Mucositis in Haematopoietic Stem Cell Transplantation & Cellular Therapy

Mouth ulcers (also known as oral mucositis) are commonly seen as a side effect of chemotherapy during stem cell transplant and cellular therapy. Inflammation of the mucosal lining of the mouth may develop into mouth ulcers causing pain, mouth bleeding, risk of infections, difficulty eating, swallowing and talking.

Mucositis usually occurs on day 5 to 8 after starting chemotherapy and symptoms can last between 7 to 14 days before healing begins.

Symptoms varies from mild to severe:

Mild: You may feel that your mouth is sore and dry, but you can still swallow soft food, water and medications. Mouth mucosa may appear red and develop ulcers.

Moderate: You are having more pain and difficulty swallowing, but are able to drink liquids. Oral medications may need to be pounded into powder if you have trouble swallowing.

Severe: You are unable to eat or drink due to severe mouth pain and ulcers. As such, you will be given medications and nutrients via other methods such as intravenously.

Keeping your mouth clean is important to prevent mouth ulcers and infections.

• It is important to rinse your mouth thoroughly with at least 30 mL of salt-water and at least 15 mL of non-alcoholic mouthwash such as OralSeven® for at least 4 times a day after every meal and before bedtime.
• Swish the mouthwash using ballooning and sucking motion of the cheeks for at least 30 seconds for every mouth rinse. Do not swallow the mouthwash; spit the mouthwash out into the sink or a cup after swishing. 
• Avoid eating, drinking or rinsing your mouth at least 15 minutes after using OralSeven® mouthwash.
• Brush teeth gently, including dentures, using a soft and clean bristle toothbrush to remove dental plagues and food debris at least twice a day, preferably after food.
• Brush gently to avoid abrasions or bleeding, which can serve as entry points for infection.
• When your blood counts are low [absolute neutrophil count less than 1 x109 cells/L or platelet count less than 20 x109 cells/L], your doctor or nurse will advise you to stop brushing and flossing your teeth due to risk of infection and bleeding. You should continue to use your mouthwash regularly.

For example:

Time		Saltwater	Mouthwash
Morning	7AM
	7.15AM
Afternoon	1PM
	1.15PM
Night	7PM
	7.15PM
Before sleep	11PM
	11.15PM

At the first sign of mouth ulcers:

• Increase salt-water mouthwash rinsing to every 2 hours (7AM, 9AM, 11AM, 1PM, 3PM, 5PM, 7PM, 9PM & 11PM), when you are awake.
• Continue to use OralSeven® mouthwash after each meal and at bedtime (7.15AM, 1.15PM, 7.15PM, 11.15PM)

Cryotherapy for Melphalan:

You will be advised to suck on ice from 30 minutes before, during and 2 hours after chemotherapy (Melphalan). The ice therapy will help to reduce mouth ulcers by limiting blood flow to your mouth.

Dietary and lifestyle recommendations

• Eat small, frequent, nutritious meals, 5 to 6 times per day as tolerated.
• Take bland food which is high in protein such as steamed fish or minced meat.
• Take foods that are soft, easy to swallow and well-cooked such as mashed potatoes, cooked cereals or scrambled eggs. You can also soften your food with gravy or soup.
• Drink sufficient water unless otherwise instructed.
• If you are unable to swallow solid food, inform your doctor. You may be encouraged to take milk feeds and juices as advised by the dietician.
• Avoid:
  • Food that is too cold or too hot.
  • Hard or coarse food such as nuts, hard candies, crusty bread, crackers, popcorn or potato chips.
  • Spicy or sour foods such as chilli, pepper, curry, horseradish or pickles.
  • Citrus and acidic fruits such as oranges, lemons, pineapples, tomatoes or grapefruits as well as their juices.
  • Alcoholic beverages including mouthwashes that contain alcohol as it can cause irritation and dryness of mouth mucosa.
  • Wearing dentures except during mealtimes.
  • Chewing tobacco, smoking or vaping

Management of mouth ulcers is supportive based on your symptoms. Your doctor will assess your oral condition and pain score regularly. Inform your doctor if your mouth pain persists or if you are unable to swallow your medicines.

Medications and/or painkillers, may be given to relieve pain and discomfort. Inform your doctor if pain persists or worsen so that your pain medications can be adjusted based on your condition.

You should continue to maintain basic oral hygiene and mouth rinsing during this period. More frequent mouth rinsing with salt-water and mouthwash is necessary to help with the healing process.

Benzydamine (Difflam®) gargle or lozenges can relieve pain and inflammation in the mouth.

1.    Gargle 10 mL up to 4 times a day when necessary for mouth or throat pain

2.    Hold in the mouth or gargle for at least 30 seconds and spit out

3.    For lozenges: suck 1 to 2 lozenges three to four times a day with a maximum of 12 lozenges per day, when necessary for mouth or throat pain

Combination mouthwash, comprising of a topical pain-reliever (Lignocaine), a mucosal coating agent (Gaviscon®) and an anti-inflammatory agent (promethazine/codeine e.g. Procodin®), can help to relieve pain and irritation due to mucositis.

1.    Mix 10 mL of Gaviscon®, 10 mL of Lignocaine 2% viscous solution and 5 mL of Procodin®

2.    Hold in the mouth or gargle for at least 30 seconds and spit out

3.    May be swallowed slowly to relieve throat pain but take note that it can be numbing and affect your swallowing reflex

4.    To allow the medicine to take effect, wait at least 30 minutes before eating or drinking

5.   Repeat up to 3 times a day when necessary for mouth or throat pain

These instructions contain general information and advice on how to safeguard your health. However, this list is not exhaustive, and your condition may be unique, so you should follow any specific instructions given to you by your doctor. Please seek clarification from your doctor if you are unsure.