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Alert Number 74

More on Mouth Sores: An Expert Weighs In

Date: January 31, 2005

A highly respected CLL expert who read my previous Alert on mouth sores and therapy had the following comments. Since he did not want to be directly quoted, I have bullet pointed his comments below. He draws an important distinction between oral sores directly caused by chemotherapy drugs attacking the oral lining, versus sores caused by opportunistic infections such as thrush (caused by a yeast called Candida) and Herpes during a period when the patient has suppressed immune system function. We can hope to lessen the severity of the first kind with popsicles and ice chips, but the second kind caused by direct infections needs drugs to combat the viral, fungal and bacterial perpetrators. It also helps to limit the length of time the patient is immune suppressed (neutropenic).

  • The incidence and the degree of mucositis is variable and related to the type of chemo agent in use. It is also important to distinguish between mucositis caused by chemotherapy and mouth sores due to infections. The most common forms of mouth infections are Candida, oral Herpes, etc.
  • Some chemo drugs have have a higher incidence of mucositis, such as 5-Flurouracil(5FU) based treatments used often in colorectal cancers and methotrexate used commonly in breast cancer and some lymphomas. For these individuals, oncology nurses have for years offered popsicles, ice chips, etc. to cause constriction of the small blood vessels in the lining of the mouth, which hopefully decreases drug delivery there, and therefore decreases the incidence of mucositis.
  • This practice of giving out ice chips or popsicles is most often a nursing protocol not requiring an MD order. Patients often bring their own special flavors in a small cooler.
  • Other chemo agents have little or no incidence of mucositis and the use of popsicles / ice chips is less urgent. For instance in standard doses, agents that are commonly used in CLL such as fludarabine, Rituxan, pentostatin have a low incidence of chemo-induced mucositis. If mucositis does occur in a given CLL patient after use of these drugs, then it makes sense to use oral cryotherapy (popsicles) for future cycles.
  • Higher doses of chemotherapy drugs carry increased risk of oral mucositis. For instance the dose of Cytoxan(cyclophosphamide) used in CHOP, FCR, etc., rarely causes mucositis, whereas the dose used in bone marrow transplant conditioning regimens almost always causes it.
  • So in summary, the incidence of mucositis is related to the type of drug and the dose of the drug.
  • The second aspect of this is mouth sores due to infections. Here is where we actually see more of a problem in our CLL patients. Due to the immunosuppression associated with chemo such a fludarabine, etc., there is an increased incidence of oral candidiasis, herpes stomatitis, cold sores, etc. Therefore it is important to do a good oral exam. With Candida (thrush) most clinicians can recognize it and it can be treated clinically with Nystatin, Mycelex troches or oral Fluconazole.
  • If the question arises, it is important to do a quick swab for fungal or viral cultures. If cultures are positive for Herpes simplex or there is a high clinical suspicion of Herpes involvement, treatment with acyclovir or a related antiviral is needed. For mouth sores caused by active infections, cooling techniques are not preventative.
  • More frequent use of growth factors such as G-CSF, GM-CSF (Neupogen, Neulasta, Leukine), etc., have helped decrease the incidence of mucositis by decreasing the time over which the patient is neutropenic.

Be well.


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