Download B4 Oncology: Oral Dysfunction

ONCOLOGY: ORAL DYSFUNCTION
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XEROSTOMIA (DRY MOUTH)
Definition:
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Xerostomia is not a disease but can be a symptom of certain
diseases. It is abnormal dryness of the mouth
Pathophysiology
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Radiation therapy injures the parenchyma of the salivary glands,
eventually leading to fibrosis and secretory hypofunction
The effects are dose-related and permanent (or temporary),
resulting in a condition called post-radiation xerostomia (oral
dryness)
Signs & Symptoms
- Dry mouth (main)
- Reduced salivation
- Dental problems
- Burning sensation and sore
throat
- Oral mucosa red, dehydrated
and fissured
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- Dry lips, corners of the mouth
and tongue (cracking or
bleeding)
- Painful ulcerations or the oral
tissues
- Infection and mucositis
- Opportunistic infections (i.e.,
Candida albicans)
Differential Diagnosis (Other causes of Xerostomia)
- Oral infections
- Poor salivary gland function
Risk Factors
- Having cancer
- Receiving chemotherapy or radiation
- Taking different medications that may cause xerostomia
- Having other underlying conditions that could cause/predispose to it
(i.e., oral infections)
Precipitating/Predisposing Conditions/Medications
Conditions
Medications
- Sjogren's syndrome - an
- Several hundred current
medications can cause
autoimmune disease, causes
xerostomia. These include
xerostomia and dry eyes.
- Nerve Damage - Trauma to the
antihypertensives,
head and neck area from surgery
antidepressants, analgesics,
or wounds can damage the
tranquilizers, diuretics and
nerves that supply sensation to
antihistamines c.
- Cancer Therapy:
the mouth. While the salivary
Chemotherapeutic drugs
glands may be left intact, they
cannot function normally without
can change the flow and
the nerves that signal them to
composition of the saliva.
Radiation treatment that is
produce saliva.
- Other: bone marrow transplants,
focused on or near the salivary
endocrine disorders, stress,
gland can temporarily or
anxiety, depression, and
permanently damage the
nutritional deficiencies may cause
salivary glands.
xerostomia.
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Want patients to get rid of old brushes that have bacteria that can
cause infection
Act of brushing is more important than toothpaste; all pdcts
equivalent
Cleanse dental prosthese
Floss if tolerated to prevent plaque formation
Frequently rinse with sodium bicarbonate solution to remove food
debris, provide hydration, neutralize oral acidity and liquefying
thick secretions; sodium bicarbonate can be used as alternative to
toothpaste
Avoid commercial mouthwashes with alcohol because may
increase dryness and irritate oral cavity (use Biotene mouthwash)
Attend frequent dental consultations
Other
Frequent sips of water
Ice chips, Popsicles, jello
Coat oral cavity with small amounts of vegetable oil 2-3 times
daily and before bed
Avoid lemon because acidic – can irritate
Don’t use glycerin – humectant so draws moisture out
Special food preparation - blended and moist foods are easier to
swallow
Smoking cessation: nictotine gum - mastication stimulates saliva
production
Papaya can be used for “ropey” saliva
Pharmacological Options
1. Artificial saliva products
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Salivart, Oralbalance - artificial saliva gel formulations
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Moistir – artificial saliva spray formulation
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Have chemical and physical properties which resemble those of
natural saliva
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Use as often as required
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Contain thickening agents to increase viscosity
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No side effects but their main limitation is cost and temporary
nature of the relief provided
2. Other products
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Biotene chewing gum – mechanical stimulation of chewing sugarfree gum can promote salivary flow. Also forces saliva between
the teeth, thereby aiding in the prevention of caries. Any
sugarless gum/candy will work
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Oral balance gel – biotene product – long lasting moisturizer
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Lip balms, moisturizers, vasoline – choose water soluble form to
 risk of aspiration
3. Systemic therapy
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Pilocarpine (Salagen) – a cholinergic agonist is the most
thoroughly studied
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Could be used to relieve radiation-induced xerostomia
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Can be used with artificial saliva because work by different
mechanisms
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Sweating is most common side effect. Other include chills,
nausea, urinary frequency, increased lacrimation, palpitations and
GI disturbances
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Have to monitor for signs of toxicity (side effects) and should
caution patients that drug may affect night vision which could
impair their ability to drive safely.
