Mucositis
| Classification according to ICD-10 | |
|---|---|
| K12.3 | Oral mucositis (ulcerative) |
| ICD-10 online (WHO version 2019) | |
The mucositis is an inflammation of the mucous membranes (mucosa). It often occurs as part of chemotherapy or radiation therapy as so-called radiogenic mucositis and can affect the entire digestive tract. Cancer treatment is aimed specifically at cells with a high rate of division or regeneration. In addition to the cancer cells, these are also the mucous membrane cells.
Mucositis in cancer therapy
The tissue-destroying effect of radiation therapy has an impact on the mucous membrane, the taste buds , the teeth and the tooth support system , on the soft tissue , the muscles , the temporomandibular joints and the salivary glands . Side effects of radio (chemo) therapy in the head and neck area manifest themselves as the enoral mucositis, dry mouth (xerostomia) and changes in taste. Subsequent mucosal atrophy , ulcers , radiation caries and jaw clamps (trismus) can develop . Reactive oxygen species stimulate further cell factors in a cascade-like reaction sequence, which destroy the body's own cells. At first only the covering tissue (epithelium) becomes inflamed. As a result, the tissue continues to be destroyed, which can lead to ulcers. Bacteria, fungi and viruses colonize the mucous membrane in excess. In the course of therapy, the extremely painful mucositis represents the greatest impairment of the patient's quality of life and often limits oncological treatment, which reduces the chances of tumor healing.
classification
The Working Group on Supportive Measures in Oncology (ASO) has made the following classification of mucositis with reference to the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC):
| Degree | Symptoms |
|---|---|
| Grade 0 | no change |
| Grade I. | slight reddening (no aphthae, no ulcers) |
| Grade II | patchy mucositis, possibly aphthous ulcers (no ulcers) |
| Grade III | confluent, fibrinous mucositis, possibly aphthous ulcers (no ulcers) |
| Grade IV | Ulceration, necrosis, spontaneous bleeding |
frequency
Mucositis occurs differently after chemotherapy and radiation therapy:
- 40% with standard chemotherapy
- 75% with high dose chemotherapy
- 70–80% for bone marrow transplants
- 85–100% for radiation in the head and neck area
Prevention and therapy
Comprehensive dental restoration, including any necessary tooth extractions, should be carried out before radiotherapy . During radiation therapy, intensive oral hygiene must be carried out , if necessary with daily professional teeth cleaning and regular mouth rinsing after every ingestion of food. Additional irritating factors such as alcohol, nicotine, extremely cold, very hot, as well as acidic or spicy foods and drinks must be avoided. During and after the irradiation - up to six months - no mucosal- supported prostheses may be worn. Mucous membrane retractors ("radiation protection splints") should be worn during irradiation. Local and systemic pain therapy , antibiosis and antimycosis will often be necessary. A fibroblast growth factor (palifermin) can be prescribed medically. When chemotherapy is necessary in oncology , several local anesthesia with vasoconstrictor in the mouth / jaw area should be administered to prevent pronounced mucositis , which reduces the build-up of the chemotherapeutic agent into the mucous membrane. In addition, a thirty-minute cold therapy by sucking ice cubes before the radiation therapy can increase the local vasoconstriction during radiation therapy. The resulting insufficient supply of oxygen to the tissue reduces the cellular sensitivity to radiation .
The individual 3-D radiation planning leads to better protection of the oral mucous membranes. ( Level of evidence II B)
Symptomatic therapy mainly includes pain therapy. Adequate pain therapy in accordance with the WHO guidelines is recommended, starting with topical analgesics through to opioid therapy.
