Instructor: Dr. Heddie Sedano, D.D.S. Dr.Odont.
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ORAL COMPLICATIONS DURING CANCER TREATMENT: LECTURE (p. 2)
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ORAL MUCOSITIS. Oral mucositis (OM) is a frequent, iatrogenic, dose
limiting, severe complication of systemic cancer chemotherapy,
bone marrow transplantation (BMT), and local irradiation for tumors
in the head and neck area. Both radio- and chemotherapy interfere
with the normal process of cell replication affecting both malignant
and normal cells. The effect on the oral mucosas is one of cessation
of the rapid proliferation of normal epithelial cells with consequent
cellular atrophy followed by necrosis, epithelial sloughing and
ulceration. The exposed underlying connective tissue becomes an
open door to infection which will be more marked in those patients
which have undergone full body radiation and are in
immunosuppression such as BMT patients.
OM generally develops within 3 to 15 days after the beginning of
radiation but it starts earlier and is of shorter duration in patients
treated with chemotherapy. It is known that the turnover rate of the
epithelial cells of the oral mucosa is around two weeks and that is
the approximate time that it takes for OM to manifest. Any of the
oral mucosas can be the site of OM but preferentially those that do
not keratinize such as lips, buccal, soft palate, ventral tongue and
pharyngeal mucosas. OM can be clinically classified
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Figure 1. This patient had undergone chemotherapy for an
adenocarcinoma of the lung. Note the various areas of erythema and
ulceration at the tip and borders of the tongue. Also note absence of
filiform papillae and early candida infection on the dorsal surface of
the tongue. This mucositis can be classified as type II: erythema
with patchy ulceration.
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in different stages according to its severity as: I) Erythema, II)
Erythema with patchy ulceration and III) Erythema with confluent
ulceration (16). The inflammatory reaction and the edema increases
with the severity of the lesion. The various cells participating in the
inflammatory process, i.e.: lymphocytes, neutrophils, monocytes and
macrophages liberate cytokines which increase the local
inflammatory reaction. Some patients may develop purulent
mucositis. Pain always accompanies OM and it can be so intense as
to need morphine as a palliative. Either chemo- or radiotherapy is
temporarily suspended in patients which develop severe cases of OM.
Severe OM is a high risk factor for alpha-hemolytic streptococcal
bacteremia (20). Superimposed infection on this type of mucositis
further complicates its clinical course and management. It is a well
known factor that mucosal toxical reactions do not allow usage of
radiation and chemical drugs in higher doses than those presently
used for the treatment of carcinomas of the head and neck regions.
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