
<b>A sore mouth during chemotherapy or radiation treatment is called stomatitis.   If stomatitis is bothersome during treatment, it can have a severe effect on diet and hydration of the patient, and can be a limiting toxic effect of the treatment.  However, not everyone gets stomatitis or mucositis.  And if they do, usually the symptoms are relieved by the magic mouthwash [recipe below] and/or anti-thrush medication.</b>

Stoma means "mouth", and -itis means inflammation of.   Sometimes other mucous membranes besides those of the mouth are affected:  the nose, esophagus [swallowing tube], stomach, small and/or large intestines, eyes, vagina, and urethra, for example.  The general term for the inflammation of the mucous membranes of the body is "mucositis".  

Stomatitis is sometimes a side effect of radiation to the head and/or neck, sometimes it is a side effect of chemotherapy.  These treatments are more toxic to rapidly dividing cells, and the cells of the mucosa [mucous membranes, or lining] of the mouth are rapidly dividing.  Stomatitis can involve any or all of the tissues of the lips, gums, inside of the cheeks, tongue, and/or palate.  Mucositis can involve any of the mucous membrane tissues.

As the cells of the mucosa are damaged by the chemo or radiation, and die, the mucous membrane thins and then erodes, exposing underlying tissue.  This is painful.  The pain of eating with an inflamed mouth may prevent adequate nutrition and impair survival of the patient.  The fissures and ulcers that occur, exposing underlying tissues, are roadways for oral bacteria to enter the bloodstream.  When the white cell count is low [and it often is during episodes of stomatitis], these bacteria entering the blood stream through oral ulcers and fissures can set off a blood borne infection [sepsis] than can progress to death.

Stomatitis can occur 7-14 days after chemo and lasts 2-3 weeks.  It often occurs at the same time as neutropenia [low level of white cells.] 

<b>If you are going to have chemotherapy or head or neck irradiation, first see your dentist. </b> 

<b>The first signs of a problem will probably come from being extra sensitive to foods that are particularly spicy, sour, or acidic.  In time, actual sores may develop, similar to cold sores, or white patches, or painful swallowing.

1. Notify your doctor.  Ask about magic mouthwash.</b>

2. Try Tylenol for pain relief. 

3. Brush your teeth often. It is very important to keep your mouth and teeth clean while you are taking chemotherapy. Buy a brush with soft bristles (you may want to forego electric toothbrushes as they tend to be harsher to the gums), use warm water, and use a fluoride toothpaste. It is best to brush your teeth any time you eat something, but at least 3 times a day. In addition, do not floss or use waterpiks if you are having trouble with bleeding due to a low white count. Not only will you further irritate your gums but you could have a serious problem getting your gums to stop bleeding. 

4.  Do not use alcoholic mouth rinses. Oral-B makes a great non-alcoholic fluoride rinse, and your dentist can write you a prescription for something stronger. You can also use a baking soda and water mixture (one teaspoon baking soda per 8 ounces of water) to rinse your mouth. It not only serves the purpose of a mouthwash, but it will soothe aching gums.   Rinsing your mouth with the mixture for a minute at a time four times a day will help reduce the bacterial count in your mouth as well, and may cut down on infectious complications.

5. Keep your lips moist with glycerine, KY jelly or some other non petroleum product.  This will also help you to avoid bleeding problems on your lips if they become so dry they start to crack.
 
6. Your diet. This really depends upon the person. If you have severe problems, you will want to avoid any foods that are too hot or too cold. Lukewarm, room temperature type foods will be best.  See what temperature feels least painful while eating.   You also will want to stick with smooth foods that you don't have to chew, like puddings, jellos, applesauce, pureed foods, smoothies, cream soups. Don't be embarrassed to eat baby food -- like Hawaiian Delight, and Blueberry Buckle.
 
7. Use a straw when you drink liquids. This will help to transport the liquid to the back of your throat without touching the problem areas. Milk can be soothing as it coats, and if you are having problems eating you can kill two birds with one stone by adding Carnation Instant Breakfast to the milk. If you drink three packets a day you will get your total daily protein requirements. 
   Avoid tomato and orange juices as they are acidic and be painful in your mouth; replace them with grape or apple juices. 

8. Use the Magic Mouthwash before eating.  If you have thrush [a yeast infection in the mouth] use the nystatin suspension after eating.  Usually the stomatitis heals as the white cell count returns to normal.



<b>Magic Mouthwash Recipe</b>

Your doctor writes the prescription and the pharmacist makes it up. 
Many hospitals have their own variations.
You swish it around in your mouth and spit it out BEFORE meals.
<b>This mouthwash numbs your mouth, so you can eat.   
 
1/3 Maalox 
1/3 liquid Benadryl 
1/3 viscous lidocaine 2% solution 

If there is thrush [a yeast infection] in your mouth, your doctor will be able to diagnose this.  Nystatin suspension, one or two teaspoons to be swirled around to coat your mouth AFTER each meal might be prescribed. </b>Sometimes tablets of diflucan or other medication are prescribed instead of the nystatin suspension.

