Mouth Sores in Cancer Patients - Oral Mucositis

Mucositis and mucosal inflammation are terms used for cancer treatment-related mouth soresas descriptions of these lesions.

Mucosal inflammation is an open sore or ulcer inside the mouth. Many diseases can cause mouth sores and inflammation. Here, however, we will examine those resulting from cancer and cancer treatment.

Our article has the following main headings and subheadings:

1. Introduction to oral mucositis and nutrition
2. Factors affecting nutritional status
• Cancer
• Cancer treatment
• Mucositis
3. Nutritional assessment
• When is nutritional assessment performed?
• Nutritional screening test
4. Nutritional therapy for mucositis
• Oral nutrition
• Parenteral and enteral nutrition
  - Who should receive enteral (mouth, stomach, small intestine) nutrition
  - Who cannot receive enteral nutrition
  - Enteral nutrition strategy
  - Who should receive parenteral (intravenous) nutrition
  - Those unable to receive parenteral nutrition
  - Parenteral nutrition strategy
  - Parenteral and enteral nutrition at home
  - Withdrawing parenteral nutrition
• Special considerations
  - Religious beliefs
5. Recommendations for mouth sores

1- Introduction to Oral Mucositis and Nutrition

Oral mucositis is a condition involving painful lesions on the mucous membranes of the mouth. It is a common side effect of cancer treatment, generally becoming more severe as chemotherapy or radiation doses increase. Mucositis can devastate nutritional status because its oral pain often prevents people from eating solid foods and sometimes even swallowing.

In very severe cases, cancer treatment must be interrupted to allow the oral mucosa to heal and nutrition to resume. In other cases, parenteral or enteral nutritional supplementation may be needed. Parenteral nutrition means feeding through an intravenous tube, while enteral nutrition means feeding through a gastric tube, such as a tube placed in the stomach.

Nutritional support is a fundamental component of cancer treatment and helps individuals maintain body weight. Individualized nutrition plans assess changing nutritional requirements throughout treatment. They aim to help patients maintain a healthy body weight by ensuring consumption of the necessary daily calories orally, enterally or parenterally.

Consequently, many people with cancerous tumors have already developed poor nutritional status when diagnosed, before treatment begins or mucositis develops.

2- Factors Affecting Nutritional Status

Cancer

Poor nutritional status, manifested by rapid weight loss, is often an early cancer symptom and results from a condition called anorexia-cachexia syndrome.

Anorexia is loss of appetite and the desire to eat. Even people who continue consuming their normal calorie requirements are affected by cancerous tumors and may begin losing weight.

Cachexia is a tumor-induced condition characterized by protein-energy malnutrition and involuntary weight and muscle loss. People with upper gastrointestinal cancers, whose treatment is most likely to trigger mucositis, are particularly likely to develop cachexia.

Anorexia-cachexiacauses malnutrition and muscle loss through metabolic changes. Cancerous tumors consume glucose, amino acids and lipids, typically supplying nutrients to the individual with cancer. Thus, someone with cancer consumes more energy at rest, known as basal energy expenditure, than someone without cancer. They consequently need to eat more to maintain weight.

Anorexia-cachexia syndrome affects almost everyone in advanced cancer. It causes further malnutrition and adversely affects treatment response, outcomes and survival prospects. Besides metabolic changes, cancer can alter taste and cause nausea and vomiting. These symptoms can worsen anorexia.

Many people are already poorly nourished before cancer diagnosis. They may have developed cachexia and/or anorexia before treatment. Estimates suggest that among survivors of head and neck cancer , one third were malnourished when treatment began.

Cancer treatment

Nutritional status should be improved before cancer treatment because it affects treatment tolerance and outcomes. For example, if a patient cannot tolerate high-dose treatment and the dose must be reduced, treatment will be less successful in eliminating the tumor. Patients who lose more than % 20 of body weight experience greater treatment toxicity (side effects). They therefore face a greater risk of conditions occurring in proportion to cancer treatment dose or toxicity. Mucositis is one such condition.

Mucositis

Mucositis is among the most frequent side effects of chemotherapy and radiation therapy. It causes severe mouth pain and can cause or worsen malnutrition. Its relationship with nutritional status is multifaceted. The painful oral lesions make eating and drinking difficult, generally reducing energy intake and interest in food. While mucositis causes malnutrition, good nutrition has been shown to improve its symptoms and reduce treatment toxicity. When symptoms improve, nutritional intake rises. Until recently, improving symptoms was difficult because no effective treatment was available.

In recent years, the adverse effects of mucositis on nutrition and its broader effects on health and quality of life have gained recognition, and new treatments have emerged. For example, antioxidant treatments, glutamine therapy and the recently approved mucoadhesive gel Gelclair create a protective barrier around the oral mucosa. These new options may reduce mouth pain and help people with mucositis eat.