Is Treatment Required?
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Yes. If not treated, xerostomia can produce serious negative effects
on the patients’ quality of life, affecting dietary habits, nutritional
status, speech, taste, tolerance to dental prosthesis, and increases
susceptibility to dental caries. The increase in dental caries can be
devastating in many patients and therefore special care must be
made to control this condition.
Monitoring
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Monitor for the degree of oral dryness, development of new dental
caries, mucosal cracking and ulcerations, oral infections.
Goals of Therapy
- To increase the flow of saliva (when possible)
- To provide oral moisture by other means
Non-pharmacological Options
1. Meticulous oral hygiene
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Practice mouth care in the morning, after meals and before
bedtime to keep mouth clean and to stimulate salivary function
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Use soft bristle toothbrush (e.g., Biotene supersoft) and
fluoridated low-abrasive dentifrice (e.g., Boitene Toothpaste).
Alternatively use sponge toothettes.
Sebastian – October 2002
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ONCOLOGY: ORAL DYSFUNCTION
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MUCOSITIS
Definition:
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Also known as stomatitis
It is the inflammation of the oral mucosa – ranges from redness to
severe ulcerations
Mucositis can occur anywhere along the digestive tract from the
mouth to the anus. (We’re just concerned with the mouth)
Pathophysiology
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Chemotherapy can cause tissue damage leading to oral mucositis
via a direct and/or indirect mechanism
Areas that have high rate of proliferation, such as the stem cells of
the oral mucosa, are particularly sensitive to the direct cytotoxic
effects of these agents
Once the continuity of the epithelial lining is disrupted, a painful and
debilitating mucositis results from a sequence of tissue destruction,
inflammation and infection
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The indirect effect of chemotherapeutic drugs occurs as the bone
marrow function is suppressed during the nadir of treatment,
rendering the individual extremely susceptible to infection.
Signs & Symptoms
- Unpleasant taste sensations
- Reduced salivation (may be
(dysgeusia)
causing taste alterations)
- Decrease in taste perception
- Oral pain (due to ulcerations or
(hypogeusia)
edema) – almost always present
- Absent taster perception
with oral mucositis
(ageusia)
- Difficulty eating, talking and/or
swallowing
Differential Diagnosis
- Opportunistic oral infections
Risk Factors
- Having cancer
- Receiving chemotherapy or
radiation
- Being less than 20 years of age
- Pre-existing periodontal disease
- Hematological cancers or
tumors involving the
oropharyngeal mucosa
- Having other underlying
conditions that could
cause/predispose to it (i.e.,
xerostomia)
Precipitating/Predisposing Conditions/Medications
Conditions
Medications
- Xerostomia
- Cancer Therapy:
Chemotherapeutic drugs
- Hematological cancers or tumors
involving the oropharyngeal
Intensity is dependent on
mucosa
individual drug, drug regimen,
- Periodontal disease
dosages, rout and frequency.
Radiation treatment that is
focused on or near the salivary
gland can temporarily or
permanently damage the
salivary glands.
Is Treatment Required?
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Yes. If not treated, mucositis will worsen, be extremely painful,
preventing the patient from eating and necessitating hospitalization
for hydration, narcotic pain medication, and/or total parenteral
nutrition. The destruction of the protective mucous membrane can
also place the patient at a serious risk of infection.
