Oral Complications
Summary of Key Points
Incidence
• Mucositis, a major dose-limiting toxic effect of chemotherapy for solid tumors, develops in 5% to 40% of patients.
• Mucositis develops in 70% to 100% of patients who receive high doses of chemotherapy with bone marrow rescue.
• Mucositis is the most troublesome acute reaction for patients undergoing radiation therapy directed at the oral cavity.
• Radiation therapy directed at the oral cavity frequently causes a host of other oral complications including xerostomia, dental caries, tissue necrosis, and taste alterations.
Etiology of Complications
• Oxidative stress caused by cytotoxic chemotherapy and radiation therapy leads to upregulation and subsequently amplification of multiple inflammatory pathways in a complex process. This subsequently leads to mucosal ulceration.
• Secondary infections occur as a result of treatment-induced immunosuppression.
Prophylactic Measures
• The importance of instituting oral hygiene protocols in patients receiving chemotherapy is well established.
• Cryotherapy is the most conventional and easy to use preventative method, at least for 5-fluorouracil–based bolus therapy, and it appears to have implications for other chemotherapeutic regimens as well, such as edatrexate and high-dose melphalan therapy.
• Keratinocyte growth factor has been approved by the Food and Drug Administration for use with high-dose chemotherapeutic regimens associated with high rates of mucositis and has shown promise in other settings as well.
• Low-level laser therapy has shown promise, but its use is limited for now to centers that are able to support its use.
• Pretreatment dental care, good oral hygiene, and sophisticated treatment planning is recommended for patients receiving radiation therapy.
Treatment
• Overall, evidence is lacking regarding the efficacy of various agents in promoting healing of the oral mucosa after mucositis is established.
• Systemic analgesic therapy of mucositis pain with narcotic medications is well established and recommended.
• Antibiotics and/or antifungal medications should be given to patients with evidence of infection.
• In the palliative setting, various mouthwashes are widely used in clinical practice based on provider preference and experience. These mouthwashes most frequently contain combinations of diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin, and corticosteroids. The efficacy of these measures has not been adequately evaluated to date.
