Sucralfate, an antiulcer
drug, binds to ulcerated tissue by attaching to proteins in the
damaged mucosa. It forms an adhesive -like protective coating.
Available in tablet form, it can be dissolved in water to make a
rinse. Dyclonine or lidocaine can be added to the solution to
decrease pain and can be swished and expectorated or swallowed up to
six times per day.
Zilactin is a medicated gel
that contains tannic acid and forms an occlusive film cover oral
ulcerations. It must be applied to dried tissue, which often causes
increased discomfort and decreases patient acceptance.
Capsiacin- found in chilli
peppers acts upon nerve endings to provide temporary pain relief.
Morphine- a CNS analgesic,
depresses pain impulse trnsmission. Effective in managing mucositis
pain in cancer patients, but dry mouth is one of its adverse effect.
It does not improve the health of the mucosa.
patch)- a very potent short acting opioid, used primarily as an
anesthetic. Available in a sustained release transdermal delivery
system with half life of 33 hrs. Useful in patients unable to take
oral medications. Patch must be changed every 3 days.
growth factor- influences growth, development and repair of
epidermal tissues, accelerates wound healing, increases number of
stem cells that survive a dose of radiation therapy.
Fibroblastic growth factor (renifermin)-
stimulates salivary gland hyperplasia and salivary gland output.
Maintaining a moist oral mucosa may help reduce the severity of
factor-present in biologic fluids including saliva. Palys a role in
healing damaged mucosa, less tissue damage when higher levels are
present in ECF.
Cancer chemotherapy is an
oxidative process. Radiotherapy and chemotherapy generate free
radical species, which require antioxidants to be neutralized.
Beta-carotene has been proved useful in chemotherapy induced
Vitamin E in combination
with vitamin C- act on a cellular level by protecting the cell
membrane and preventing peroxidation.
Glutamine- very important
during stress. It has successfully reduced radiotherapy and
chemotherapy induced mucositis by three mechanism-a) as a cellular
fuel, b) as a precursor of nucleotides needed for cell regeneration,
c) as a source of glutathione, which is a potent antioxidant. 4gms
of powdered glutamine in oral oral rinse in a swish and swallow
suspension, twice a day decreases intensity and duration of
Glutathione- is the body’s
main antioxidant. Blood levels of glutathione are reduced by
radiotherapy and severe inflammation. It can be used as intraoral
spray or oral dissolvable tablets.
immunomodulatory and antiangiogenic agent, inhibits tumor necrosis
factor associated with oropharyngeal ulcers. To prescribe
thalidomide the practitioner must register with the System for
Thalidomide Education and Prescribing Safety (STEPS) to minimize
substantial risks of teratogenecity.
In the future, the control
of mucositis may be found in cellular engineering and manipulation.
Cytokine-stimulated neutrophils recovery using agents such as
granulocyte colony stimulating factor and granulocyte macrophage
colony-stimulating factors decreases the duration of mucositis
either by limiting epithelial damage or by decreasing the likelihood
of secondary infection and delayed healing. Transforming growth
factor-beta 3 and interlukin-2 have demonstrated promising efficacy
by transiently limiting the rate of basal oral epithelial growth
proliferation in vitro and in vivo, thereby modifying the frequency
and severity of chemotherapy-induced mucositis.
Amifostine- enhances the
tolerance of normal tissues to a given dose of radiation and
decreases treatment morbidity. Cytoprotective mechanism involves DNA
protection, repair acceleration and antioxidant function. Prevents
salivary gland injury induced by radiation, reducing xerostomia,
mucositis and hematological abnormalities. Given i.v or s.c. Life
threatening anaphylactoid reaction, nausea, vomiting, hypotension
and hypocalcemia associated with amifostine treatment have been
Cryotherapy in the form of
ice chips, used for 5 minutes prior to drug administration and for
25 minutes afterward, can decrease the mucositis associated with
5-fluorouracil, possibly by causing local vasoconstriction and
reducing local delivery of the agent.
Low intensity laser therapy-
improves wound healing and accelerates replication of cells. Low
energy helium-neon laser seems to be safe, simple, atraumatic and
efficient method for prevention and treatment of chemotherapy and
radiotherapy induced mucositis.
