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Mucositis: Oral, Esophageal and Gastrointestinal Problems and Solutions
Julie Schwenka, PharmD, Ernest H Rosenbaum, MD, Alexandra Andrews,Charles M. Dollbaum, MD, PhD, Robert J. Ignoffo, PharmD

Topics to Discuss with Your Medical Team
Prevention and Treatments
Nutritional Tips

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Mucositis occurs when cancer treatments break down the rapidly divided epithelial cells lining the GI tract, particularly in the oral cavity, leaving the mucosal tissue open to ulceration and infection. Mucositis can occur anywhere along the digestive tract from the mouth to the anus. Oral Mucositis is probably the most common, debilitating complication of cancer surgery, chemotherapy and radiation. It occurs in 20-40% of patients treated with chemotherapy alone and up to 50% of patients receiving combination radiation and chemotherapy. The consequences of mucositis can be mild requiring little intervention to severe (hypovolemia, electrolyte abnormalities, and malnutrition) that may result in fatal complications.

Taste loss tends to increase in proportion to the aggressiveness of treatment. Nausea, pain, vomiting, diarrhea, a sore or dry mouth may make eating difficult. Thus maintaining adequate nutrition is a challenge for cancer patients. Reduction of caloric intake can lead to weight loss, loss in muscle mass strength and other complications, including a decrease in immunity. Cancer patient education must discuss the risks and the under-reporting of mucositis. Delayed or reduced medical treatment doses may limit chances for a cure. The potential impact of morbidity and mortality with oral Mucositis should not be underestimated and requires active treatment.

Chemotherapy and radiation to the head and neck prevent cells in the mouth and GI tract from reproducing, which makes it hard for tissue to be repaired. The mouth has a delicate balance of natural bacteria and fungi, so if you receive any one or both of these therapies, it can lead to a decrease in salivation. This decrease in salivation upsets the natural balance of bacteria in the mouth causing infections, mouth sores and tooth decay.

It is important to know who is at risk of mucositis and to prevent complications to help improve quality of life and maximize your therapy. These risk factors include radiation to the head and neck, high dose chemotherapy, bone marrow transplantation, certain single agent anti-cancer drugs or a combination of these. Symptoms of mucositis should be treated as soon as they appear. It is important to be educated about proper nutrition and oral hygiene to help prevent or lessen these symptoms. Once you are aware of proper nutrition, you will be able to maintain adequate hydration, maintain your immunity and help prevent nausea as well as protecting your teeth.

Topics to Discuss with Your Medical Team
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1.Notify your doctor for any excessive bleeding, nausea, fever or pain associated with your mucositis.
2.Let your doctor know of all your medication allergies and a list of your current medications (including over-the-counter drugs, herbal products and vitamins).
3.Ask your medical team for dietary and nutritional needs tailored just for you.
4.Do not allow pain or nausea to get out of control. Take your medicine at the beginning of symptoms to prevent vomiting or excessive pain.
5.Make sure you have an emergency contact phone number from your medical team in case of any emergencies.
6.Keep your medical team well informed for any signs of infection. Also make sure you tell them of symptoms getting better or worse.
7.Keep a journal of your pain scale and when you have nausea so your medical team can make the best recommendations for you.

Prevention and Treatments
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Prevention will not stop mucositis from occurring but it can help alleviate some pain and lessen some of the side effects and symptoms of mucositis. It is important to be educated about mucositis, how to take care of yourself and to have a good relationship with your physician and dentist.
The first step in prevention is to see if your doctor can recommend a dentist that deals with cancer patients. You will need to have your teeth and gums evaluated and if you wear dentures, to make sure they fit properly. If any work is needed (teeth extractions or refitting of dentures), it should be completed at least one month prior to starting therapy to make sure your mouth has completely healed and prevent damage to your existing teeth, gums or jaw bones.
The next step to taking care of your mouth is proper brushing techniques and oral hygiene. If you smoke, it is extremely important that you stop smoking. Your doctor will be able to help you with smoking cessation programs. You should use a soft bristle toothbrush and brush your teeth 2 to 3 times daily (after eating). If necessary, due to sensitivity or mouth sores, you may need to use foam toothbrushes with an antibacterial rinse. You should choose mild tasting toothpaste with fluoride, for example Prevident®. Some flavorings in toothpaste may irritate the mouth. If your toothpaste is still too irritating, you can use a solution made of 1 teaspoonful salt dissolved in 4 cups of water. You should gently floss your teeth once daily.
If you develop mucositis or it worsens, you will need to increase brushing to every 4 hours and at bedtime. This will help keep the mouth moisturized and help prevent any infections. It is important to brush and floss very gently. You will want to rinse your mouth frequently to prevent cavities with antiseptic mouth rinses, for example, Peridex® or Periogard®. You can make your own rinse by mixing 1 teaspoon of baking soda in 8 ounces of water or 1/2 teaspoon salt and 2 tablespoons dissolved in 4 cups of water. If you are being treated with high dose chemotherapy or a bone marrow transplant, your doctor can give you some new medication that can prevent or shorten the duration of mucositis.
Your mouth may become dry and you will want to keep it moisturized. This can be due to a decrease in your saliva production or the mucositis directly. Some easy remedies include chewing ice chips, chewing sugarless gum, or sucking tart candy. If these do not work there are artificial saliva products that your physician can prescribe for you or some over-the-counter products are available like Oral Balance®. Since your saliva barrier is compromised you should avoid eating or drinking products containing sucrose to prevent cavities.
Pain is also a very serious complication of mucositis. Aspirin containing products and nonsteroidal anti-inflammory products like Motrin® or Naprosyn® should be avoided due to their effect on platelets, which can increase the risk of bleeding. You can also use topical products like Orajel® or some prescription products like viscous lidocaine or a new product called Gelclair®. If the pain becomes more severe you may need your doctor to prescribe you stronger pain medications, such as Vicodin®, Percocet® or Tyco #3®. To help clean oral sores you can rinse with a solution consisting of 1 part 3% hydrogen peroxide with 2 parts of saltwater (1 teaspoon of salt mixed in 4 cups of water).
Saliva helps protect the mouth and gums from infection. These infections can be bacterial, fungal or viral in nature. For mild fungal infections, topical oral suspensions or dissolving tablets can be prescribed. You will need to swish or dissolve the medicine in your mouth and depending on your doctor’s directions, either swallow or spit out the medicine. It is important to not use any medicine containing alcohol because it will burn the mouth. For worsening fungal, bacterial and viral infections, your physician will need to prescribe oral medications, such as antibiotics, to eradicate them. You should also remove any dental appliances and soak them in antiseptic solutions (Listerine® or Peridex®)

Nutritional Tips
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These nutrition tips will help if you are experiencing dehydration, taste changes, decreased appetite or pain with eating.
1.Eat small frequent meals throughout the day.
2.Try to have a balanced diet to maintain energy and your immunity.
3.Avoid spicy, hot or cold foods if it is painful to eat or you are having nausea. Eat food that is a little bland and at room temperature.
4.Drink lots of fluid, broth or drinks like Gatorade. This will keep you hydrated.
5.Eat food high in calories and protein to maintain weight and nutrition. Take vitamins and minerals.
6.If your mouth is too sore, eat soft or blended foods like ice cream, pudding, soup, and applesauce.
7.Zinc supplements may help with taste changes.
8.Some prescription medications are available to help increase appetite like Megace® or Marinol®.
9.Avoid your favorite foods when you are receiving chemotherapy. You may develop a taste aversion to them by association.
10.Use spices or flavoring to make your food taste better. Eat whatever you can tolerate to maintain weight.

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