- Systemic analgesia. Patient-controlled morphine therapy is the pain therapy of choice for mucositis under high-dose chemotherapy with stem cell transplantation . (Level of evidence IB)
- Topical analgesia: Benzydamine and morphine can be considered. Benzydamine is applied topically, has an anti-inflammatory, analgesic and antimicrobial effect. Randomized controlled clinical studies show a reduction in the frequency and intensity of ulcerations and pain in radiogenic mucositis. (Level of evidence IA)
Prophylaxis and therapy of gastrointestinal mucositis
Oral administration of 2 × 500 mg sulfasalazine minimizes the incidence and severity of radiogenic enteritis . (Level of evidence II B). Sucralfate enemas are recommended for the treatment of chronic radiogenic proctitis in patients with rectal bleeding. (Level of evidence II A)
Prophylaxis under chemotherapy (no high-dose protocols)
- Ranitidine and omeprazole are recommended for prophylaxis during chemotherapy with CMF. (Level of evidence II A)
- If loperamide fails , Octreotide is recommended at a dose of 100 μg sc twice daily. (Level of evidence II A)
Prophylaxis under radio-chemotherapy
- Amifostine is recommended for the prophylaxis of esophagitis during radio-chemotherapy. (Level of evidence III C)
Peri-implant mucositis
Initially, peri-implantitis is usually preceded by mucositis, an inflammation of the mucosa surrounding the implant neck, whereby the transition from mucositis to peri-implantitis is fluid. The therapy consists of debridement , mechanical cleaning of the implant surface. The additional use of local or systemic antibiotics or disinfectants , such as chlorhexidine digluconate , did not result in any improvement in therapy.
Mucositis in a reduced general condition
In immunosuppressed patients (after organ transplantation ), patients with autoimmune diseases or malfunctions of the immune system , patients with non-autoimmune inflammatory reactions (severe allergic asthma ), infections with fungi, viruses or bacteria occur more frequently due to the weakened immune system of the body, which in turn lead to inflammation the lining of the mouth, throat and esophagus. Patients with a poor general and nutritional condition, older age and existing problems in the mouth area ( periodontitis , poorly fitting prostheses), severely dehydrated people, patients who depend on oxygen and patients with gastric tubes are at greater risk to develop mucositis.
See also
literature
- Joint statement by DGZMK and DEGRO
- Evidence based clinical practice guidelines for mucositis secondary to cancer therapy , Multinational Association of Supportive Care in Cancer (MASCC) as of February 1, 2014
Web links
- As a cancer patient to the dentist Publisher: Cancer Information Service of the German Cancer Research Center (DKFZ), German Dental Association (BZÄK), National Association of Statutory Health Insurance Dentists (KZBV), September 3, 2014. Accessed September 3, 2014
- Radiation Therapy Oncology Group (RTOG)
- European Organization for Research and Treatment of Cancer (EORTC)
Individual evidence
- ↑ a b W. Dörr, E. Dörr u. a .: Side effects of radiotherapy in the oral cavity. In: MMW Advances in Medicine. Volume 152, Number 46, November 2010, ISSN 1438-3276 , pp. 37-39, PMID 21229722 .
- ↑ ASO guideline mucous membrane toxicity ( Memento of the original from February 28, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ MH Seegenschmiedt: side effects . In: M. Wannenmacher, J. Debus, F. Wenz (Eds.): Radiation therapy . Springer, Berlin / Heidelberg 2006, ISBN 978-3-540-22812-7 , pp. 229-284 , doi : 10.1007 / 978-3-540-68520-3_13 .
- ↑ LS Elting, YC Chang u. a .: Risk of oral and gastrointestinal mucosal injury among patients receiving selected targeted agents: a meta-analysis. In: Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer. Volume 21, Number 11, November 2013, pp. 3243-3254, ISSN 1433-7339 . doi: 10.1007 / s00520-013-1821-8 . PMID 23636648 . (Review).
- ↑ a b W. Dörr, J. Haagen et al .: Treatment of oral mucositis in oncology. ( Memento of the original from November 23, 2015 in the web archive archive.today ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: In Focus Oncology. No. 7-8, 2010, pp. 1-5. Retrieved September 1, 2014.
- ↑ a b c d e Petra Feuer, Maria Steingräber, Petra binder, Mukositis -Guidelines , Multinational Association of Supportive Care in Cancer (MASCC), in: Im Focus Onkologie 11/2004, pp. 57–60. Retrieved October 31, 2015.
- ↑ S. Renvert, A. Aghazadeh, H. Hallstrom, GR Persson: Factors related to peri-implantitis - a retrospective study. In: Clinical oral implants research. [Electronic publication before printing] June 2013, ISSN 1600-0501 , doi: 10.1111 / clr.12208 , PMID 23772670 .
