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Stomatitis / Fibrosis

Stomatitis

Stomatitis, a general term for an inflamed and sore mouth, can disrupt a person's ability to eat, talk, and sleep. Stomatitis can occur anywhere in the mouth, including the inside of the cheeks, gums, tongue, lips, and palate.

Oral side effects of cancer therapy are very common, and unfortunately most patients who receive head and neck radiation therapy develop oral complications. This is particularly true of those receiving radiation and chemotherapy, as the combination compounds the risk.

Mucositis is painful inflammation or ulceration of the mucous membranes anywhere along the gastrointestinal tract. Stomatitis (oral mucositis) refers to inflammation and ulceration that occur in the mouth.

Stomatitis can affect any of the structures in the mouth: cheeks, gums, tongue, throat, lips, and roof or floor. Radiotherapy to the mouth results in substantial local oral mucosal damage in both acute and late stages. Radiation-induced stomatitis is characterized by xerostomia (dry mouth due to lack of saliva), diffuse erythema, ulceration, taste alteration, oral soreness, dysphagia, difficulty talking, and mouth odor.

Causes of and medications commonly associated with stomatitis:
  • Chemotherapy
  • Radiotherapy
  • Loose-fitting dental prosthetics
  • Trauma
  • Poor dental hygiene
  • Smoking
  • Hematologic malignancies (stomatitis develops at 2 to 3 times the rate of solid tumors)
  • Infection (viral, fungal and bacterial)
  • Dehydration
  • Medications
  • Alcohol use

Medications associated with stomatitis:

  • Chemotherapy
  • Anti-hypertensives
  • Opioids
  • Antibiotics (indirect)
  • Diuretics (increase risk of dehydration in compromised state)
  • Anticholinergics
  • Antihistamines and decongestants
  • Steroids
  • Antidepressants

The treatment options for stomatitis are the same whether the patient is receiving palliative or curative treatments. Subtle variations in treatment depend on prognosis and life expectancy. Many of the side effects of cancer therapy can often be prevented. The recommended approach supported by the evidence uses pretreatment oral assessment to identify and eliminate asymptomatic oral infections, including minor dental caries, periodontal disease, and oral infections due to prosthesis or restorations, which might irritate oral mucosa. The oral assessment should be at least 2 weeks, but preferably 3 weeks, before cancer therapy begins to allow time to address any concerns.

Stepwise Approach to Symptoms of Stomatitis:

  • Coating agents such as bismuth salicylate, sucralfate, or other antacids
  • Water-soluble lubricants for mouth and lips
  • Topical analgesics, such as benzydamine hydrochloride
  • Topical anesthetics, such as viscous lidocaine (might impair gag reflex for a short period)
  • Oral or parenteral analgesics/pain medications, including opiates if needed, for pain not controlled with above

Fibrosis

Fibrosis, is the formation of excess fibrous connective tissue in an organ or tissue during a reparative or reactive process. This can be a reactive, benign, or pathological state. This is a common biological response to the intense cancer treatments patients undergo. Physiologically this acts to deposit connective tissue, within muscle and other tissues, which can obliterate the normal architecture and function of the underlying muscle or anatomical structure. Connective tissue does not have the elasticity of normal muscle tissues. When the deposits are excessive they can be described as pathological. This can result in compromised movement and function of the area in which this process has taken place.

Late oral complications of radiation therapy are chiefly a result of chronic injury to vasculature, salivary glands, mucosa, connective tissue, and bone. The development of fibrotic tissues is a common late development in oral cancer patients. The types and severity of these fibrotic changes are directly related to radiation dosing and intensity, including total dose, fraction size, and duration of the radiation treatments. Fibrosis involving muscle, dermis, and the temporomandibular joint result in compromised oral function. Trimus, or the inability to open the mouth completely, can be caused by the deposition of layers of non-flexible fibrotic tissues within the muscles that control the opening and closing of the lower jaw/mandible. This severely debilitating process must be offset by early, preventative stretching exercises of these muscles beginning with the very first radiation treatments and repeated several times a day throughout treatments, often for a month or more post treatment.

Fibrosis after the combination of a neck dissection and that area being radiated can lead to lack of range of motion in the shoulder and arm. Early identification of this development and appropriate therapy to reduce its impact is important. The addition of rehabilitation medicine physicians and therapists with extensive training in neuromuscular and musculoskeletal medicine, as well as in the principles of functional restoration to the treatment team is important. They can significantly impact efforts to improve the long-term quality of life for cancer survivors with radiation fibrosis syndrome through aggressive physical therapy during treatments and after completion of them.