Stomatitis in oncology

oral stomatitis

1. MANAGEMENT OF ADVERSE
EVENT OF CHEMOTHERAPY:
STOMATITIS
DR ANKUR SHAH
MEDICAL ADVISOR

2. WHAT IS CANCER? AND IS IT
CURABLE? WHAT IS
CHEMOTHERAPY?
A. Cancer is an umbrella term for a large group of diseases
caused when abnormal cells divide and invade other tissue and
organs.
A. Yes
A. Chemotherapy drugs kill rapidly growing cancer cells but can
also harm perfectly healthy cells, causing side effects
throughout the body.

3. The Side
Effects of
Chemotherapy
on the Body

4. WHAT IS MUCOSITIS?
•Mucositis is inflammation of the
mucosal surfaces throughout
the body.
•It typically involves redness and
ulcerative sores in the soft tissues of the mucosa.
•Oral mucositis manifests as erythema,
inflammation, ulceration, and hemorrhage in the
mouth and throat.
Image from: Spielberger, Ricardo; Kepivance
TM
: A Breakthrough for Oral Mucositis Associated with Myeloablative
Hematopoietic Stem Cell Transplantation; City of Hope National Medical Center, Department of Hematology and Bone
Marrow Transplantation

5. RISK FACTORS
Age ( young children and elderly)
Gender ( women are at greater risk for severe mucositis)
Oral health and oral hygiene
Reduced salivary function
High expression of cytokines
Altered drug metabolisms

6. Kills rapid growing cells
(esp. mucus membrane)
Irritation to the
Mucous membrane
Inflammation occurs
Ulceration occurs if not
detected or treated
Stomatitis
RISK FACTORS
•Treatments (Chemotherapy and radiation therapy)
•excessive alcohol intake
•excessive tobacco use
•hot and spicy food
•cheek biting
•poor oral hygiene
•ill fitted oral appliances
•nutritional deficiency

7. CAUSALITY
•Mucositis is a frequent complication of anticancer
treatment, including chemotherapy and radiation therapy.
•Due to high-dose chemotherapy and/or radiation
preconditioning, it is particularly common in patients
preparing for bone marrow transplantation (BMT).
Source: Bellm LA, Epstein JB, Rose-Ped A, Martin P, Fuchs HJ. Patient reports of complications of bone
marrow transplantation; Support Care Cancer. 2000 Jan;8(1):33-9

8. Source: http://symptomresearch.nih.gov/Chapter_17/sec2/cghs2pg1.htm
SITES OF MUCOSITIS
•While the oral mucosa is the most frequent site of mucosal
toxicity, mucositis also is common along the entire alimentary
tract:
•Esophagus – duodenum – colon
•Stomach – ileum/jejunum – rectum
•GI mucositis occurs via a mechanism similar to that in the oral
mucosa, only the damage to the mucosal layer is more aggressive
than in oral mucositis.
•Although less common, treatment of ovarian and
nasopharyngeal cancer also can result in vaginal and nasal
mucositis.

9. 60%
40%
Mucositis Reported
Mucositis Not Reported
20%
80%
25%
75%
EPIDEMIOLOGY
•40% of patients receiving standard-dose chemotherapy
•80% of patients receiving radiation therapy for head and neck cancer
•75% of all patients undergoing BMT
Source: Bellm et al. 2000
Mucositis Frequency:
Standard-Dose Chemotherapy
Mucositis Frequency: Radiation for
Head and Neck Cancer
Mucositis Frequency: BMT with
High-Dose Chemotherapy and/or
Radiation Pre-Conditioning

10. CLINICAL CONSEQUENCES
Painful condition that interferes significantly with patient
functioning and tolerance for cancer therapy
Functional implications may include:
•Inability to tolerate food or fluid intake
•Difficulty or inability to talk*
*Borbasi S, Cameron K, Quested B, Olver I, To B, Evans E. More than a sore mouth: patients' experience of
oral mucositis. Oncol Nurs Forum. 2002;29:1051-1057, and Bellm et al. 2000.
**Bellm et al. 2000

11. CLINICAL CONSEQUENCES
(CONTINUED)
Hospital admission or extended hospitalization for total
parenteral nutrition, iv analgesia, and iv antibiotics
•62% of patients require hospitalization.*
•70% of patients with Grade 3-4 oral mucositis require feeding
tubes.*
Reduction or cessation (dose-limiting toxicity) of cancer
treatment in 35% of patients*
*Sonis ST, Elting LS, Keefe D, Peterson DE, Schubert M. Perspectives on cancer therapy-induced
mucosal injury. Cancer. 2004;100(9 Suppl):1995-2025

12. DIFFERENTIAL DIAGNOSIS AND
TREATMENT
Mucositis is distinguishable from other forms of
inflammatory disorders in terms of:
•causality
•clinical presentation/lab findings
•severity
•treatment
The presence and severity of radiation- or chemotherapy-
induced mucositis is routinely documented in clinical
progress notes.