Goals of Therapy
- To provide comfort, minimize oral infections, and maintain the
patient’s nutritional status
Non-pharmacological Options
1. Meticulous oral hygiene
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As described under xerostomia
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Will provide comfort, control of bad breath, stimulation of the
appetite, sensation of taste and prevention of dental caries,
periodontal disease and oral infection
Pharmacological Options
1. Agents to moisturize oral cavity and to maintain cleanliness
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Just as described under xerostomia
Sebastian – October 2002
2. Agents to maintain mucosal integrity and promote healing
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Agents that clean and moisturize the mouth are essential to
maintain the integrity of the mucosal lining and to promote healing
when alteration in integrity occur
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Sucralfate – acts by binding to damaged mucosal surface
proteins, thus forming a protective coating. Local production of
prostaglandin E2, a known cytoprotectant, is increased
3. Agents to prevent infection
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Chlorhexidine – gargle (or swish) and spit four times daily,
usually after completion of mouth care. Should not eat or drink for
as long as possible after doing a rinse. Dysgeusia and brown
staining of the teeth may occur with prolonged use. The dentist
can remove the staining. Needs to be used 6x daily to achieve
efficacious dose
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Fluoride – topical application should be done in patients at high
risk for developing dental caries. Decreases demineralization and
increases remineralization of dental lesions. Should used fluoride
gel in dental trays or brushed on the teeth at bedtime
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Benzydamine – Has local anesthetic properties & is used as an
alternative to lidcaine, may be irritating due to 10% alcohol
content (so can dilute 1:1 with water). May be swallowed if
required. Can cause GI upset. May last longer than lidocaine by
15-20min. Used only if lidocaine is not tolerated or can’t be used
for some reason – do not use together.
4. Agents to control pain
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Topical anesthetics – produce temporary anesthesia in local
areas. May impair swallowing and thus enhance the danger of
aspiration. Numbness of the tongue or buccal mucosa may also
enhance the danger of unintentional biting (don’t chew gum while
product is working). Patients should test temperature of foods
and drinks to avoid burning themselves. Examples include:
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Lidocaine viscous – Onset of action is about 30 seconds and
action lasts about 30 minutes. Label recommends waiting for 60
minutes before eating but can eat right after to help with
dysphagia. About 5-10 mL is enough because it is contact time
that is important (swish in mouth for 1 min). If throat mucosa is
involved, can swallow up to 60 mL per day without side effects
(arrythmias) – can dilute with equal amount of water to make it
easier to sip slowly to maximize contact time.
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Mucaine – Antacid containing mucosal anesthetic. Thick liquid
so contact time is increased
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ASA-containing gum (e.g., Aspergum) – Ineffective locally, and
only provides pain relief when the active contents are absorbed
systemically. ASA should be avoided in cancer patients because
of its effect on platelets.
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Sucrets – contains Dyclonine, an anesthetic; recommended by
lecturer based on clinical experience
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Magic Mouth Wash - contains nystatin, cherry flavoured sugar
free koolaid, and lidocaine. Limits flexibility in titration. Nystatin
may not be of benefit before meals; supposed to be administered
PC due to better contact time. Avoid products with the following
ingredients: antihistamines (topical rxns), Tetracycline (only
effective systemically + allergic rxns may occur), decadron (only
effective systemically)
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Scope – alcohol content – avoid anything over 6 %
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Biotene mouthwash should be used instead of scope– no
alcohol content, can help fight dental caries
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oral sodium bicarbonate & water solution (1 tsp in a cup of
water) – preservatives required in commercial preps (can be
irritating, so better to make it at home; no real upper limit on use.
Can use it in a spray bottle or as alternative to toothpaste; can
also buy club soda, which has bicarbonate in it
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Systemic Analgesics – May be used to provide some additional
pain relief. Use of liquid preparations like acetaminophen and
codeine elixir may increase patient compliance.
Monitoring
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Monitor for the degree of oral dryness, development of new dental
caries, mucosal cracking and ulcerations, oral infections.
CASE 2 (Mrs. Goodyear) Key points
 Lidocaine viscous 2% 30 mL QID prn M 500mL (1 month)
 script conducive to inappropriate use
 30mL is too much; 5 -10 mL more reasonable
 sig: “ AC & HS prn “are better directions for use
 revise one month supply amount
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ONCOLOGY: ORAL DYSFUNCTION
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ORAL CANDIDIASIS (THRUSH)
Definition:
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A yeast infection of the mucous membranes of the mouth and
tongue.
