ORAL COMPLICATIONS DURING CANCER TREATMENT: LECTURE (p. 5)

Oral Regimen for Patients Receiving Chemotherapy and Radiation Therapy

The following are general guidelines to be individualized by your doctor. Follow your doctor's advice or discuss any questions with your doctor.

Rinses

1. Rinse with a warm, dilute solution of sodium bicarbonate (baking soda) or salt & bicarbonate (also commercially available as Sage Salt & Soda Rinse) every two hours to bathe the tissues and control oral acidity. Two teaspoons of bicarbonate (or one teaspoon of table salt plus one teaspoon of bicarbonate) per quart solution is recommended.
2. If you are experiencing pain, rinse with one teaspoonful of elixir of Benadryl before each meal. Be careful when eating while your mouth is numb to avoid choking.
3. If your mouth is dry, sip cool water frequently (every ten minutes) all day long. Allowing ice chips to melt in the mouth is comforting. Artificial salivas, eg, Sage Moist Plus spray, Moi-Stir, Salivart, Xero-Lube, Orex, can be used as frequently as needed to make the mouth moist and slick. A mouth moisturizing gel, ie Sage Mouth Moisturizer or OralBalance gel may be helpful when applied to the gums. Keep the lips lubricated with petrolatum or a lanolin- containing lip preparation. Commercial mouthrinses with alcohol bases, coffee, tea and colas with caffeine should be avoided as they tend to dry the mouth.
4. If oral yeast infection develops, antifungal medications can be prescribed.
   1. Nystatin pastilles*; let one dissolve in the mouth five times a day, or
   2. Let a 10 mg clotrimazole (Mycelex)* troche dissolve in the mouth five times a day,
   3. Swish with Nystatin oral suspension for two minutes timed by a clock. Either spit out or swallow, as directed by your dentist or physician.

1. Floss your teeth after each meal. Be careful not to cut the gums.
2. Brush your teeth after each meal. Use an ultrasoft, even-bristle brush and a bland toothpaste preferably containing fluoride, eg, Aim, Crest, Colgate. Brushing with a sodium bicarbonate - water paste is also helpful, Arm & Hammer Dental Care toothpaste and tooth powder and Sage Mouthpaste dentifrice are bicarbonate based. If a toothbrush is too irritating, cotton-tip swabs (Q-tips) or foam sticks (Sage Ora-Swab or Toothette) can provide some mechanical cleaning.
3. A pulsating water device, eg, Water-Pik, Hydrofloss or Viadent irrigators, will remove loose debris. Use warm water with 1/2 teaspoonful each of salt and baking soda and low pressure to prevent damage to tissue.
4. Have custom, flexible vinyl trays made by your dentist to self- apply fluoride gel to the teeth for five minutes once a day after brushing.
5. Rinse with an antiplaque solution (Peridex) two or three times a day when you cannot follow other oral hygiene procedures, if prescribed by yout dentist.
6. Follow any alternative oral hygiene instructions prescribed by your dentist,

Adequate nutrition and fluid intake are very important for oral and general health. Use diet supplements eg, Carnation Instant Breakfast, Meritene, Ensure. If your mouth is sore, a blender may be used to soften food.

Maintenance

Have your oral health status reevaluated at regularly scheduled intervals by your dentist.

Supportive

A humidifier in your sleeping area will alleviate or reduce nighttime oral dryness. Be sure to properly clean unit to prevent bacterial and fungal buildup.

The above regimen is also applicable to patients with oral problems associated with HIV and AIDS.

*These are prescription drugs that must be prescribed by your dentist or physician

Wright W, Haller J, Harlow S, et al: An oral disease prevention program for patients receiving radiation and chemotherapy. JADA 1985; 110:43-47.

A number of mucosal protectants and their possible role in head and neck radio- or chemotherapy have been the subject of several publications (1,8,9,14-19,21,22). Many of these are in early stages of evaluation and are not available for clinical usage. They can be summarized as follows:

1. Fractioned irradiation stimulates epithelial basal cell proliferation and it is possible that the epithelal cells themselves liberate cytokines that stimulates the growth of basal epithelium. This mechanism will most likely prevent serious damage to the oral mucosa and accelerate the repair process after mucositis have taken place.
2. Interleukin-1 is a cytokine produced by lymphocytes, monocytes, epithelial cells, fibroblasts and vascular epithelium and it stimulates basal cell turnover in several normal tissues but has no effect in the growth of tumors. Its use may enhance prevention and healing of mucositis.
3. Epidermal Growth Factor (EGF) may also influence rapidity of healing and it should be used after completion of chemotherapy and not before.

1. PTA lozenges (Polymyxin E, Tobramycin and Amphotericin B): this medication should be started two days before therapy and continued during radiation (generally fractioned irradiation with a total dose of 64 Gy or more). It has been proved to reduce duration and degree of mucositis in patients irradiated for oral carcinoma.
2. Benzydamine hydrochloride is a nonsteroidal drug with anesthetic, anti-inflammatory and antimicrobial properties which reduces the severity of radio-mucositis.
3. Some commercial rinses containing chlorhexidine have been shown to worsen established radio-mucositis besides altering taste and staining teeth (8,9). Therefore, their use in treating mucositis is not recommended. The adverse effect is mostly extreme pain due to the alcohol content of these rinses. Chlorhexidine in Canada and Europe can be obtained without alcohol (4).
4. Because of the dramatic reduction of immunocytes in acyclovir is used in Bone Marrow Transplant patients. This will inhibit replication of the herpes simplex virus and so reduce the risk of developing a rampant herpetic gingivo-stomatitis but it has no effect on mucositis.
5. Granulocyte macrophage-colony-stimulating factor (GM-CSF) is still under study. Rovirosa and co-workers (19) have concluded that mouthwashes with GM-CSF heal oral ulcers produced as a consequence to radiotherapy for carcinoma of the head and neck regions.
6. Aminothiols are sulphydryl compounds that protect from the effect of ionizing radiation by scavenging free radicals. Some studies have shown that they partially protect salivary glands from radiation but there are no studies on its effects on buccolaryngeal mucosas. These compounds are highly toxic and have been administered in very small doses in IV form before each radiation appointment.
7. Prostaglandin E1 analogue misprostol is being investigated because laboratory trial on rats have shown that it protects the gastric mucosa from several injurious agents i.e.: alcohol, hydrochloric acid, thermal injuries and others.
8. Nitroxides are stable free radicals that protect mammalian cells from super-oxide-induced and hydrogen-peroxide-induced cytotoxicity. There are yet no studies on oral mucosas but they have been shown to protect hair follicles from the effects of radiation.
9. Silver nitrate 2% seems to give some protection when applied on the oral mucosa three times daily for five days before and the first two days of radiation. The mechanism by which this protection takes place is still unknown (12).
10. Oral rinsing with povidone-iodine added to the regular prophylaxis regime have been shown to reduce the severity and duration of radiochemotherapy-induced mucositis. Povidone-iodine oral rinses are recommended as an additional, safe, prophylactic treatment for patients undergoing radiation, chemotherapy or both for malignancies of the head and neck regions (1).
11. Antibiotics and hyperbaric oxygen have been used pre-irradiation in order to prevent ORN but these methods need further assessment in order to ascertain their validity.

Low energy helium-neon laser illumination of the oral mucosa before high dose chemotherapy or total body irradiation has been reported to reduce the severity of oral mucositis in BMT patients. (3,6).