In recent years, 3 approaches have made substantial contributions to mucositis treatment:

• Dexamethasone mouthwash for everolimus-related mouth sores in breast cancer treatment
• A drug that prevents radiotherapy-related mouth sores to an unprecedented degree
• Preventing mouth sores from head and neck cancer treatments with melatonin gel

3- Nutritional Assessment

When is nutritional assessment performed?

Healthcare professionals usually assess cancer patients' nutritional status regularly, identifying those at risk of anorexia, cachexia and/or malnutrition. Early identification of nutritional risk before status begins deteriorating is vital, because once malnutrition or cachexia starts, very few people regain lost weight or muscle.

Nutritional status should be assessed before treatment. Such assessments sometimes reveal malnutrition in people who believe their diets are adequate. This particularly applies to people with head and neck cancers, who have a high mucositis risk.

Nutritional screening test

Healthcare workers use screening questionnaires to assess nutritional status in cancer. Individuals are generally asked to complete a questionnaire, or allied healthcare personnel complete it. Basic dietary information and measurements of body weight and height guide nutritional screening assessment.

4- Nutritional Therapy for Mucositis

Nutritional therapy is an important component of cancer care. Because mucositis is a very common side effect, many people receiving cancer treatment develop it, and those with mucositis are almost always receiving active cancer treatment when it develops. Healthcare professionals therefore assess each individual's likelihood of developing mucositis during treatment and consider this when developing a nutritional strategy.

Nutritional therapy aims to preserve weight and health in individuals well nourished at treatment onset, and reverse weight loss or nutrient deficiencies in poorly nourished individuals. It should also improve quality of life during treatment. Intensive nutritional therapy has been shown to stabilize or reverse weight loss in % 50-88 of individuals receiving cancer treatment.

Nutritional therapy generally begins before treatment. Initially, it simply involves healthcare professionals explaining possible nutritional side effects and the importance of adequate intake. Nutritional education continues throughout treatment and may intensify as treatment dose increases, for example through a special diet or feeding tube. Nutritional therapy may continue for at least one year, up to three years, after treatment ends.

Nutritional therapy should be prepared with a dietitian specializing in nutrition for people with cancer. Unproven or alternative treatments read in magazines or online should be used only if recommended by an accredited dietitian and with specialists' knowledge.

People with mucositis are particularly likely to struggle with oral food intake and may therefore need enteral or parenteral nutritional support.

Oral Nutrition

Oral nutrition includes all methods encouraging greater intake by mouth, including nutritional supplements and high-calorie or high-protein formulations. It is preferred over parenteral nutrition. Healthcare professionals recommend it whenever possible. Maintaining an overall balanced diet, eating varied foods from different sources and groups, is important. However, dietary modifications such as increased protein or particular micronutrients may be required to maintain weight.

Many people struggle to obtain adequate oral nutrition and need professional help planning meals. Dietitians can help people receiving cancer treatment plan meals and ensure sufficient intake. Someone with mucositis is generally encouraged to eat frequent meals, up to 6 daily, rich in protein, energy and micronutrients to avoid weight loss. Appetite-stimulating formulations may also be given to make them feel hungry more often and encourage more frequent eating.

People with mucositis should benefit from a carefully chosen diet containing soft foods that are easy to chew and swallow and do not irritate the oral mucosa.

The following tips may help select suitable foods:

Eat soft foods: Eat soft foods. Cook vegetables and other foods until soft. Soft fruits such as bananas, strawberries and watermelon can be eaten raw. Stone fruits, apples and other fruits can be stewed. Other foods that may be easy to eat include custard, pudding, vegetable purees, oats, cooked breakfast cereals and scrambled eggs. Coarse foods such as meat can be minced.

Fluid intake: Fluids may be taken with meals to reduce mouth irritation. Milk, liquid nutritional supplements and high-energy nutritious drinks can be taken between meals or with main meals when intake is inadequate. Individuals can also improve the quality of fluids by adding meat or chicken broth to meals.

Avoid irritating foods: many foods, particularly spicy, acidic or salty ones, may irritate the oral mucosa. Dry, coarse foods such as raw vegetables and crackers should also be avoided.

Avoid hot foods: hot foods may also irritate the mouth, so people with mucositis should eat cold or room-temperature foods.

Use ice: ice or ice blocks can help numb the mouth.

Cut food into small pieces before eating.

- Related topic: Chemotherapy and nutrition – 14 useful tips and a snack recipe

Parenteral and enteral nutrition

Although oral nutrition is preferred where possible, tube feeding may often be necessary, particularly in gastrointestinal and head and neck cancers. Many people with head and neck cancers may have a parenteral or enteral feeding tube placed before treatment. Such nutrition aims to reduce further weight loss and treatment toxicity and improve treatment response.