<b>References:
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For a more detailed discussion of stomatitis, below are some excerpts from an article in the Cancer Control Journal, Volume 2 Number 5,  H. Lee Moffitt Cancer Center & Research Institute.

The article is copyright by the H. Lee Moffitt Cancer Center, but &&url </b>

" Many patients who receive standard-dose chemotherapy experience some degree of mucositis, while most patients treated with high-dose chemotherapy experience severe complications. When the mucous membranes are exposed to ionizing radiation, inflammatory changes are expected. Combined modality therapy consisting of concurrent radiation and chemotherapy can produce highly symptomatic stomatitis (in patients with head and neck cancer) or esophagitis (in patients with lung or mediastinal tumors). Mucositis can be a dose-limiting complication that can interfere with attempts to increase the dose intensity of cancer therapy."

"Clinicians tend to restrict the definition and evaluation of mucositis to the oropharynx and lips, perhaps because of the easy accessibility of these areas for evaluation. Chemotherapy can affect all mucous membranes, however, and evaluation should include the eyes, nose, esophagus, vagina, bladder, and entire gastrointestinal tract." 

"Oral mucositis from chemotherapy usually is preceded by the sensation of dry mouth and lips starting several days after administration of chemotherapy. If the complication progresses, the lips become chapped and whitish patches develop in the mucocutaneous junctions of the oropharynx. These patches usually are painful and can interfere with eating. If no complication or extension occurs, healing takes place over a period ranging from several days to several weeks... Evidence for mucositis in less visible sites includes dysphagia in the esophagus and abdominal tenderness and diarrhea in the gastrointestinal tract. Involvement of the nasal passages is manifested by dryness and irritation, and periocular involvement is indicated by dryness and excess tearing. Cough may reflect bronchial irritation. Finally, severe mucositis can produce a breakdown in the barrier component of the immune system, allowing for bacterial translocation from the gastrointestinal tract to the bloodstream.... In neutropenic patients, such bacteremia can be life threatening. "

"Chemotherapy can damage the oral and gastrointestinal mucosa through direct or indirect toxicity. The mechanism for direct mucositis is nonspecific cell kill of rapidly dividing basal epithelial cells that results in epithelial thinning, inflammation, decreased cell renewal, and ultimately ulceration. These painful lesions also produce an increased risk for local and systemic infection. "

"Indirect mucotoxicity is a byproduct of chemotherapy-induced myelosuppression. Profound granulocytopenia permits oral infections by Gram-negative bacilli, Gram- positive cocci, fungi such as Candida species, and viruses (particularly Herpes simplex). These infections usually occur at the site of direct mucositis or other oral trauma. A patient with a platelet count of 10 x 10 to the ninth per liter or less is at risk for spontaneous bleeding from oropharyngeal ulcerations. Indirect mucotoxicity is associated with the white blood cell count nadir following chemotherapy and most often occurs 12 to 14 days after drug administration...."

"Those agents that can produce direct mucositis at standard doses include ...  alkylating agents such as  ifosfamide and anthracyclines such as doxorubicin...  This toxicity can be dose- and schedule-related, "


"A well-established prophylaxis for direct mucositis currently is unavailable, other than a prescription of suboptimal doses of chemotherapy, a downward dose modification in subsequent treatment courses following toxicity, ... Prophylactic chlorhexidine ... and nystatin or clotrimazole... may be given to reduce the risk of indirect mucotoxicity from bacteria and fungi in patients at high risk for greater than grade 2 or prolonged toxicity. Prophylactic fluconazole reduces the risk of oropharyngeal candidiasis at the risk of the development of resistance...  Herpes simplex virus-antibody-positive patients undergoing high-dose chemotherapy with stem cell rescue should be given acyclovir 250 mg/m squared intravenously every eight hours for prevention of mucocutaneous infections from viral reactivation." 

"A patient with stomatitis should follow a regular mouth-care routine of rinsing the oral cavity with distilled water or sterile normal saline solution for a full minute at least four times per day, followed by gently brushing the teeth, gums, and tongue with a fluoride toothpaste. Patients at high risk for neutropenia and thrombocytopenia should use disposable foam sticks instead of toothbrushes to reduce possible pain, bleeding, and transient bacteremia that can occur following brushing. Acidic, salty, spicy, and coarsely textured foods should be avoided. "

"Treatment of mucositis is primarily supportive. Patients with low to moderate pain can be managed with local anesthesiology. Most institutions have their own version of "magic mouthwash," a combination product of the topical treatment of mild oropharyngeal pain. ...Patients with severe pain require systemic narcotic analgesics." 

"The consequences of chemotherapy-induced mucositis can be severe and can interfere with patients' quality of life, reduce dose intensity of therapy, and further increase the risk of systemic microbial infection. Agents or techniques are needed to prevent or reduce the severity of mucosal toxicity of chemotherapeutic agents." 

"Copyright ©, H. Lee Moffitt Cancer Center & Research Institute. These sources should be used for informational purposes only. If you have a health-related problem, please consult a physician."  

doctordee
compiled December 2003
