______________________________________________ Oral Cancer and Complications of Cancer Therapies
discontinuation of bisphosphonates several months prior to the extraction procedure should be considered carefully [95]. All patients who are being treated with bisphosphonates or denosumab should be counseled regarding the possibility of MRONJ developing, including early signs, and the importance of good oral hygiene [90]. When MRONJ does develop, the stage of the disease should be determined, which will in turn guide the treatment plan. MRONJ is categorized as [90]: • Stage 0: No exposed/necrotic bone with non-specific symptoms or clinical and radiographic findings • Stage 1: Exposed/necrotic bone with no symptoms and no evidence of infection • Stage 2: Exposed/necrotic bone with pain and clinical evidence of infection • Stage 3: Exposed/necrotic bone with pain, infection, and one or more of the following: ‒ Exposed necrotic bone extending beyond the alveolar region ‒ Oral antral/oral nasal communication ‒ Pathologic fracture ‒ Extra-oral fistula ‒ Osteolysis extending to the inferior border of the mandible or sinus floor Patients with stage 1 MRONJ are usually treated conservatively, with oral antimicrobial rinses (e.g., chlorhexidine 0.12%) and no surgical intervention. Stage 2 MRONJ is treated with the use of antibiotic therapy in addition to oral antimicrobial rinses; certain cases may require surgical intervention to reduce the volume of colonized, necrotic bone. Stage 3 disease often impacts quality of life and requires more intensive interven- tion. These patients usually require surgical debridement/ resection in combination with antibiotic therapy [90].
While radiotherapy-induced xerostomia and all of the prob- lems associated with it are long-term or permanent, those associated with chemotherapy dissipate after the comple- tion of the regimen. Chemotherapy is usually given in an incremental fashion, with several days or weeks separating the appointments. Xerostomia may be a continuous problem until enough time has elapsed after the last session. A 2015 Cochrane Review concluded that cryotherapy (i.e., holding ice chips or ice water in the mouth from 5 minutes prior to 30 minutes after treatment) is effective in reducing mucotoxicity [96]. A simple act to palliate the symptoms associated with this xerostomia and mucositis is to frequently suck on ice chips. Being that the cost and risks of this preventative measure are virtually nonexistent, cryotherapy should always be considered. Neurologic effects may be seen in some patients on chemo- therapy. Vincristine sulfate is the chemotherapeutic agent most commonly associated with this problem [51; 97]. Chemo- therapeutic agents exert varied effects on any nerve. The most commonly affected nerves that serve the oral and maxillofacial complex are the facial and trigeminal nerves. The facial nerve is the major source of motor innervation for the muscles of facial expression. Transient neural toxicity manifests as weakness of these muscles and decreased facial muscular coordination. The trigeminal nerve is another cranial nerve that provides sensory innervation to many portions of the face and for those structures within the oral cavity. Symptoms of neural toxicity present in a variety of ways. Pain that mimics that of dental origin may affect both the maxillary and the mandibular arches. There may be temporary paresthesia in the soft tissues or in the teeth. Pain in the temporomandibular joint (TMJ) may mimic TMJ problems. Patients should be reassured that these problems will regress after chemotherapy is completed. Special Considerations Special considerations for the oral complications of chemo- therapy include the pediatric population and those patients who receive bone marrow transplants. Unfortunately, many children must undergo the rigors of chemotherapy. This often affects tooth development and craniofacial growth in children younger than 12 years of age [98]. Effects are even more severe in children younger than 5 years of age [98]. Additionally, children are subject to all of the other chemotherapy-induced problems. Their immature immune systems are less capable of the provision of defense against oral infections. Any anticipated dental treatment should be cleared through the oncologist. Patients who have received bone marrow transplants are particularly prone to infections [81]. Chemotherapy and radia- tion therapy are used to eliminate the normal and malignant cells within the bone marrow in anticipation of replacement marrow from a donor. As a result, the patient has virtually no immunocompetence. Patients are usually required to take immunosuppressive drugs for life and may be subject to life-threatening sepsis from dental infections that would be self-limiting in immunocompetent individuals. Any dental
OTHER ORAL COMPLICATIONS OF CHEMOTHERAPY
Systemic chemotherapy can have oral manifestations that are dependent on the agent(s) used, their dosage, and the duration of therapy. As with any medication, there is a considerable variability in the tolerance for a given pharmacotherapeutic regimen as well as any side effects. As noted, one such effect may be xerostomia. This problem is associated with some che- motherapeutic agents more than others. The parotid glands, with their serous secretions, are the glands most frequently affected. Because chemotherapeutic agents are administered as a systemic therapy, these substances course through all sali- vary glands. With the serous component reduced, the saliva develops a mucus-laden, ropey consistency. The decreased lubrication exacerbates the pain associated with concurrent areas of mucositis and makes it difficult to wear any dental prostheses. Eating, speaking, and swallowing may become difficult, and the taste of foods may be altered.
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