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Reprinted from the Alpha Omegan, Vol 91:23 1998
Oral Sequelae of Chemotherapy: A Complex Problem That Can Be Solved by Prevention
Myron F. Levenson, D.D.S., F.I.C.D.
Editor's note: These facts are of utmost importance to clinicians involved with adult patients who are undergoing chemotherapy
Surgery radiation, and chemotherapy are the main methods or protocols for the effective treatment of cancer.
Treating the usual oral complications of chemotherapy involves palliative topical medications, rinses, and analgesics. These are often not very effective and can produce serious painful side effects in an already troubled patient.
The recent advent of preventive anti-emetic drug therapy (Zofran [Cerenex]) prior to the chemotherapy infusion has eradicated the dreadful nausea and vomiting associated with cytotoxic drug therapy. The clinical comfort in cancer patients is truly remarkable.
A review of current literature focusing on oral mucositis as a result of cancer treatments describes effects such as: xerostornia; oral ulcers; viral, bacterial, and fungal infections; painful mastication and deglutition; hemorrhage, cellulitis etc.
In attempting to treat the resulting oral mucositis of chemotherapy, dentists and oncologists have been aiming their efforts at alleviating the mucositis problems of ulcers and pain after the drugs have caused much suffering and trauma in the cancer patient.
A small pilot study demonstrated the effectiveness of preventing the oral manifestations (mucositis) prior to the chemotherapy by the constant use of ice chips or sipping the melting ice at the same time the chemotherapeutic solutions were being infused into the patient's arm by the oncological technician.
It is enlightening to note that one patient developed severe oral mucositis, deep ulcers on the lateral and ventral tongue surfaces, the buccal mucosa, and floor of the mouth when (mistakenly) a hot beverage was offered to the patient to drink during an infusion of chernotherapy drugs. It was this incident that initiated the pilot study.
The rationale of a chilled oral mucous membrane effectively reducing untoward oral mucous membrane symptoms during the chemotherapy dose is most likely based on the phenomenon of constriction of the blood supply by the cold temperature during the intravenous injection, reducing the volume and activity of the blood borne drugs to the structures in the oral cavity.
Since most cancer treatment protocols for specific cytotoxic drugs extend over periods ranging from 6 months to a year, the patient is exposed repeatedly to their searing, painful effects following each treatment.
Current treatment, inadequate as it is, following the diagnosis of oral mucositis, is aimed at maintaining the patient's comfort.
All irritating traumatic personal oral hygiene procedures such as flossing or hard brushing, are delayed until the white blood count improves by action of the bone marrow.
Alcohol based drugs should be avoided, due to their irritating and drying effect. A 50/50 mixture of Benylin and milk of magnesia is helpful. Viscous lidocaine has been used, but inhibits taste, swallowing, and the gag reflex. Neutral fluoride applications may also be used. Gastric ulcer coating agents (Sucrasulfare suspension) may also help. Various topical rinses to debride and neutralize the oral cavity are useful, as also are aloe vera adhesive patches.
In general, the clinical entity of oral mucositis is so painful and stressful to the patient undergoing chemotherapy that, at times, the treatment has to be withheld or the patients has to continue with suffering and reduced ability to eat normally or be fed with intravenous hyperalimentation.
Greater effort by the medical, dental, and pharmaceutical professions must be made to prevent the oral complications of cancer treatments, not just reassuring patients that the pain will resolve when chemotherapy is discontinued.
Palliation of oral mucositis complications can be one of the most distressful procedures that health care workers are called upon to treat.
References
1. RAMOSE. Oral aspects of chemotherapy: patient information . TX Dent J VAIL45, 1994.
2. Mealgy BL Semba SE, Hatlman WW. Dentistry and the cancer patient: oral manifestations and complications of chemotherapy. Compend Contin Educ Dent 1994; 15:12521260.
3. Barker BF, Barker GJ. Oral complications and management of cancer chemotherapy. Northwestern Dentistry 1990; 69(9):2325.
SCD Special Care in Dentistry, Vol 18 No 6 1996. Reprinted with permission.
Myron F. Levenson, D.D.S., F.I.C.D.
Myron Levenson is associate professor of pediatric clinical dentistry at Case Western Reserve University School of Dentistry in Cleveland, Ohio. He has lectured and published numerous articles in the dental literature He is a member of the Cleveland Alumni Chapter of Alpha Omega.