13. Local, Denture-Related Lesion Aphthous UlcerOral Thrush
Oral Mucositis*
* Spielberger, Ricardo; Kepivance
TM
: A Breakthrough for Oral Mucositis Associated with Myeloablative Hematopoietic Stem
Cell Transplantation; City of Hope National Medical Center, Department of Hematology and Bone Marrow Transplantation
Because these conditions can coexist in
immunocompromised patients, differential
diagnosis is critical.
DIFFERENTIAL DIAGNOSIS: ORAL

14. NURSING MANAGEMENT
•The nurse instructs the patient in the importance and techniques of
preventive mouth care
•The nurse monitors the patients physical and psychological response
to treatment
•Advise the patients to avoid dry, bulky and irritating foods and fluids,
as well as alcohol and tobacco
•Encourage the patient to increase fluid intake

15. PHYSICIAN DUTIES
•Some physician may be recommended a variety of dietary
measures to treat stomatitis.
•Cottage
•Cheese
•Buttermilk
•Yogurt
•Ask for history of radiation or chemotherapy regimen.
•Do oral exam noting evidence of lesions within the mouth and
tongue.

16. STOMATITIS
Stomatitis currently is a more specific diseases of the
oral mucosa.
Stomatitis
Acute
Necrotizing
Ulcerative
Stomatitis
Aphthous
Stomatitis
Herpetic
Stomatitis
Gangrenous
Stomatitis
Oral
Mucositis

17. Soreness
± erythema
Erythema,
ulcers;
patient can
swallow
solid food
Mucositis
to the extent
that
alimentation
is not possible
Ulcers with
extensive
erythema;
patient cannot
swallow food
Grade 2 Grade 3
Severe Mucositis
Grade 1 Grade 4
World Health Organization’s Oral Toxicity Scale
WHO’s Oral Toxicity Scale

18. Severity Everolimus dose adjustments and management
recommendations
Grade 1
Minimal symptoms, normal
Diet
·No dose adjustment is required
·Manage with saltwater (0.9%) or nonalcoholic mouthwash several
times a day
Grade 2
Symptomatic but can eat and
swallow modified food
·Temporary dose interruption until recovery to grade <-1
·Reinstate everolimus at the same dose
·If stomatitis recurs at grade 2, interrupt dose until recovery to grade <-
1. Reinitiate everolimus at a lower dose.
·Manage with topical analgesics mouth treatments (e.g. benzocaine)
with or without topical corticosteroids (i.e., triamcinolone oral paste)
Grade 3
Symptomatic and unable to
adequate aliment and hydrate
orally
·Temporary dose interruption until recovery to grade <-1
·Reinstate everolimus at the same dose
·Manage with topical analgesics mouth treatements (e.g. benzocaine)
with or without topical corticosteroids (i.e. triamcinolone oral paste)
Grade 4
Sypmtoms associated with life
threatnening consequences
•Discontinue everolimus and treat with appropriate medical therapy

19. IMPLEMENT AN ORAL CARE PROTOCOL
USING:
a. Non-irritating agents - Normal saline with or without baking soda, Sterile water, avoid mouth
washes with alcohol.
b. Soft-bristle toothbrush
c. Floss
d. Use foam toothettes.

20. HEALTH TEACHINGS
•Avoid commercial mouth washes, citrus fruit juices, spicy
foods, extremes in food temperature, crusty or rough
foods
•Use straw to facilitate fluids bypassing inflamed lesions (if
indicated)
•Use soft tooth brush or toothettes for oral care
•Check for proper fit of dentures

21. PATIENT EDUCATION
Patients and family care providers should learn about :
a.The importance of oral care during cancer treatment to decrease
morbidity and mortality
b.Systematic care of oral cavity—promote health and avoid
trauma
c.Assessment of the oral cavity (i.e., at least daily during therapy)
d.Signs and symptoms to report (i.e., changes in sensation or
taste, presence of ulcerations and/or bleeding)

22. THE MOST
IMPORTANT THING IN
ILLNESS IS NEVER TO
LOSE HEART.