Drug Therapy for Mouth Disorders: Mucositis, Plaque, Halitosis, and Xerostomia

Basic oral hygiene is an important component of care for any patient with cancer. The purpose is to decrease the complications associated with pain, oral microorganisms, and bleeding. Prior to cancer therapy, a baseline pretreatment oral mucosal assessment should be completed to rule out pre-existing conditions or infections that might aggravate impending mucositis. Although it takes 5 to 7 days for mucositis to develop after chemotherapy or radiation therapy, oral hygiene regimens should be started when chemotherapy or radiation therapy is iniated. Oral hygiene, oral irrigations, and methods to relieve dry mouth and lips can be very effective in providing comfort.

Pain associated with oral mucositis can be a major complication that contributes to poor nutrition and hydration. To be effective, topical applications of medication for pain must come in contact with the tissue. Therefore it is advisable to schedule these routines immediately after cleaning the oral cavity. In addition to the previously described protectants, local anesthetics, and analgesics, the following are routine approaches to treating pain in the oral area.

• Lidocaine: Viscous lidocaine 2% before meals to relieve pain. Frequent applications are required, and the sense of taste is diminished. Care must be taken to make sure the patient is not burned by the food because the entire mouth and throat are anesthetized.
• Milk of magnesia can be used to rinse the mouth and coat the mucous membranes.
• Nystatin liquid can be swished in the mouth for 1 minute and then swallowed (swish and swallow routine), or clotrimazole lozenges may be chewed or sucked and then swallowed to reduce candidal oral infections.
• Sucralfate suspensions applied topically have been reported to provide effective pain relief.
• Oral or parenteral analgesics (e.g., morphine) should be administered for severe pain.
• A new medicine – recombinant human keratinocyth growth factor, palifermin (Kepivance) – has been approved specifically for use in preventing and treating the mucositis that develops in leukemia or lymphoma patients undergoing chemotherapy before bone marrow transplantation.

Plaque

Plaque is controlled by toothburshing, flossing between teeth, and using mouthwashes. If plaque is removed regularly, calculus will not form. Using a dentifrice (toothpaste) and flossing between teeth helps remove dental plaque and stain, resulting in less halitosis and periodontal disease and fewer dental caries. Other devices, such as oral irrigators (WaterPik), spongetipped applicators, or electric toothbrushes, can be used for patients who wear orthodontic appliances are physically or mentally handicapped, or lack manual dexterity and require someone else to clean their teeth. Therapeutic mouthwashes also help reduce plaque accumulated above the gumline.

Halitosis

Halitosis is treated most easily by eliminating causes such as smoking and certain foods. Regularly brushing the teeth or dentures and using dental floss between teeth can remove particles of decaying food. Mouthwashes and breath mints can mask halitosis but usually last less than 1 hour. If halitosis is persistent without a readily identifiable cause, such as smoking or diet, a dentist should be consulted for a thorough examination to ensure that no other pathologic condition is underlying cause.

Xerostomia

Xerostomia is treated by changing the medicines that cause dry mouth or with artificial saliva. Artificial saliva products do not stimulate natural saliva production but mimic the viscosity, mineral content, and taste. Patient with xerostomia should be seen by a dentist regularly to help avoid additional dental carries and ensure proper denture fit to prevent gum irritation. Commercially available saliva substitutes include Salivart, MouthKote, Saliva Substitute, and Moi-Stir. All are available as sprays for easy administration.