, MD, of Memorial Sloan-Kettering Cancer Center, New York, and Lynn M. Schuchter, MD, of the University of Pennsylvania, Philadelphia. It remains to be seen whether palifermin will be approved for protection against mucositis caused by other factors.

Natural treatment for mucositis

If you develop mucositis or it gets worse, you may need to increase the number of brushings (with the softest toothbrush possible) every 4 hours and at bedtime. This will help keep the mouth hydrated and prevent any infection. It's important to brush and floss very gently . You will need to rinse your mouth frequently with antiseptic mouthwashes , to prevent infections and periodontal (gum) inflammation . A natural treatment for mucositis is to make your own mouthwash by mixing 1 teaspoon of baking soda in 8 ounces of water or ½ teaspoon of salt and 2 tablespoons of sodium bicarbonate dissolved in 4 cups of water. This solution has the dual benefit of cutting off some of the significant phlegm/mucus production that is a by-product of treatments, and helping to eliminate it.

natural remedies

If you are receiving high-dose chemotherapy or a bone marrow transplant, your doctor may prescribe medications that can prevent or shorten the duration of mucositis. Your mouth can get dry and you'll want to keep it hydrated. Easy remedies include chewing on chunks of ice , chewing sugar-free gum, or sucking on sugar-free sour candies. If these natural mucositis remedies don't work, there are artificial saliva products that your doctor can prescribe or over-the-counter enzyme products and their collateral products, toothpaste and bath. Biotene mouthwash , which are free from strong flavorings and foaming agents which can be very irritating to sensitive tissues being treated. As your salivary barrier is compromised, you should avoid eating or drinking products containing sugar to prevent cavities.

To help clean mouth sores and naturally treat your mucositis , you can rinse with a solution of one part 3% hydrogen peroxide and two parts salt water (1 teaspoon of salt dissolved in 4 cups of water). For mild fungal infections, topical oral suspensions or dissolving tablets that contain antifungals may be prescribed. You will need to swipe or dissolve the medication in your mouth and, as directed by your doctor, swallow or spit out the medication. It is important not to use any medicine containing alcohol , as this can burn your mouth. If fungal, bacterial, and viral infections worsen, your doctor will need to prescribe oral medications, such as antibiotics or antifungals, to eradicate them. Likewise, if you wear braces, you will need to soak them in antiseptic solutions.

Treat mucositis with growth factors

Keratinocyte growth factor (KGF) is a substance produced naturally in the body that stimulates the growth, repair and survival of cells that protect the lining of the mouth and digestive tract. An artificial version of human KGF has been developed in the form of palifermin and is currently indicated for patients with hematological malignancies or blood cancers (leukemia, lymphoma and myeloma) who are undergoing bone marrow or bone marrow transplantation. stem cells. Palifermin has been found to decrease the duration and severity of mucositis in these patients. As mentioned previously, it remains to be seen whether palifermin will be indicated for oral cancer patients.

Fight against pain due to mucositis

Pain is a significant problem with mucositis and warrants early intervention. Actions that can help reduce the pain of mucositis:
  • In mild cases, ice cubes, popsicles, or ice chips can help numb the area, but most cases require more extensive intervention to relieve the pain.
  • Topical pain relievers include lidocaine, benzocaine, dyclonine hydrochloride (HCl) and Ulcerease® (0.6% phenol).
  • Corticosteroids such as prednisone can be effective.
  • Benadry® elixir, lozenges and pain relievers can help reduce mouth pain.
  • Squeezing and gargling with Xylocaine Viscous Anesthetic Gel 2% may help you eat if you have pain in your mouth, pharynx, or esophagus. Use 5 ml (1 tsp) of Viscous Xylocaine before meals. (Hold in mouth for one minute, then spit out.) This may increase your ability to eat by mouth while the anesthetic effects work.
  • Cepacol lozenges, Chloraseptic spray and lozenges, or using tea (especially chamomile) for washing and gargling may be helpful.
  • Frequent use of a mild mouthwash can help reduce discomfort or pain. Mouthwashes, which combine enzyme protection and soothing oral moisturizers, are available over the counter at pharmacies. We recommend Laclede's Salivea dry mouth products, which are available on Amazon.
  • Blow diluted Milk of Magnesia, Carafate Slurry, or Mylanta into your mouth.
  • Oral Balance is a dental gel that moistens the mouth while wounds heal and also contains enzymes that help control oral bacteria. You may need to apply it often during the day. It can be obtained over the counter.
  • GI Cocktail: 1 tbsp (15mL) Cherry Maalox (acid reducer) + 1 tsp (5mL) + Nystatin (antifungal) + 1/2 tsp (2mL) Hurricane Liquid (analgesic) original flavor. Mix the ingredients carefully. Swallow and gargle for one minute, then swallow immediately before each meal.
  • Orabase B (over the counter) is an adhesive paste containing a topical anesthetic (benzocaine) which may be helpful.
  • Over-the-counter pain relievers, such as Tylenol, and prescription pain relievers or opioid pain relievers are often needed to relieve pain or discomfort.
  • You can also use topical products like Orajel or certain prescription products like viscous lidocaine to temporarily ease discomfort.
  • If the pain becomes more severe, your doctor may need to prescribe stronger painkillers. In cases of oral cancer, it is not uncommon for the pain to be severe enough to require the use of opioids.

Ask your doctor before using products containing aspirin and nonsteroidal anti-inflammatory products like Advil, Motrin, or Naprosyn. Your doctor may want you to avoid these products because of their effect on platelets, which may increase your risk of bleeding. A popular topical agent that seems to be recommended by treatment teams is a so-called " magic mouthwash ". Some patients report good results with a combination of lidocaine (a numbing agent), Benadryl, Maalox, and nystatin (an antifungal). One of the problems with using topical agents is the inability to effectively coat all areas and the fact that pain relief may be brief.

In patients with mucositis who do not obtain pain relief with topical agents, narcotic analgesia is often necessary. This will require a prescription from your treating staff, until the mucous membrane begins to heal, especially in patients unable to swallow . It is important to note that mucositis is transient during the treatment phases themselves, and narcotics for mucositis pain relief will also be temporary. Patients must not "suffer" to avoid using narcotics; they will not become dependent on them if used correctly for this very real pain . Narcotics used for pain relief also cause constipation, and appropriate stool softeners should be taken with them.

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