Oral Care Prior to
Every patient about to
receive radiation to the head and neck must under go a comprehensive
dental evaluation to identify risk factors for the development of
oral complications. All services required for the patient to be in
optimal oral health need to be provided as well as initiation of an
aggressive preventive regimen. Many patients with head and neck
cancer are noncompliant with routine oral hygiene and dental care.
Ninety seven percent of
dentulous patients need dental care prior to initiation of
radiation. Evaluation should be done at least 3 weeks before
radiation to allow adequate time for wound healing. Knowledge of the
location of the radiation field and total dose of radiation are
important factors in formulating a treatment plan. For example,
treatment of nasopharyngeal and soft palate tumors present a
decreased risk for ORN. Since the body of the mandible is generally
not in the field. Therefore, it is less critical to remove
mandibular molars prior to initiation of radiation. For lesions in
the floor of the mouth, tongue, and tonsillar pillar, and retromolar
tumors that require radiation of the major salivary glands and the
body of the mandible, there is an increased risk of radiation caries
and osteoradionecrosis. Practitioners need to be more aggressive
about removal of questionable mandibular molars and premolars prior
to radiation. If, due to the size or location of the primary tumor,
the goal of radiation palliation, pre-radiation extractions may only
be indicated when retention of teeth could cause discomfort.
A thorough oral examination
should be performed, including.
Full mouth radiographs and a panoramic radiograph
Identification of periodontal disease
Assessment of oral hygiene
Assessment of the patient’s motivation to comply with the necessary
Identification of all restorative needs
Identification of periapical infections, unerupted teeth, root tips,
and other pathological conditions
Preprosthetic surgical needs
Evaluation of prosthetic appliances
Proper fit and comfort
Potential sources of irritation
Removal of soft liners, which become colonized with yeast and can
become a source of irritation to friable mucosa.
Oral care during
During radiation, patients
need to be monitored weekly. Palliative treatment for musositis
should be give.
Use of saliva substitutes
should be encouraged to lubricate dried mucosal tissues and decrease
the chance of traumatic ulceration. Patients can be started on a
diet of semisoft food, moistened with liquids or gravies and
cautioned to avoid spicy, acidic or mechanically irritating foods.
Good oral hygiene and daily fluoride use must be reinforced.
Trismus prevention exercises
should be reviewed. Denture wearing should be discouraged, except
Oral care after
Following the completion of
radiation therapy, patients should be observed once or twice during
the first month. Then they can be placed on a 3 to 4 month recall
schedule. The goal is to prevent radiation caries and periodontal
disease, decrease the risk of development of osteoradionecrosis and
manage some of the chronic side effects such as xerostomia. The oral
mucosa should be examined for areas of irritation or ulceration. If
present, the causative agent should be identified and corrected if
Review of literature has
delineated a vast number of agents that have been identified as
effective in prevention and treatment of mucositis in cancer
patients. However, no single agent is universally effective. It is
extremely important to prevent mucositis or atleast reduce its
severity and complications. Any of the available methods should be
thus used singly or in combination to get optimum benefit.
Greenburg MS, Glich M. Burket’s Oral Medicine and Treatment, 10th
ed. Noida: Gopson Papers Limited; 2003.
Orad RA, Blanchaert RH. Oral Cancer. The Dentist’s Role in
Diagnosis, Management, Rehabilitation and Prevention. 1st
ed. London: Quintessence Publishing Co, Inc.; 2000.
Velez I, Tamara LA, Mintz S. Management of oral mucositis induced by
chemotherapy and radiotherapy: An update. Quintessence
International, Volume 35 (2), 2004; 129-35.
Barker G, Loftus L, Cuddy P, Barker B. the effects of sucralfate
suspension and diphenhydramine syrup plus kaolin-pectin on
radiotherapy-induced musocitis. Oral Surg Oral Med Oral Pathol 1991;
Epstein JB, Moore PS. Benzydamine hydrochloride in prevention and
management of pain in oral mucositis associated with radiation
therapy. Oral Surg Oral Med Oral Pathol 1986; 62: 145-48.
Stokman MA, Spijkervet FKL, Boezen HM, Schouten JP, Roodenburg JLN,
Vries EGE. Preventive Intervention Possibilities in Radiotherapy-
and Chemotherapy-induced Oral Mucositis: Results of Meta-analyses. J
Dent Res 2006; 85 (8): 690-700.
