Cancer Treatment-Induced Mucositis Pain: Strategies for Assessment and Management

Figures & data

Table 1 Biological stages of mucositis

Initiation	Message generation	Signaling and amplification	Ulceration	Healing
Direct irreversible and reversible damage to DNA	Transcription factors such as NF-κ B, upregulate a number of genes in the epithelium, causing increased production of messaging and effector proteins.	Apoptosis and tissue injury	Epithelial integrity destroyed. Bacteremia and sepsis possible.	Intact wound surface forms, continued epithelial proliferation.

Abbreviations: DNA, deoxyribonucleic acid; NF, nuclear factor.

Table 2 Mouth assessment tools

Name of tool	Scale	Anatomic measures	Functional measures	Comments
WHO Criteria	0–4	Yes	Yes
OAG	8–24	Yes	Yes	Assesses voice and talking
MacDibbs mouth assessment	0–21	Yes	Yes	Includes fungal and viral cultures
Spijkervet scoring system	0–4	Yes	No
OMI		Yes	No
CALGB assessment guide	0–4	Yes	Yes
Lorentz mucositis index	0–36	Yes	No	Schulz-Kindermann et al 2002

Abbreviations: CALGB, cancer and leukemia group B; OAG, oral assessment guide; OMI, oral mucositis index; WHO, World Health Organisation.

Table 3 Harris mucositis-related pain assessment tool

Time	Pain	Swallow	Eat	Talk	Visual assessment	Intervention	Response to intervention
	Location	Intensity
Location	Intensity	Swallow	Eat	Talk	Visual assessment	Intervention	Response to intervention
Lips, tongue, mucosa, gingiva, esophagus, stomach, gut, anus	0–10	A–able W–with difficulty U–unable	A–able W–with difficulty U–unable	A–able W–with difficulty U–unable	Color, presence of ulcers, red areas, white areas, dryness Middle–local	Early-oral care, saline or bicarbonate rinses 1–some improvement treatment such as sucralfate or benzydamine if available Late–systemic analgesics	Patient rating based on decrease in pain intensity, 0–total response in symptoms 2–no difference 3–some worsening of symptoms 4–significant worsening of symptoms

Table 4 Oral care protocol

Mouth care	Recommended intake	Avoid
• Floss once a day	• Maintain appropriate fluid intake (1–3 L/day)	• Smoking
• Use a new, soft-bristled toothbrush once a month or with each chemo cycle		• Rough, hard foods
• Brush for 90 seconds 3 times daily	• Maintain nutritional status	Acidic foods (grapefruit, lemon orange)
• Use fluoride toothpaste	• Non-acidic fruits (banana, mango, melon, peach)
• Rinse w/bland mouth rinse, 30 seconds, before meals and before bedtime. Do not swallow.		• Alcohol
• Keep lips lubricated		• Alcohol-containing and highly flavored oral care products

Note: Sources are: Larson et al 1998; Epstein and Schubert 1999; Rubenstein et al 2004.

Table 5 Growth factor mouthwashes

Reference	Growth factor	Type of study	Sample	Findings
Malik et al 1997	TCDO	Double-blind, randomized, placebo-controlled	62 patients with mucositis, all diagnoses	Improved oral intake in treatment group, shorter subjective reports of pain
Karthaus et al 1998	G-CSF	Random, placebo-controlled	8 patients over 32 chemo cycles with high grade lymphoma	Significantly shorter hospital stays, fewer episodes of Grade 4 mucositis, earlier recovery, reduction in need for opioids in treatment group
Bez et al 1999	GM-CSF	Pilot study	10 patients with mucositis, BMT	Treatment group more likely to have symptoms lasting <9 days
Foncuberta et al 2001	TGF-beta 3	Phase II double-blind, randomized, placebo-controlled	125 patients with solid tumors or lymphomas	No effect
Melichar et al 2001	GM-CSF	Pilot study	10 patients with chemotherapy-induced mucositis, 21 control patients	Oral administration improves oral symptoms and normalizes intestinal permeability

Abbreviatons: BMT, bone marrow transplant; G-CSF, granulocyte colony-stimulating factor; GM-CSF, granulocyte-macrophage colony-stimulating factor; TCDO, chemically-stabilized chlorite-matrix; TGF, transforming growth factor.

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