Dry, sore mouth (oral mucositis)

Dry or sore mouth (oral mucositis) is a side effect of some lymphoma treatments. This information gives general suggestions to help you manage the symptoms of oral mucositis.

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What is oral mucositis?

What are the symptoms of oral mucositis?

How does lymphoma treatment cause oral mucositis?

Will I get oral mucositis?

How long does oral mucositis go on for?

What can I do to help myself if I have oral mucositis?

What treatment is there to help prevent or treat oral mucositis?

What is oral mucositis?

Oral mucositis is where the soft lining in the inside of your mouth (mucous membrane) is damaged. It can happen when lymphoma treatment affects healthy cells in your mouth.

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Symptoms of oral mucositis

Oral mucositis can make your mouth become swollen, red and painful (inflamed). It can cause symptoms such as:

• pain when you swallow
• mouth ulcers (sores), which can lead to infection (including oral thrush)
• bad breath (halitosis)
• dry, sore mouth and lips.

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How does lymphoma treatment cause oral mucositis?

Oral mucositis can happen as a side effect of some lymphoma treatments. 

The aim of treatment is to destroy lymphoma cells. However, it can also damage healthy cells, including cells in the lining of your mouth. This can lead to oral mucositis.

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Will I get oral mucositis?

You might get oral mucositis with chemotherapy, radiotherapy, and some targeted treatments. It can also happen after a stem cell transplant. 

We give information about these treatments and the risk of oral mucositis below.

Your medical team should tell you about your individual risk of developing oral mucositis before you begin lymphoma treatment. They can also talk to you about any ways you can reduce this risk. 

It is important to tell your medical team about any dental or gum issues you are aware of, so that they can take necessary precautions to reduce your risk of oral mucositis.

Amanda Lane, Haematology Advanced Nurse Practitioner

Chemotherapy

The likelihood of developing oral mucositis as a side effect of chemotherapy, and how severely, depends on factors including the following:

• the type of drug or drugs you have
• the dose of drug or drugs you have
• how many cycles of chemotherapy you have and how much time between them
• whether you had oral mucositis as a side effect of chemotherapy in the past – having it once increases your risk of developing it again with your next cycle of chemotherapy.

Symptoms generally start at around 7 to 10 days after you start treatment. For most people, they last for around 2 to 3 weeks after finishing treatment.

Radiotherapy

Radiotherapy to the head and neck can cause oral mucositis, particularly when given at a high dose. The risk of sore mouth increases if you have both radiotherapy and chemotherapy (sometimes called ‘chemo-radiotherapy'). 

Symptoms usually start between 12 and 15 days after starting treatment. They usually clear up between 6 to 8 weeks after finishing treatment.

Stem cell transplant

Oral mucositis can be a side effect of treatments given as part of a stem cell transplant – the high-dose chemotherapy and/or the drugs given to dampen down your immune system (immunosuppressive drugs). 

Symptoms often start around a week after starting treatment. They often start to improve around 2 to 3 weeks after finishing treatment.

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How long does oral mucositis go on for?

Usually, oral mucositis gets better once you finish your lymphoma treatment and your neutrophil counts return to the levels they were at before you had treatment. However, the general length of time for this varies depending on different factors, including your treatment type (chemotherapy, a targeted therapy, radiotherapy or stem cell transplant).

For some people, sore mouth goes on for longer. This can happen if you have a low number of a type of white blood cell called neutrophils (neutropenia) that continues for a while. Symptoms improve once your blood cell counts improve.

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What can I do to help myself if I have oral mucositis?

Speak to your medical team for advice about how to manage oral mucositis. There are some things you can do that might help to prevent symptoms or manage those that develop. Below, we offer some general tips that you might like to discuss with your medical team, including about:

• food, drink and lifestyle
• mouth (oral) hygiene
• keeping your mouth moist
• pain relief.

Food, drink and lifestyle

You might find eating and drinking uncomfortable or painful if you have oral mucositis. 

You can try to limit the amount of irritation to your mouth in the following ways:

• Make sure foods and drinks are not very hot.
• Eat soft foods such as mashed potato, scrambled eggs or soup.
• Use a straw if you find drinking painful, although make sure you keep them clean to prevent bacteria collecting inside them – note that it can be harder to tell how hot a drink is when using a straw.

It might help to avoid:

• foods with rough textures or sharp edges, like crisps and crusty bread
• fizzy drinks
• spicy foods
• citrus fruits and their juices
• acidic products, like vinegar and uncooked onion
• smoking and vaping (using e-cigarettes)
• alcohol, including in mouth rinses.

