.................... ................................................ LElTERS TO THE EDITOR (Editor‘s note: The following observations are of importance to clinicians caring for patients who are undergoing chemotherapy.)

Oral sequelae of chemotherapy: A complex problem that can be solved by prevention

urgery, radiation, and chemotherapy are the main methods or protocols for the effective treatment of S cancer.

Treating the usual oral complications of chemotherapy involves palliative topical medications, rinses, and anal- gesics. 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 dreaded 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: xerostomia; oral ulcers; viral, bacterial, and fungal infec- tions; 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 chemotherapy drugs. It was this incident that initiated the pilot study.

The rationale of a chilled oral mucous membrane effec- tively reducing untoward oral mucous membrane symp- toms 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 cyto- toxic 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 chemo- therapy that, at times, the treatment has to be withheld or the patient has to continue with suffering and reduced ability to eat normally or be fed with intravenous hyperalimentation.

pharmaceutical professions must be made to prevent the oral complications of cancer treatments, not just re- assuring patients that the pain will resolve when chemotherapy is discontinued.

the most distressful procedures that health care workers are called upon to treat.

Greater effort by the medical, dental, and

Palliation of oral mucositis complications can be one of

- Myron F. Levenson, DDS, FICD Associate Professor, Pediafric Dentistry School of Dentistry Case Western Reserve University Cleveland, OH 44106

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Ramose YL. Oral aspects of chemotherapy: patient information. TX Dent J 845,1994. Mealgy BL, Semba SE, Hallmon WW. Dentistry and the cancer patient: oral manifestations and complications of Chemotherapy. Compend Contin Educ Dent 15:1252-60,1994. Barker BF, Barker GJ. Oral complications and management of cancer chemotherapy. Northwestern Dentistry 69(6):23-5,1990,

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SCD Special Care in Dentistry, Val 17 No 1 1997 5

To the Editor:

wholeheartedly agree with Dr. Kenneth Shay in his statements regarding the responsibility of dental professionals to sensitize our medical colleagues about

the unacceptable consequences of hyposalivation and xerostomia (SCD 16, Number 1). Interdisciplinary education is an essential element for the continuing improvement of total medical management and the enhancement of our patients’ lives. However, I would like to point out that hyposalivation is one of many ”unacceptable side-effects” associated with anticholinergic drugs. Urinary retention, constipation, raised ocular pressure, tachycardia, postural hypotension, and confusion are also prevalent. A competent provider, dental or medical, attempts to provide comprehensive treatment with a minimal impact on the quality of life of her/his patient. It is unfortunate that suitable medications with comparable outcomes and acceptable side-effects

have not been developed. Even those which are potential alternatives have side-effects such as anorexia, agitation, and sexual dysfunction. Until the availability of more acceptable drugs, all health providers must assist and support one another toward the betterment of our patient populations. A dental professional, working in consort with a competent and caring physician, may have to accept and treat his patient’s xerostomic condition-as the physician accepts the risks of broken hips, confusion, etc. Dry mouth is certainly not trivial. However, it is our responsibility to realistically prioritize xerostomia as well as the role of special care dentistry in the medical management of the total patient. We should give our medical colleagues the credit that they truly deserve.

-Ira R. Parker, DDS, MPH Department of Medicine University of California, San Diego

6 SCD Special Care in Dentistry, Yo1 17 No 1 1997