Who Should Receive Enteral Nutrition

Enteral nutrition helps people with functioning digestion who cannot consume enough orally. This may occur particularly when mucositis or other side effects become severe enough to jeopardize treatment. An enteral tube is preferred because gastrointestinal organs continue digesting food. Enteral nutrition also allows more efficient nutrient absorption than parenteral feeding and is more cost-effective. An enteral tube has a lower infection risk and is easier to implement than parenteral nutrition.

Who Cannot Receive Enteral Nutrition

Enteral nutrition is contraindicated in certain patients, including those with:

A malfunctioning gastrointestinal (digestive) system;

• Malabsorption conditions
• Gastrointestinal obstructions preventing swallowing or digestion
• Severe bleeding
• Severe diarrhea 
• Severe vomiting
• Conditions preventing enteral feeding tube placement
• Inflammatory bowel conditions

Enteral Nutrition Strategy

An enteral feeding tube can be placed at many points in the gastrointestinal tract. A healthcare professional determines the best location, mainly according to how long enteral nutrition will be needed, whether less or more than two weeks.

There are numerous ways to administer enteral feeding solutions; for example, a pump can push solution into the tube at regular intervals throughout the day, or nutrients may be delivered continuously. The solution's energy value, measured in calories, varies with individual needs and the feeding method, such as continuous or intermittent feeding.

A range of formulations containing all nutrients can be given through an enteral tube. Formulas containing specific nutrients, such as protein, fat, fiber or glutamine, are also available and may supplement standard formulas in people deficient in particular nutrients.

Parenteral nutrition is suitable only for individuals without gastrointestinal function, meaning unable to digest food. These include people with: 

• Severe mucositis
• Severe nausea or vomiting
• Gastrointestinal obstruction
• Short bowel syndrome and
• Ileus (intestinal obstruction). Parenteral nutrition should not be used in individuals with:
• A functioning bowel 
• No obtainable intravenous access
• A need for nutritional support for <5 days

Parenteral Nutrition Strategy

Parenteral nutrition is administered intravenously; if no access exists, a catheter must be placed to deliver the formula. Solutions should be tailored to individual needs. They typically contain amino acids, dextrose, lipids, vitamins, minerals and elements, fluids and electrolytes. Some may also contain insulin, heparin and antacids.

Parenteral and Enteral Nutrition at Home

Both enteral and parenteral formulas can be administered at home, so this nutrition need not prevent hospital discharge. Healthcare professionals should teach recipients and caregivers how to administer formulas and clean the feeding tube to prevent infection. Individuals receiving enteral or parenteral nutrition at home need a safe, clean environment and must continue attending hospital or clinic for medical checks.

Withdrawing Parenteral Nutrition

Parenteral nutrition cannot be stopped abruptly. It should be reduced gradually while oral or enteral feeding is reintroduced. If a person tolerates consuming %50 of nutritional requirements enterally or a full liquid diet, meaning all requirements orally but as liquids rather than solids, parenteral treatment can be halved. When they can consume %75 of requirements enterally or eat solids in addition to liquid nutrition, parenteral nutrition may be withdrawn completely.

Special considerations

Religious Beliefs

Some individuals fast periodically as part of religious traditions. Waiving traditions that restrict food intake during cancer treatment is essential to ensure treatment is as effective as possible. People who normally observe religious fasting periods should inform their doctor and consult relevant religious leaders about waiving dietary restrictions during treatment.

5- Recommendations for Mouth Sores

• Check your mouth at least once daily and report changes to your doctor.
• Use a flashlight and mirror to inspect inside your mouth.
• Check for ulcers, blisters, sores, red streaks or spots.
• Tell your doctor about any mouth pain.
• Keep your mouth clean and moist.
• Brush your teeth before bed and within 30 minutes after meals.
• Brush even if you have mouth sores. If your mouth hurts, use a soft toothbrush, cotton swab or cleaning stick with a soft sponge tip.
• If your platelet count is low, do not floss, as it may cause pain and bleeding.
• You can use a water-based oral moisturizer inside your mouth and on your lips.
• If your mouth is very dry, drink water and other fluids throughout the day. Artificial saliva and chewing gum can keep your mouth moist.
• Care for your dentures if you have them.
• Remove your dentures during the day and brush them frequently.
• Soak dentures in antiseptic cleaning solution for a few minutes and rinse.
• If you have mouth sores, wear dentures only while eating.
• Do not wear dentures while sleeping.
• Avoid poorly fitting dentures.

What Irritates the Mouth?

• Mouthwashes containing more than %6 alcohol
• Sour, spicy and hot foods and drinks
• Smoking and chewing tobacco 
• Excessive alcohol

Consult Your Doctor If You Have: 

• Redness or excessive dryness in the mouth
• Mouth sores or pain
• White spots, streaks, sores or blisters in the mouth
• Bleeding in the mouth
• Difficulty swallowing
• Fever of 38°C or higher

Consult your doctor promptly if you have these signs or complaints. Never follow hearsay advice on your own without your doctor's knowledge. Your doctor will perform the necessary tests and provide appropriate treatment. 

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