Mouth (oral) hygiene

Oral mucositis can increase your chance of infection in the mouth. Take steps to help lower this risk in the following ways:

• Clean your teeth twice a day, using a soft-bristled (manual or electric) toothbrush – you could also try using a mild toothpaste if you find the flavour of regular ones too strong.
• Use an alcohol-free mouth rinse after eating.
• Floss gently once a day if you already floss – however, stop if you have a low platelet count (thrombocytopenia) or if flossing makes your mouth bleed.
• If you can, visit your dentist before you start lymphoma treatment – you might not be able to have dental work done during or soon after treatment.

Alcohol-free mouth rinses

Alcohol-free mouth rinses are available to buy without prescription – you could ask your medical team if they can suggest a particular one. They might also be able to prescribe one that has anaesthetic in, to help reduce pain.

Some people make their own mouth rinse by mixing a teaspoon of salt with boiled water that has cooled down. 

Moistening a dry mouth

There are simple things you can try to help moisten your mouth if it feels dry, for example:

• sip fluids throughout the day
• eat foods that have a lot of water in, like cucumber, watermelon and jelly
• chew gum or suck a boiled sweet to trigger saliva production
• keep your lips moist with a lip balm.

You could also ask your medical team about artificial saliva treatments, to help trigger saliva production. These come as sprays, gels, tablets or lozenges.

Some of my patients have found cool boiled salt water preferable to a medicinal mouthwash as it can be less drying and irritating to the mucous membrane (soft lining of the mouth). The salt can also help to reduce inflammation and bacteria. However, if you have ulcers or pain, speak to your medical team to discuss what treatment options are best for you.

Amanda Lane, Advanced Haematology Nurse Practitioner 

Pain relief

If pain is a symptom of your oral mucositis, the following might help lessen it:

• suck on something cold, like an ice lolly or an ice cube, unless you have sensitive teeth
• if you usually wear false teeth (dentures), leaving them out might be more comfortable –the NHS website has information about dentures and how to look after them.

You can speak to your medical team about suitable pain relief medication. They might suggest paracetamol or aspirin – if you have it in dissolvable form, you might find it easier to swallow. However, it is important to check with your medical team which options are safe for you before you take any medication. 

You might be prescribed pain relief medicines, such as a cream or gel (topical treatment) to put inside your mouth, a mouth rinse or tablet.

I often prescribe a gel that comes in a sachet. The contents dissolve into water, which you then swill around your mouth to create a protective coating of the mucous membrane (soft lining of the mouth). You can also apply it directly to the inside of your mouth. This can really help to lessen pain.

Amanda Lane, Advanced Haematology Practitioner

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What treatment is there to help prevent or treat oral mucositis?

In addition to things you can try to help yourself if you already have oral mucositis, you might be prescribed medication to help prevent or treat symptoms of oral mucositis.

If you are at a high risk of developing oral mucositis, your medical team might prescribe medication to help prevent you from developing it. This is to help lower your risk of infection, which can be serious and need treatment urgently with antibiotics. 

If you develop possible signs or symptoms of infection anywhere in your body, contact your clinical nurse specialist or another member of your medical team straightaway.

Examples of when you might have medicine to prevent oral mucositis are:

• if you have a chemotherapy drug that carries a high risk of causing oral mucositis. In such cases, you will be given folinic acid, either as an injection or through a drip (infusion) after your treatment.
• if your immune system is lowered by a low number of neutrophils (neutropenia), if you’ve had a stem cell transplant or if you have human immunodeficiency virus (HIV).

Cryotherapy

Cryotherapy is a way of cooling your mouth with ice. This could be, for example, by sucking on an ice cube or ice lolly, or drinking ice-cold water. 

Cryotherapy is sometimes used to help prevent oral mucositis for people having some types of chemotherapy, but it isn’t suitable in all cases. 

You might be given a form of cryotherapy 5 minutes before your treatment, which you continue for around 30 minutes during treatment.

Palifermin

Palifermin is a drug that can help trigger the growth of new cells in your mouth and throat. It can therefore help to prevent and heal mouth sores that develop as a side effect of lymphoma treatment. Palifermin is usually given as an injection before you have treatment for lymphoma.

Low-level laser therapy (LLLT)

With low-level laser therapy (LLLT), low energy beams of light are directed at the soft lining (mucous membrane) of your mouth. It is given using a small instrument called a probe. This might be put inside your mouth (intra oral treatment) or outside your mouth, close to your cheek (extra oral). The energy beams can help with the growth of new cells. 

LLLT could help to:

• reduce the severity of oral mucositis
• speed up the healing of wounds, such as mouth ulcers
• bring down swelling (inflammation)
• lower pain.

LLLT is sometimes used with radiotherapy and chemotherapy. However, it needs specialist equipment and is only available in some specialist cancer centres. Your medical team can advise on whether this is a suitable treatment option for you.

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