MUCOSITIS

By : Nisha Mathew

DEFINITIONMucositis refers to an inflammatory

process involving the mucous membranes of the oral cavity and the gastrointestinal(GI) tract.

ETIOLOGY & RISK FACTORS Patient- related factorsFACTORS DESCRIPTIONAge Children/elderly are at great risk.

Oral hygiene Poor oral health/hygiene increases the risk.

Salivary secretion function

Reduced salivary flow increases the susceptibility to mucositis.

Genetic factors Patients who express higher level of cytokines are at higher risk.

BMI Low BMI(<20 in males & <19 in females) increases the risk.

Renal function Decreased renal function increases the risk.

Smoking Person who smoke may be at higher risk .

Previous cancer treatment

Patient treated previously for cancer may be at higher risk.

Oral microflora Patients with higher level of microflora are at higher risk.

Gender Women greater than men.

Treatment-related risk factors

FACTORS DESCRIPTION

Chemotherapy agents 5-Flurouracil,methotrexate and Etoposide produce high rate of mucositis.

Chemotherapy dosage

High dosage chemotherapy regimens are associated with its higher incidence.

Type of stem cell transplant

Allogenic stem cell transplant recipients experience higher rates of mucositis.

Radiation site Radiation administered directly to head & neck, thorax and abdomen produce higher rates of mucositis.

Combined modality Use of chemotherapy in conjunction with radiation therapy is associated with increased risk ad severity of mucositis.

Pathogenesis of mucositis1.Initiation

2.Primary damage response

3.Signalling/ amplification

4.Ulceration

5.Healing

1 INITIATION DNA and non-DNA damage results in distinct

submucosa and basal epithelium injury.

Damage to underlying cells begins downward spiral of cellular injury later.

Mucosa appears normal.

PRIMARY DAMAGE RESPONSE Apoptosis of epithelial cells.

Activation of transcription factor(NF-kB) leads to amplification of injury.

Activation of pro-inflammatory cytokinesIL-6,IL-1β,TNF-α damages connective tissue and endothelium.

Patient unaware of injury.

SIGNALLING/AMPLIFICATION Pro-inflammatory cytokines continue to damage

submucosa.

Cellular molecular pathways amplify damaging process.

Patient continue to be unaware of injury despite increased cellular ravages.

ULCERATIONo Injury manifested by ulceration that penetrates

from epithelium into submucosa.

o By-products of colonizing microflora cause infiltration of inflammatory cells.

o Patient start experiencing painful lesions as a result of which impaired swallowing, communication and nutritional deficiency occur.

HEALING Regeneration of epithelium.

Increased production WBC’s to fight infection.

Normal cellular process returns, cleaning up debris and decrease swelling.

Subsequent radiation or chemotherapy halt healing process leading to severe mucositis.

CLINICAL MANIFESTATIONS Asymptomatic erythema. Redness of oral cavity. Erythema replaced by erosion Ulceration covered with white fibrous pseudo

membrane. Pain. Xerostomia

ASSESSMENT WHO SCORE Based on a combination of subjective, objective and

functional outcomes: ♦ Subjective– Soreness as described by the patient ♦ Objective – Presence of erythema and ulcerations ♦ Functional– Ability to eat solids, liquids or nothing

by mouth

WHO ORAL MUCOSITIS SCALE Grade 0 – No objective findings, function irrelevant

Grade 1 – Erythema plus pain, function irrelevant – May include mucosal scalloping with or without

erythema or soreness

Grade 2 – Ulceration, ability to eat solids

Grade 3 – Ulceration, ability to eat liquids

Grade 4 – Ulceration, nothing by mouth

THERAPEUTIC APPROACHES ORAL CARE Brush all tooth surfaces Allow toothbrush to air dry. Floss daily. Rinse the mouth with bland mouthwash Avoid tobacco alcohol and irritating foods. Use water based moisturizers Maintain adequate hydration.

PALIFERMIN Recombinant human keratinocyte growth

factor(KGF1,Fibroblast growth factor) or palifermin recommended in patients with hematological malignancies, high dose chemotherapy, stem cell transplantation.

60µg/kg per day for 3 days before and 3 days after the treatment.

CRYOTHERAPY Using ice chips and cold water in mouth causing vasoconstriction of oral cavity.

Indicated when patients receive high dose of melphalan,bolus dose of edatrexate,bolus dose of 5-FU.

Cryotherapy recommended 5 mins prior to infusion, during and 30 mins following the infusion.

NOT RECOMMENDED FOR PRACTICE Use of granulocyte macrophage colony

stimulating factor mouthwash.

Use of sucralfate.

Use of chlorhexidine mouthwash. These agents have no benefit in treating oral

mucositis

SUMMARY Patients describe oral mucositis as the most painful and

debilitating symptoms associated with cancer treatment.

By alleviating or lessening oral mucositis patient may be able to receive the needed dose of radiation or chemotherapy to cure and control the cancer.

Nurses can assist patients to manage oral pain and other side effects that may lead to better nutritional intake, potential elimination of infection and improved quality of life.

BIBLIOGRAPHY Yarbro Connie Henke,Wujcik Debra,Gobel Holmes

Barbara; principles and practice in cancer nursing;jones & barlett publications;seventh edition,page no;808-816.

WEB http://www.cibmtr.org/CutlerC_MucositisASB.pdf

THANKYOU