at all levels: mild (relative risk [RR] 0.64), moderate (RR 0.38), and severe (RR 0.24; Riley, et al., 2017). It should be noted that patients receiving chemotherapy with oxaliplatin (part of a standard treatment for colorectal cancer) are likely to suffer cold sensitivity, which would make the use of ice chips inappropriate for those patients (Dana- Farber Cancer Institute, 2014). Other interventions that produced a significant difference compared with a placebo or no treatment were amifostine and hydrolytic enzymes. Even with these reported interventions, there still is not a treatment approach that is universally employed for mucositis. Topical agent-induced oral ulceration Directly applying over-the-counter medications such as aspirin, hydrogen peroxide, potassium tablets, and phenol-containing medications to the mucosa may produce epithelial necrosis and ulceration (Butler, 2016; Durso, 2008; Kalmar, 2016; Rostami & Brooks, 2011; Fitzpatrick, Cohen, & Clark 2019). A superficial chemical injury of the oral mucosa can develop because of topical application of aspirin (Lewis & Jordan, 2012). Aspirin application can produce a whitish and corrugated appearance Fixed drug eruption Systemic medication-induced cutaneous disorders often display a characteristic clinical morphology such as urticaria, hypersensitivity syndrome, pseudolymphoma, photosensitivity, pigmentary changes, lichenoid dermatitis, vasculitis, Stevens- Johnson syndrome, or fixed drug eruption (Butler, 2016; Durso, 2008; Jain & Gupta, 2015; Kalmar, 2016; Nair, 2015; Fitzpatrick, Cohen, & Clark 2019). Fixed drug eruption involves the development of one or more annular or oval erythematous patches with hyperpigmentation when the lesions resolve. Lichen planus-like (Lichenoid) reactions It is well established that some oral drug reactions have clinical, histopathological, and even immunopathological features in common with idiopathic lichen planus, pemphigoid, pemphigus, and erythema multiforme (Worsnop, Wee, Natkunarajah, Moosa, & Marsden, 2012; Kumarasinghe, et al., 2019). Typically, lesions are isolated, but bilaterally symmetrical involvement is common. Clinically, lichen planus-like lesions may manifest as both papuloreticular and erosive lesions, with the latter characterized by shallow, irregular ulcerations or erosions, with a peripheral border of fine keratotic striae, often radiating from the lesion center. Erythema multiforme-like reactions Some drug-induced vesiculobullous or ulcerative lesions that mimic other immunological diseases are erythema multiforme- like reactions (Durso, 2008; Kalmar, 2016; Lewin, Farley-Loftus, & Pomeranz, 2011; Massot & Gimenez-Arnau, 2014; Fitzpatrick, Cohen, & Clark 2019). As in idiopathic or virally induced cases, drug-induced erythema multiforme-like reactions have a rapid onset and variable expression, ranging from lesions limited to the oral mucosa to widespread mucocutaneous involvement. Sulfonamides, sulfonylureas, and barbiturates are among the most common culprits in drug-induced erythema multiforme. Pemphigoid-like reactions The distribution of pemphigoid-like reactions varies from limited oral mucosal lesions to other mucosal or cutaneous sites. The clinical manifestations of these lesions include vesicles or bullae that break down into shallow ulcerations. The involvement of the gingiva tissues may be generalized or multifocal, with marked erythema and erosion of the superficial gingiva (desquamative gingivitis). In 2012, Kanjanabuch and colleagues reported a Pemphigus-like reactions The most common cause of pemphigus-like reactions is thiol- containing drugs (Pietkiewicz, Gornowicz-Porowska, Bowszyc-
For relief of pain and discomfort caused by mucositis, the use of several anesthetics, analgesics, and mucosal coating agents (acting as cytoprotectants) has been suggested. Viscous lidocaine and benzydamine have been suggested as periodic rinses. Reports have been encouraging for the use of sucralfate suspensions for relief of pain and resolution of mucositis (Lalla et al., 2014). The Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology has also made recommendations for care that would be especially helpful to individuals practicing in a tertiary cancer center or practitioners interested in providing ongoing care to patients with mucositis (Lalla et al., 2014). in the oral mucosa, with erosion and ulceration of more severely damaged areas. Aspirin’s low pH causes erythema and tissue necrosis and, with increasing time, coagulative necrosis. The most frequently involved site is the buccal sulcus or alveolar attached gingiva. For most patients, healing occurs once the chemical is removed (Jordan & Lewis, 2013, Fitzpatrick, Cohen, & Clark 2019). Initially, limited lesions occur. Additional lesions arise with re- exposure when hyperpigmented macules activate, developing a violet-colored middle surrounded by erythematous rings. The major categories of agents thought to cause fixed drug eruption include antibiotics (especially trimethoprim- sulfamethoxazole), antiepileptics, nonsteroidal anti-inflammatory drugs (NSAIDs), and phenothiazines. Medications may produce a site-specific eruption pattern. Many drugs have been associated with mucocutaneous eruptions resembling lichen planus (lichenoid reactions). Notably, lichenoid lesions have been associated with the use of dental restorative materials (McParland & Warnakulasuriya, 2012; Kumarasinghe, et al., 2019). Contact with restorations containing amalgams or other materials has been associated with lesions that clinically and histologically resemble lichen planus. The etiology of these lesions presumably has an allergic or toxic component or may be related to the presence of plaque on the restorations. Substituting other materials for amalgams may improve some oral lesions (Syed, Chopra, & Sachdev, 2015; Kumarasinghe, et al., 2019). These lesions initially manifest as erythematous macules or patches followed by short-lived vesicles or bullae and ragged and shallow ulcerations. Hemorrhagic ulceration and crusting of the labial vermilion zone are common. Stevens-Johnson syndrome and toxic epidermal necrolysis – more severe reactions – additionally involve conjunctivitis of the ocular mucosa and urethritis of the genital mucosa. In toxic epidermal necrolysis, diffuse bullae formation and subsequent denudation affect significant proportions of the skin and mucosal surfaces. case of atenolol-induced mucous membrane pemphigoid. (Atenolol is used to treat hypertension.) Other medications implicated in pemphigoid-like reactions include thiol-containing drugs and sulfonamide derivatives, as well as therapeutic classes of NSAIDs, cardiovascular agents, antimicrobials, and antirheumatics (Stavropoulos, Soura, & Antoniou, 2013; Yuan & Woo, 2015).
Dmochowska, & Dmochowski, 2015). Drugs implicated include penicillamine, rifampicin, diclofenac, phenol drugs, and, rarely,
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