Drs. Sonis and Fey are to be commended for their timely
and thorough article on the oral complications of cancer therapies. It has been
our experience that these side effects are not being adequately addressed in the
clinical setting. This is especially true the further one is removed from large
cancer treatment centers in urban areas.
The standard of care for this area of patient care was investigated and, in
part, established at a 1989 National Institutes of Health (NIH) consensus
development conference. It was the recommendation of the participants that
all patients receiving chemotherapy and head and neck irradiation be given a
complete dental evaluation prior to the initiation of cancer treatment.
As clinicians, we are concerned that this is not done on a routine basis,
especially because mucositis is the number 1 dose-limiting factor for both
chemotherapy and head and neck irradiation. We see this as a window of
opportunity that is being overlooked in the majority of patients in regard to
the prevention of infection and pain, the ability to adequately maintain
nutrition, and the establishment of a better quality of life as patients
progress through cancer treatment.
Neglected Aspect of Care
As reflected in this article, it is evident that great strides have been made
in both chemotherapy and radiation therapy since 1989. How unfortunate it is for
the majority of cancer patients that the recommendation of a pretreatment dental
screening is not routinely followed. Although it is true that not all patients
receiving cytotoxic treatments develop oral complications, the potential for
such complications exists in 100% of these patients.
The condition of a patient’s oral health is a great predictor of whether or
not oral side effects will occur.[2,3] For at least a quarter of a century, the
thrust in both medicine and dentistry has been toward prevention. Why is it that
this aspect of patient care, when applied to the cancer patient, is so
neglected? Why is there not a greater cooperative effort being forged between
the medical and dental communities for the benefit of this patient population?
The NIH recently reported that when a cancer patient dies from an infection,
54% of the time the causative organism originates in the oral cavity. With
this as a documented fact, it is unconscionable that a more proactive stance is
not being taken with regard to prevention. Many excuses are given for not having
patients schedule pretreatment dental screenings. However, even the reasoning
that such a screening would seriously delay treatment is not valid, as a greater
number of dentists are aware of the expediency of the protocol and of the
treatments required. They stand ready and able to be a part of the patient’s
1. NIH Consensus Statement: Oral complications of cancer therapies:
Diagnosis, prevention, and treatment; April 17-19, 1989. 7(7):1-11, 13.
2. Oral Health in America: Report of the Surgeon General, Part 3, pp 105-106.
Rockville, Md: US Department of Health and Human Services, May 25, 2000.
3. Silverman S Jr, Kramer, AM: Drugs for neoplastic disorders, in ADA Guide
to Dental Therapeutics, chapter 27. Chicago, ADA Pub, 2000.
4. Khan SA, Wingard JR: Infection and mucosal injury in cancer. Journal of
the National Cancer Institute Monographs, no. 29, pp 31-36, 2001.
5. Chemotherapy and your mouth. Oral Health, Cancer Care, and You, NIH
Publication 99-4361. Rockville, Md; US Department of Health and Human Services,
National Institutes of Health, 1999.
6. Sonis ST, Oster G, Bellm L, et al: Oral mucositis and the clinical and
economic outcomes of hematopoietic stem cell transplantation. J Clin Oncol