Fast Fact and Concept #121: Oral mucositis: diagnosis and assessment
Author(s): CF Henson; Robert Arnold
The term mucositis refers to the inflammatory response of the oral-pharyngeal mucosa as a result of radiotherapy that includes the mucosa within the radiation field, or from systemic chemotherapy. The term stomatotoxicity is more specific to mucositis affecting the oral mucosa. Mucositis results from the destruction of rapidly dividing epithelial cells of the oral-pharyngeal mucosal epithelium and the secondary release of inflammatory mediators such as TNF-alpha and interleukin-1 beta.
The Radiation Therapy Oncology Group (RTOG) describes five grades of acute mucositis:
- Grade 1: Injection/may experience mild pain not requiring analgesics
- Grade 2: Patchy mucositis which may produce an inflammatory serosanguinitis discharge/may experience moderate pain requiring analgesia
- Grade 3: Confluent fibrinous mucositis/may include severe pain requiring opioid analgesic
- Grade 4: Ulceration, hemorrhage or necrosis
- Grade 5: Death resulting from mucositis
Both patient-related factors and treatment-related factors influence the severity of mucositis. Increased total dose of radiation, fraction size, and volume of normal tissue in the irradiated field all increase the risk of mucositis. Not all chemotherapy agents produce the same risk of mucositis, 5-fluoruracil, doxorubicin and methotrexate commonly cause mucositis while vincristine does not. The simultaneous combination of radiation and chemotherapy used in head and neck cancer will cause more intense mucositis than single-modality therapy. Patient-related factors such as the overall condition of the oral mucosa prior to therapy, pre-existing xerostomia, pre-existing collagen-vascular disorders, the underlying nutritional status, and the development of neutropenia during therapy all impact the development and severity of mucositis.
In head and neck cancer, virtually all patients undergoing radiation, with or without chemotherapy, will develop grade 1 and 2 mucositis. More severe mucositis (grade 3 or higher) develops in approximately 41% of patients receiving combined radiation and chemotherapy to the head and neck and in 21% of patients receiving radiation therapy alone.
Clinical signs of mucosal damage and cell death appear after the first 1 to 2 weeks of radiation therapy and as early as 3 days after chemotherapy. Initial mucosal damage results in patchy erythema, edema, atrophy and whitening of the mucosal tissue with increased sensitivity?patients report a burning sensation in the mouth. Further loss of mucosal epithelium becomes most prominent in the fourth or fifth week of standard fractionation radiation resulting in fibrinous exudation, confluent inflammation, and ulceration (see FF# 66-67). The mouth sores and swelling can lead to significant oral pain, pain with swallowing, weight loss and dehydration. Mucosal damage predisposes the patient to oral superinfection leading to further pain and alterations in taste and appetite and decreased quality of life. Resolution of oral mucositis occurs several weeks after the completion of RT and chemotherapy.
A thorough assessment of the patient with mucositis should include:
- Pain assessment to include thorough review of analgesics used, effect and toxicities
- Nutritional assessment
- Quality of life assessment including screening for depression
- Complete oral examination; assessment for local fungal, bacterial, or viral infections
- References:
Bernier J, Domenge C, Ozsahin M et al. Postoperative Irradiation with or Without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer. N Eng J Med, 350:1945-1952, 2004
Cooper JS, Pajak TF, Forastiere, AA et al. Postoperative Concurrent Radiotherapy and Chemotherapy for High-Risk Squamous-Cell Carcinoma of the Head and Neck. N Engl J Med 350 (19):1937-1944, 2004
Fu K, et al. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys 48:7-16, 2000
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Henson DF and Arnold R. Fast Facts and Concepts #121: Oral Mucositis: Diagnosis and Assessment. September 2004. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.
Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007. For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu
Disclaimer: Fast Facts provide educational information; this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
Creation Date: 9/2004
Format: Handouts
Purpose: Self-Study Guide, Teaching
Audience(s)
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Training: Fellows, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice |
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Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery |
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Non-Physician: Nurses |
ACGME Competencies: Medical Knowledge, Patient Care
Keyword(s): Non
pain symptoms & syndromes; cancer
Specific Disease and Organ System Category(s):
Cancer