ORAL COMPLICATIONS DURING CANCER TREATMENT: TREATMENT

Rx:	Diflucan (Fluconazole) tablets 100 mg.
Disp:	15 tablets.
Sig:	1 tablet per day for 4 days then 1 tablet every 3 days.

Ask the patient to mix 1 part of hydrogen peroxide in 6 parts of warm water and add a dash of salt. Instruct to intraorally swish this mixture for 2 to 4 minutes several times a day. This is a good alternative to chlorhexidine.

For active mucositis:

1. a bland and liquid diet avoiding alcohol, caffeine or any other irritant such as tobacco products. Food should be lukewarm.

2. rinse the mouth frequently with a mixture of 1/2 tsp each of baking soda and salt dissolved in a large glass of warm water

3. to reduce inflammation prescribe:

   Rx:	Dexametasone (Decadron) elixir 0.5 mg/5 ml
   Disp:	100 ml
   Sig:	Hold 5 ml (1 teaspoon) in the mouth for 5 minutes and spit out 4 or 5 times a day.

4. to alleviate pain recommend to put crushed ice in the mouth to numb the oral mucosa, popsicles and ice cream can be used as well for that purpose.

5. When pain is severe topical anesthetics should be prescribed:

   Rx:	Diphenhydramine HCL (Benadryl elixir) or Promethazene 12.5 mg/5ml 50/50 with Kaopectate (or Malox)
   Disp:	8 oz (or 200 ml)
   Sig:	1-2 tsp q2h rinse and spit out.
   Note:	Dyclonine HCL 0.5% 1 oz can be added to the above prescription to enhance anesthetic power.

6. Dyclonine can be also prescribed as a topical anesthetic:

   Rx:	Dyclone (Dyclonine HCL 0.5% or 1.0%)
   Disp:	1 oz bottle
   Sig:	Rinse with1 tsp. full for 2 minutes and spit out before each meal
   Note:	topical anesthetics reduce the gag reflex so patients must be advised to take caution when eating or drinking in order to avoid respiratory compromise.

7. If Candida infection supervenes then antifungal medication must be prescribed:

   Rx:	Clotrimazole (Mycelex) troches 10mg.
   Disp:	50 troches.
   Sig:	Dissolve 1 troche in mouth 5 times a day.
   Rx:	Nystatin pastilles, 200,000 units.
   Disp:	50 pastilles.
   Sig:	Dissolve 1 pastille in mouth 5 times a day.
   Rx:	Diflucan (Fluconazole) tablets 100 mg.
   Disp:	15 tablets.
   Sig:	First day 2 tablets then, 1 tablet per day.

Rx:	Stannous fluoride gel 0.4%
Disp:	4.3 oz
Sig:	Put 7 to 10 drops in a custom tray and cover teeth for 5 minutes every day. Gel must not be swallowed.

Recommend the use of toothpaste containing fluoride. There are a variety of stannous fluoride gels available in the market such as:Flo Gel, Nova Gel, Ommni Gel, Thera-Flur among others.

The best treatment of ORN is prevention, as previously mentioned, but if in spite of it osteonecrosis develops then the following treatments, alone or in combination, can be utilized:

1. hyperbaric oxygen (HBO) treatment consists of 90 to 120 minutes sessions (each session is called a dive) in a single or multiplace chamber at 2 to 3 atmospheres absolute pressure, breathing 100% oxygen by mask. The number of dives varies with the extent of ORN. The aim of HBO treatment is revascularization of bone and soft tissues. Oxygen in hypoxic tissues induce fibroblast growth and new capillary formation.
2. long term intravenous antibiotics, generally in daily doses of 1 million units of penicillin G and in severe cases followed by feneticillin 625 mg orally 4 times a day for 1 week. This treatment also varies with the degree and extent of ORN.
3. surgical removal of the necrotic bone.
4. if facial deformity ensues as a consequence to surgery then reconstruction can be obtain with autologous bone grafts or microvascular osseous grafts.
5. intraoral or facial prosthetic reconstruction is also a means of treatment (4).