Oral Mucositis

Aka: Oral Mucositis, Stomatitis

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II. Definitions

  1. Stomatitis
    1. Inflammation of the mouth and lips
    2. Broader term that includes Oral Mucositis
  2. Mucositis
    1. Painful inflammation and ulceration of the Gastrointestinal Tract
    2. Typically caused by Chemotherapy or Radiation Therapy

III. Causes: Stomatitis

  1. Vitamin Deficiency (typically associated with recurrent Aphthous Ulcers)
    1. Iron Deficiency Anemia
    2. Vitamin B1 Deficiency (Thiamine Deficiency)
    3. Vitamin B2 Deficiency (Riboflavin deficiency)
    4. Vitamin B6 Deficiency (Pyridoxine deficiency)
    5. Vitamin B9 Deficiency (Folic Acid Deficiency)
    6. Vitamin B12 Deficiency (Cobalamin Deficiency)
  2. Specific lesions
    1. Angular Stomatitis
    2. Aphthous Stomatitis
    3. Herpes Gingivostomatitis
      1. Involves Tongue and Hard Palate
    4. Nicotinic Stomatitis
    5. Acute Necrotizing Ulcerative Gingivitis (Vincent's Stomatitis)
    6. Reactive Infectious Mucocutaneous Eruption (RIME)
      1. Follows respiratory tract infections
    7. Local Trauma or reaction
      1. Ill-fitting dentures
      2. Contact Dermatitis
    8. Mouth Chemical Burn Causes
      1. Angiotensin Receptor Blocker
      2. NSAIDs
      3. Aspirin
    9. Oral Mucositis associated with high dose Chemotherapy (within 14 days) or head/neck Radiation Therapy
      1. See management below
      2. Often involves Buccal mucosa
      3. Risks include smoking, poor Oral Hygiene, female gender, Malnutrition
      4. Twice the risk of infection (and severe cancer-related mucositis is associated with increased mortality, RR 4)
        1. May be complicated by Oral Candidiasis (Thrush) or Herpes Gingivostomatitis
    10. Allergic Contact Stomatitis (Delayed-Type Hypersensitivity) Causes
      1. Chlorhexidine Gluconate (Peridex)
      2. Topical Corticosteroids
      3. Budesonide (Rhinocort)

IV. Management: General Stomatitis

  1. See Oral Ulcer
  2. See Pharyngitis Symptomatic Treatment
  3. Treat specific causes
    1. Angular Stomatitis
    2. Aphthous Stomatitis
    3. Herpes Gingivostomatitis
  4. Symptomatic management
    1. General measures
      1. Consider debriding with soft ToothBrush
    2. Saline rinses
      1. Prepare one teaspoon salt in 32 ounces water
      2. Some recipes recommend adding bicarbonate
    3. Topical over-the-counter agents
      1. Amphojel (coats lesions)
      2. Zilactin (forms film over the lesion)
    4. Topical prescription agents (expensive)
      1. Episil (viscous gel)
      2. Mugard (oral rinse)
      3. Gelclair (viscous gel)
    5. Consider topical combination agents
      1. Viscous Lidocaine 2% swish and spit
        1. Exercise caution in dosing and toxicity
      2. Magic Mouthwash
        1. Typically compounded (e.g. Lidocaine, Benadryl, Maalox, with or without a Corticosteroid and/or Antibiotic)
      3. First Mouthwash BLM (commercially prepared)
        1. Diphenhydramine, Lidocaine, Maalox, and Simethicone
    6. Avoid unhelpful or harmful agents
      1. Avoid Sucralfate (ineffective)
      2. Avoid Chlorhexidine (ineffective)
      3. Avoid Alcohol-based rinses (may exacerbate pain)
      4. Avoid Hydrogen Peroxide (may delay healing)

V. Management: Mucositis due to Chemotherapy or Radiation Therapy

  1. Evaluate for complications of mucositis and poor oral intake (esp. Chemotherapy and Radiation Therapy related)
    1. Severe Dehydration
    2. Electrolyte abnormalities (e.g. Hyponatremia, Hypokalemia)
    3. Failure to Thrive
    4. Secondary Oral Infections
      1. Antifungal rinses may be used prophylactically
    5. Bleeding lesions
      1. Keep Platelet Count >20,000
      2. Apply local pressure
      3. Topical Tranexamic Acid (TXA)
  2. Prevention
    1. Brush with a soft ToothBrush twice daily
    2. Rinse with bland mouthwash four times daily
    3. Full Dental assessment BEFORE head and neck radiation
    4. Limit foods that are acidic, rough or sharp, and reduce starches
    5. Avoid Tobacco and Alcohol
  3. Symptomatic management of lesions
    1. Viscous Lidocaine 2% swish and spit
      1. Exercise caution in dosing and toxicity
    2. Bland Mouthwash in mucositis
      1. Mix of 1 tsp Table Salt and 1 tsp Baking Soda in 1 pint water
      2. Repeat up to evevery 4 hours for mild to moderate mucositis pain
      3. Equivalent to rinses containing Anesthetics, Antihistamines and steroids)
    3. Other agents used in Chemotherapy and Radiation Therapy induced mucositis
      1. Doxepin 0.5% solution
      2. Morphine 2% mouthwash preparation
      3. Keratinocyte growth factor preparation
      4. Systemic Analgesics

VI. References

  1. Negrin in Drews (2014) Oral Toxicity Associated with Chemotherapy, UpToDate, accessed online 11/05/2014
  2. Swaminathan and Dibbs in Herbert (2020) EM:Rap 20(8): 2
  3. (2014) Presc Lett 21(11): 64
  4. Eary (2026) Am Fam Physician 114(4): 393-411 [PubMed]
  5. Nolan (1991) J Oral Pathol Med 20(8):389-91 [PubMed]
  6. Sun (2014) J Oral Pathol Med [PubMed]
  7. Thongprasom (2001) Southeast Asian J Trop Med Public Health 32(3):643-7 [PubMed]

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