Page 52 Complete Your CE Test Online - Click Here flossing. Peroxide rinses were once recommended to help remove bacteria but peroxide can damage fibroblasts and keratinocytes and delay mucositis healing [181]. Cancer treatment agents most commonly associated with mucositis are [145,302]: ● ● Cytarabine. ● ● Doxorubicin. ● ● Etoposide. ● ● 5-fluorouracil. ● ● Methotrexate. ● ● Epidermal growth factor receptor inhibitors (such as afatinib, cetuximab, erlotinib, gefitinib, lapatinib, panitumumab). ● ● Multitargeted tyrosine kinase inhibitors (such as cabozantinib, ceritinib, crizotinib, pazopanib, regorafenib, sorafenib, sunitinib, vendetanib). ● ● Mammalian target of rapamycin inhibitors (such as everolimus, temsirolimus). Complications can be acute (developing during treatment) or chronic (developing months to years afterward). In general, cancer chemotherapy causes acute symptoms that resolve following treatment, with recovery of damaged tissues [181]. Primary preventive measures should begin before chemotherapy starts; appropriate nutritional intake, effective oral hygiene practices, and early detection of oral lesions are important pretreatment interventions. Patients who smoke should be offered help with cessation before treatment begins, since smoking reduces microcirculation and delays healing and is known prolong mucositis after radiation therapy [181]. Dental consultation a few weeks before cancer chemotherapy starts can sometimes help prevent complications by treating problems and starting a program of oral hygiene. Specific interventions are directed at [181]: ● ● Mucosal lesions. ● ● Dental caries and endodontic disease. ● ● Periodontal disease. ● ● Ill-fitting dentures. ● ● Orthodontic appliances. ● ● Temporomandibular dysfunction. ● ● Salivary abnormalities. If the patient is already myelosuppressed at the time of dental treatment, some corrections or prophylaxis may be needed (e.g., platelet transfusions or antibiotics if ANC less than 2000). Mucositis should be managed by good oral hygiene, and avoidance of spicy, acidic, hard, and hot foods and drinks. Dental brushing and flossing should be performed daily with assistance from professional staff [181]: ● ● A soft nylon-bristled toothbrush should be used two to three times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus and keeping them free of bacterial plaque. ● ● Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma. ● ● Oral rinsing with water or normal saline three to four times while brushing will further aid in removal of dental plaque. ● ● Rinses containing alcohol should be avoided. ● ● Toothpaste with a relatively neutral taste should be considered because flavorings can irritate oral soft tissues. ● ● Brushes should be air-dried between uses. ● ● Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use. ● ● Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. ● ● While toothbrush disinfectants have been suggested, their routine use to clean brushes has not been proven of value. The mouth should be cleaned after meals [181]: ● ● If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary. ● ● Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals. ● ● Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary. ● ● Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. ● ● Foam toothbrushes have limited ability to clean teeth but may be useful for cleaning other areas of the mouth, palate, and tongue. Management of discomfort and dryness [181]: ● ● Topical anesthetics like lidocaine in gels, ointments or sprays can help, as can diphenhydramine solution. ● ● Mucosal coating agents like Amphojel, kaolin-pectin suspension, hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin), and Gelclair (approved by the U.S. FDA as a device). ● ● Water-soluble lubricating agents, such as artificial saliva, can be used for xerostomia. ● ● A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for four hours or longer. Its application to damaged mucosa does not cause burning. ● ● Topical morphine has been shown to be effective for relieving pain, but there is concern about dispensing large volumes of the medication. ● ● Topical fentanyl prepared as lozenges in a randomized placebo- controlled study showed relief for pain of oral mucositis. ● ● Systemic analgesia (such as opioids) should be used for pain unrelieved by these measures. NSAIDs are contraindicated when thrombocytopenia is present. Head and neck radiation typically causes not only acute oral toxicities such as mucositis in almost all recipients. In contrast to chemotherapy stomatitis, which tends to resolve after treatment ends, head and neck radiation can induce permanent tissue damage (to mucosa, bone, taste buds and more) that result in lifelong risk for the patient. Amifostine can be used to help prevent damage to the salivary glands [181]. Patients who do not respond well to topical treatments and symptomatic nursing management should be referred for dietary consultation to avoid dehydration and weight loss. Peripheral neuropathy Chemotherapy-induced peripheral neuropathy (CIPN) is a result of damage to the peripheral nerves. Symptoms depend on which peripheral nerves (sensory, motor, or autonomic) are affected. CIPN usually starts in the feet and hands that may spread proximally to arms or legs [179]. It is one of the most common reasons that cancer patients stop treatment early. It can sometimes be lessened by lowering the chemotherapy dose or delaying doses, which might diminish the pain. Other patients report symptoms last long beyond chemotherapy treatment for months or years [153]. Drugs associated with CIPN: ● ● Platinum compounds (cisplatin, carboplatin, oxaliplatin). ● ● Plant alkaloids (vincristine, vinblastine, vinorelbine, etoposide) [17]. ● ● Taxanes (docetaxel, paclitaxel, cabazitaxel). ● ● Epothilones (ixabepilone). ● ● Bortezomib. ● ● Thalidomide. ● ● Lenalidomide [153]. ● ● Eribulin [17].