Almost half of all cancer patients on chemotherapy, and almost all who have radiation to the head or neck, experience mouth discomfort as a side effect of treatment. Chemotherapy medications work on rapidly-dividing cells, like cancer cells — but also attack other cells in the body, including those forming the lining of the mouth. Radiation also damages these delicate cells while it acts on the cancer. The resulting swelling and soreness in the mouth is the body's reaction to this treatment.

This discomfort can range from mild, easily treated and quick healing, to more severe problems. None of it is pleasant, and all of it can reduce a person's quality of life. That's why it's important to get medical attention to treat the problem. There are both treatments and preventive steps, including a mouth care regimen, to minimize this uncomfortable aspect of cancer treatment.

Symptoms

Warning signs of mucositis usually begin within one to two weeks after chemotherapy. These can include:

• Small ulcers or sores in the mouth, on gums and tongue; the sores may be reddish and may have white centers
  
• A burning, tingling feeling inside the mouth
  
• Whitish patches inside the mouth
  
• Inside of mouth looks red, shiny and swollen
  
• Unusual sensitivity to very hot and very cold foods
  
• Unusual mouth dryness
  
• Fever
  

Prevention & Protection

Excellent oral hygiene will improve your chances of avoiding mucositis, and if it occurs, will minimize healing time. However, even with excellent hygiene, mucositis can occur, especially when certain chemotherapy medications are used. To manage mouth soreness, take these important steps:

1. Before you begin chemotherapy or radiation, schedule a complete dental examination, informing your dentist that you will be undergoing cancer treatment. Leave time to heal from any procedures; a month is best.
   
   
   • Your blood counts should be taken before any treatment begins; it's important that your counts are adequate to withstand any dental procedures without risking infection. Your dentist and oncologist should coordinate your dental care, including the prescription of antibiotics if needed.
     
     
   • During the course of your treatment, if additional dental work is needed, your dentist and oncologist will want to closely coordinate your care, making sure that your blood counts are sufficiently normal to allow safe dental treatment. Also if your chemotherapy is being delivered through a port — a central venous catheter — a special regimen of antibiotics should be taken before dental treatment; talk with both your dentist and oncologist about this before proceeding.
   
   
   
2. Begin a daily program of oral hygiene, in consultation with your dentist. This program will probably include the following:
   
   
   • Use a soft brush and a mild, non-abrasive toothpaste for brushing after each meal.
     
     
     • Don't forget to gently brush your tongue as well as teeth and gums, to help reduce the risk of a fungus infection.
       
       
     • Change your toothbrush very frequently — every week or so.
       
       
     • Special appliances like WaterPiks and electric toothbrushes may further irritate sensitive mouth tissues and gums.
     
     
   • If your toothbrush causes pain, consider using a Toothette, a sponge-tipped swab containing a dental cleaner.
     
     
   • If your gums are painful and possibly bleeding, seek your dentist's advice about an anti-inflammatory dental rinse, such as Peridex.
     
     
   • Floss your teeth gently in the evening.
     
     
   • If you wear dentures, these must be thoroughly cleaned after every meal. If possible, avoid wearing dentures overnight while you sleep.
     
     
     • Make sure your dentures fit properly, and repair or replace them if they don't. Ill-fitting dentures can rub and cause additional pain in a tender mouth,
     
     
   • If you are told that your chemotherapy medication is particularly likely to cause mouth soreness, begin rinsing after each brushing with a solution of salt water or baking soda.
     
     
   • In general, commercial mouth washes can further aggravate a sore mouth, especially those containing alcohol. Do without them.
     
     
3. Adapt what you eat to soothe a possibly tender mouth:
   
   
   • Avoid very hot food; try eating most of your food just warm or at room temperature if your mouth is tender.
     
     
   • Some people find that cold foods, like ices and popsicles ease a sore mouth, while others find these are painful. Try this and see what works for you.
     
     
   • Highly-seasoned food sometimes aggravates mouth soreness.
     
     
   • Avoid alcohol and tobacco; both can irritate an already-sore mouth.
     
     
   • Citrus fruit and tomatoes are uncomfortable for some people with mucositis, as are salty foods. Consider restricting these in your diet.
     
     
   • In general, carbonated drinks, including sparkling water, can be irritating to a tender mouth.
     
     
   • Foods with sharp edges, such as chips and crackers, may prove irritating.
     
     
   • In general, soft, bland foods are probably the best choice for people with sore mouths.
     
     
   • Get professional help: many hospitals and cancer treatment centers have registered dieticians who can help you shape a diet that works for you during the course of your treatment.
   
   
4. Some people develop dry mouth, especially those receiving head and neck radiation. Radiation can affect the glands which produce saliva, decreasing mouth moisture and interfering with chewing, swallowing and even talking. Take special steps to keep your mouth moist and more comfortable:
   
   
   • Drink at least 8-10 glasses of non-carbonated liquids each day.
     
     
   • Select foods that are moist and soft, such as puddings, ice cream, fruit ice, yogurt, and applesauce.
     
     
   • Sucking on non-irritating hard candy (sugar-free is best) may help.
     
     
   • Popsicles and ice cubes can also provide moisture.
     
     
   • If necessary, artificial saliva can help. This can be purchased at a drugstore without a prescription.
     
     
   • Talk with a dietician about other foods and techniques to help with dry mouth.
     
     
   • For some, the drug pilocarpine provides relief. Ask your doctor about this.

Treatment

If you develop mucositis, let your health care team know at once. They will want to examine your mouth and make recommendations specific to your condition, to help you eat and drink comfortably, and to promote rapid healing.

In addition to the oral health steps and dietary measures described above, there are anesthetic and protective medications that can be used on a short-term basis that can ease pain. These include gels and ointments such as viscous (gel) xylocaine, Zilactin film, and a variety of antifungal agents like Nystatin. There are special mouthwashes and rinses combining several ingredients that can be very helpful. Your health care team will provide those most likely to help you.

Pain relief is also important. If over-the-counter pain relievers aren't sufficient to achieve good pain control, your physician may prescribe opioid medications to help you. Pain relief is an important aspect in controlling mouth soreness, because mouth pain will directly interfere with your ability and desire to eat. Good nutrition is very important in cancer treatment, so don't hesitate to make sure you receive pain medication to help you eat comfortably. For more information, see Treating Pain.

Questions for Your Doctor

In treating mouth soreness team, your health care team may include an oncologist, nurse, pain management expert and registered dietician.

1. Is it likely that my cancer treatment will cause mucositis?
   
   
2. How long is my mucositis likely to last? Will it happen every time I have chemotherapy or radiation treatment?
   
   
3. What medications should I use for pain, and how often should I use them?
   
   
4. Might my mouth become infected? What are the warning signs of infection, and what should I do if this occurs?
   
   
5. Will having mucositis interfere with the schedule for my cancer treatment?
   
   
6. Is there a dietician available to help guide me in choosing appropriate foods?
   
   
7. Specifically, how should I manage my mouth care on a daily basis?
   

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