Oropharyngeal Mucositis in Cancer Therapy
Oropharyngeal Mucositis in Cancer Therapy
It is an honor to have the opportunity to comment on this review by Drs. Epstein and Schubert on oropharyngeal mucositis. This paper will serve as an excellent teaching tool for physicians and dentists in that it provides comprehensive background information on the topic. In addition, it presents a commonsense approach to prevention and management, which should serve as a guide to practitioners.
While mucositis is recognized as a significant problem by both medical and radiation oncologists, it is disappointing that the most widespread preventive and management regimens are not evidence-based. It is exciting to see the studies that give promise to the use of genetics and biologic modifiers to prevent or treat mucositis. Equally significant but also humbling is the research showing that many therapies long recommended for mucositis may have little proven benefit. There has been limited consensus on what to recommend for patients, and it is frustrating to read about agents (such as benzydamine) that have been shown to be effective for mucositis in Europe and Canada but are not yet available in the United States.
Catch-up Efforts in Dentistry
Dentistry seems to be a decade behind medicine in the area of evidencebased practice; however, efforts are being made to catch up. Witness general dentistry and specialty organizations adding symposia on this topic, while journals have begun to ask appropriate questions before publishing. Indeed, most journals have published articles and special series on evidencebased dentistry, and one journal is now devoted exculsively to this topic. Dental schools are also emphasizing this way of thinking in their curricula. Our approach to the prevention and treatment of mucositis is not very different from that recommended by the authors. Their discussion of radiation shields is limited and references a retrospective article, which found that using extraoral blocks to shield healthy tissue reduced typical complications. The use of intraoral appliances to position healthy tissue out of the field of radiation,[3,4] or to provide some distance between metallic dental restorations and mucosa seems to be beneficial in reducing oral mucositis; however, most discussions in the literature are case reports, and no prospective studies are available. We have been providing these devices and must plan a way to study their efficacy in order to ensure that patients derive benefit and to convince third-party payors of their value in reducing treatment morbidity and cost. Head and neck radiation therapists who wish to provide these appliances to their patients must work closely with dentists and maxillofacial prosthodontists. Unfortunately, such relationships are not always found outside of the major teaching institutions.
Cooperative Care Approach
Many key factors in the prevention of mucositis and other oral complications of cancer therapy revolve around the overall oral health of the patient, including oral hygiene, status of dental restorations, and fit of denture prostheses. Oncologists have to be able to work with dentists to ensure the health of their patients. At our institution and at many other dental schools, dental students gain exposure to the practice of radiation therapy and patients with oral mucositis during hospital dentistry rotations. It is the dentists engaged in hospital-based residencies and their attendings who have the greatest opportunity to work with these patients. Although this works well at major medical centers with hospital dentistry programs, it is not always successful in smaller communities. Cancer care is not limited to large cities anymore, because smaller hospitals are establishing cancer treatment centers that are hiring oncologists who have completed fellowships at major cancer centers, and patients and their families prefer to be treated closer to home. Community hospitals may not have dental programs, and few dentists in the community have hospital privileges. Therefore, oncologists in smaller cities should establish relationships with local dentists and perhaps start study groups to promote updates in knowledge on such topics as mucositis. Oncologists in large cities should seek to interact with dental schools to enhance their educational programs. Hospital-based general practice residency programs must also be supported, as these produce dentists with extra training and experience who will be most able to work with cancer patients.
Drs. Epstein and Schubert have provided an article that will serve as an important resource for teachers and guide for practitioners. It should also serve as a reminder of the need for oncologists and dentists to work together in the areas of education, sound research development, and evidencebased patient care.
2. Ismail AI, Bader JD, Kamerow DB: Systematic reviews and the practice of evidencebased dentistry: Professional and policy implications. J Am Coll Dent 66:5-12, 1999.
3. Epstein JB, Stafehl DM, Stevenson-Moore P: Use of intraoral prostheses in external beam radiation of oral and perioral cancer. J Prosthet Dent 54:100-107, 1985.
4. Kaanders JH, Fleming TJ, Ang KK, et al: Devices valuable in head and neck radiotherapy. Int J Radiat Oncol Biol Phys 23:639- 645, 1992.
5. Eichmiller FC, Schrack RA: Simplified shielding of metallic restoration during radiation therapy. J Prosthet Dent 61:640, 1989.