White, raised, milk-curd plaques attached to the mucosal surfaces
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Candida albicans is a fungus found as part of the normal flora of the
oral cavity and GI tract
Cancer and its treatments can compromise the normal immune
mechanisms that keep the oral colonization of candidiasis under
control and convert Candida into a pathogen that causes a variety
of mucocutaneous conditions
Signs & Symptoms
- whitish velvety plaques in the
mouth and on the tongue
Differential Diagnosis
- Other opportunistic oral
infections
Risk Factors
- Depressed immune system
- AIDS
- Immunosupressed transplant
patients
- individuals in chemotherapy
Nystatin / Fluconazole can be used as secondary prophylaxis if pt is
neutropenic
Monitoring
Pathophysiology
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Applied to the mucosa or delivered as 10 mg tablets (using
vaginal tablets) 5 times daily
3. Fluconazole
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150 mg as a single oral dose has been shown to be successful in
treatment
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Could even use once weekly which increases compliance
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Monitor for signs of progression of the infection like esophageal
involvement (possibly due to treatment failure)
Monitor for systemic manifestations of the infections
ONCOLOGY: ORAL DYSFUNCTION
- slow increase in number and
size of lesions
- If the whitish material is scraped
away the base may be red
(erythematous) with pinpoint
bleeding.
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PROPHYLAXIS of Xerostomia/Mucositis (Case 1)
S&Sx?
Risk Factors
- Oral malignancies
- advanced age
- generalized poor health
- and inherited abnormalities of
the immune system.
- diabetes
Precipitating/Predisposing Conditions/Medications
Conditions
Medications
- Xerostomia
- Immunosuppressives
- Mucositis
- Cancer Therapy:
Chemotherapeutic drugs
- Hematological cancers or tumors
involving the oropharyngeal
Intensity is dependent on
mucosa
individual drug, drug regimen,
- Periodontal disease
dosages, rout and frequency.
Radiation treatment that is
- AIDS
focused on or near the salivary
gland can temporarily or
permanently damage the
salivary glands.
Drug causes
Treatment
options
Clinical
Outcome
Therapeutic
Plan
 Mr. PM: 64 yr old male, recently diagnosed with
cancer of oropharynx, is beginning radiation
treatment daily for 5 consecutive weeks
 Mr. PM’s Risk factors
- smoker 2 packs/day since age 14
- 5 teeth extracted where radiation is planned:
exposed gum, extractions indicative of history of bad
oral hygiene
 patient is on amitryptiline
 non pharmacological - as described in
“Xerostemia” (meticulous oral hygiene & other)
 reevaluate existing medications, change preps to
easily tolerated formulations
 Prevent xerostomia / mucositis and respective
complications (e.g. infection)
 nonpharmacological treatments: daily oral
hygiene, smoking cessation
 reevaluate amitryptaline; consider alternative that
is less conducive to xerostomia
 reevaluate current medications and change
formulations if they still require pharmacotherapy:
Nitroglycerin spray instead of tablets
Liquid preps of dilantin /pain medications
instead of tablets
Is Treatment Required?
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Yes. Candida infections can cause discomfort because of
dysphagia, altered taste sensation and dry mouth, and may
contribute to poor nutrition and weight loss.
Goals of Therapy
- To treat the Candida infection and to prevent reinfection
Non-pharmacological Options
1. Meticulous oral hygiene
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As described in previous cases
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Should dispose of the toothbrush at least after the infection is
finished to prevent reinfection
Pharmacological Options
1. Nystatin suspension (100,000 units/mL)
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5 mL used as a mouthwash/gargle
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Swish for 1 minute before swallowing (if pharyngeal involvement)
4-6 times daily, after oral care is performed
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Unpalatable (bad taste) so noncompliance is a problem
2. Clotrimazole 1% solution
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Similar efficacy to nystatin and may increase patient compliance
Sebastian – October 2002
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