Periodontics - A review ( Basics)
The mouth is home to more than 450 species of microorganisms. Most
of these are necessary to maintain healthy teeth and gums; in
fact, fewer than 5% have been linked to periodontal (gum)
infections. Still, even this small number can do significant
The path to gum disease has many steps, beginning with plaque
is an invisible, sticky film that covers your
teeth when starches and sugars in food interact with bacteria
normally found in your mouth. Although it is removed each time you
brush, plaque can reform within 24 hours. Plaque that stays on
your teeth for longer than two or three days can harden under your
gum line and turn into tartar. This white substance acts as a
reservoir for bacteria and makes plaque even more difficult to
brush away. Tartar is bound so tightly to teeth that it can be
removed only by a professional cleaning.
The longer that plaque and tartar persist, the more damage they
inflict. Initially, they may just irritate and inflame the gingiva,
the part of the gum around the base of your teeth. This is
commonly known as gingivitis and is the mildest form of gum
disease. Its trademark signs include bad breath and swollen, red,
bleeding, or receding gums.
Left untreated, however, gingivitis can progress to more severe
periodontitis. This final stage of gum disease occurs when ongoing
gingivitis leads to the development of pockets between your gums
and teeth that fill with more plaque, tartar, and bacteria. Over
time, these pockets can spread under your gum tissue and cause
infections that may result in tissue or tooth loss.
Researchers have discovered that people with periodontal disease
are much more likely to suffer from coronary artery disease than
those without the disease.
Scientists have advanced several theories to explain the link
between periodontal disease and heart disease. One theory holds
that inflammation caused by periodontal disease leads to impaired
functioning of the vascular endothelium, which contributes to
Still another hypothesis is based on several studies showing that
periodontal infections can be correlated with increased levels of
inflammatory mediators, such as fibrinogen, C-reactive protein, or
cytokines, which have been correlated with increased risk of
The presence of gum disease also may increase risk of stroke.
Previous research found that the severity of gum disease is
proportionally related to the amount of arterial plaque located in
the carotid arteries, the two major arteries on each side of the
neck that supply blood to the brain. Blockage here may reduce
blood flow to the brain or advance blood clots, which can lead to
a stroke. A 2005 study from the University of Minnesota found a
direct link between high levels of bacteria that cause gum disease
and thickness of the carotid arteries. This research stands out as
the first to link atherosclerosis with the type of bacteria that
causes gum disease, and not with other oral bacteria.
Diabetes is associated with increased risk of infection, which
may include oral infections such as periodontitis. Researchers
have noted that periodontal disease is a common complication of
diabetes. In fact, people with type I or type II diabetes are more
susceptible to severe, progressive periodontal disease than
Studies suggest that periodontal disease may adversely affect
blood sugar control in people with diabetes. Controlling
periodontal infection in diabetic individuals has been found to
help improve blood sugar control, as measured by a decreased
demand for insulin and decreased levels of hemoglobin A1C, a
marker of long-term blood sugar control.
Measures to combat complications of diabetes, especially
periodontitis and gingivitis, may be important in reducing
additional systemic inflammatory burden, thus potentially
preventing other conditions such as cardiovascular disease.
Premature and low-weight births.
indicate that gum disease can affect the health of pregnant women
and their unborn children. A University of Chile study found that
women with gingivitis were at higher risk of delivering premature
infants and low-weight babies than women with healthier gums. The
likely reason is that periodontitis or gingivitis bacteria
contribute to an inflammatory response of the placental membrane,
which may induce
Periodontal treatment reduced the risk of premature and low-weight
births in women with pregnancy-related gum disease.
Gum disease may also contribute
to other physical problems. For instance, some evidence suggests
that periodontal disease may contribute to lung infections like
pneumonia, or may worsen chronic conditions such as emphysema.
Experts believe this may be due to oral bacteria that move into
the airways of the throat and lungs. Poor oral health may also
accompany poor joint health. People with moderate to severe
periodontitis experience an increased risk of rheumatoid
arthritis. Gum disease is also present in many patients who suffer
from juvenile idiopathic arthritis.