**4. Protocol for management during RTP**

Patients who are to receive radiation therapy experience three main acute complications that cause functional disability and hinder the development of normal life. These are mucositis, radiodermitis and xerostomia. Weekly monitoring is required, i.e., we must see the patient once a week during the eight weeks that the treatment usually lasts. The main symptoms appear after the fifth dose of radiation. Thus, on each visit, we usually develop the following measurements covered in the protocol.

#### **4.1. RTP protocol**

plan in patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with

**10.** If extractions are recommended [51, 52], the prognosis of the tooth itself, the patient's motivation and their ability to follow oral hygiene instructions plays a role. All teeth with

**•** Moderate and severe periodontal disease (≥ 5 mm bags) especially with advanced bone

**•** Partial impaction or incomplete eruption, especially of third molars, which are not fully

**•** Root fragments that are not completely covered by alveolar bone or show radiolucency.

a questionable prognosis should be extracted before RTP:

covered by the alveolar bone or in contact with the oral cavity.

When developing extractions, patients should be handled as follows [52-54].

**•** Antibiotic prophylaxis for patients who need it, as recommended by the ADA.

**•** Rinse with antiseptic mouthwash - chlorhexidine digluconate 0.12% for one minute.

**•** Minimal trauma - regularization of the alveolar process by approximation of edges.

**•** Post-operative treatment: analgesic-anti-inflammatory medication (ibuprofen 600 mg) and

Most authors agree that the minimum delay time for RTP treatment is 15-20 days [39, 44, 52, 55]. While others indicate that, in the case of complex surgical procedures, patients must wait

**•** Antibiotics, Amoxicillin 750 mg 1/8 hours /7 days is prescribed.

**•** Minimum number of sessions, starting with mandibular extractions.

antiseptic mouthwash, chlorhexidine digluconate 0.12%.

**•** Extensive periapical lesions (if not chronic or well localized).

**•** Active periodontal disease (symptomatic teeth).

loss, mobility and furcation involvement.

**•** Teeth near the tumour or in the tumour.

chlorhexidine.

182 Updates on Cancer Treatment

**•** Caries (non-restorable).

**•** Lack of opposing teeth.

**•** Compromised hygiene.

**•** Anaesthesia with vasoconstrictor.

**•** Non-absorbable 4.0 silk suture.

**•** Anaesthetic technique:

four to six weeks [10, 54].


patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with clorhexidine

During the radiotherapy treatment - and even 18 months later - no surgery technique should be used with these patients and if an endodontic treatment is necessary, dental apex cannot be surpassed. We advise exercises and jaw movements in order to prevent trismus and, in this way, the maximum opening can be kept.

We must insist on instructions on oral hygienic to prevent rampant caries. As these patients suffer from intense pain in the oral cavity, we can advise a soft brush so as not to irritate the mucosa, accompanied by a soft diet and anticariogenic.

Fundamentally, these patients report dryness of the mouth and less saliva. The quality of saliva changes - it feels thicker which causes rampant caries. That, added to the functional disability produced by mucosistis, leads patients to abandon oral hygiene. As a result, their dental status worsens. Therefore, our treatment is based on prescribing oral rinses and insisting on the acquisition of oral hygiene habits. Basically, the purpose of it is to relieve symptoms using a formula. This includes using lidocaine hydrochloride 1% and chlorhexidine digluconate 0.12% before meals to help reduce swallowing pain [56-61].

Patients must drink at least half a litre of water a day to get a good hydration. There is a possibility of cryotherapy, above all in mucositis and occasioned by quimotherapics. There‐ fore, patients must thaw ice in their mouths every 30 minutes [62, 63].

Nowadays, there are saliva substitutes (sprays or gels that temporarily wet the oral mucosa these are palliative) and stimulants (lemon drops, chewing gum with xylitol and sialogogues, among which the pilocarpine is the most important). Pilocarpine is an on-selective cholinergic agonist, which stimulates the salivary secretion. However, in our protocol, it is not recom‐ mended due to its various side effects [64, 65]. We recommend drinking water to hydrate, diet tips and good oral hygiene

As saliva decreases, the sense of taste disappears. Thus, a zinc element can be useful for the restoration of protein responsible for the regulation of pores in taste buds. It is also important to drink an abundance of liquids with meals and to slowly chew. This will liberate flavours and stimulate saliva [32, 66].

As for mucositis, large ulcerations appear in the mucosa of the oropharynx and oral cavity. Curing this disease usually takes three weeks. However, up to two months may pass before they start to subside [15, 56-58, 67]. In terms of management, we must differentiate pain control [68] and functional disability [60, 62, 69] by combining oral solutions (lidocaine hydrochloride 1% and chlorhexidine digluconate 0.12%) and a liquid or soft diet.

The election of treatment in the first phase of ulceration is to prevent infection. This can be achieved through good oral hygiene and antimicrobial agents, such as clorhexidine mouth‐ wash, povidone iodine and hyaluronic acid gels, which form a film that restructures the epitelio. With these measures, the bacteria colonization in injuries with ulcerous mucositis is prevented but its apparition is not [70].

As previously stated, these patients experience a lot of pain and so it is necessary to use antiinflammatories. These include Benzydamine, which is used as a mouthwash and reduces concentrations of tumour necrosis factors. This is efficient in the reduction of intensity and the lasting of injuries in the mucosa [71].

patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with clorhexidine

During the radiotherapy treatment - and even 18 months later - no surgery technique should be used with these patients and if an endodontic treatment is necessary, dental apex cannot be surpassed. We advise exercises and jaw movements in order to prevent trismus and, in this

We must insist on instructions on oral hygienic to prevent rampant caries. As these patients suffer from intense pain in the oral cavity, we can advise a soft brush so as not to irritate the

Fundamentally, these patients report dryness of the mouth and less saliva. The quality of saliva changes - it feels thicker which causes rampant caries. That, added to the functional disability produced by mucosistis, leads patients to abandon oral hygiene. As a result, their dental status worsens. Therefore, our treatment is based on prescribing oral rinses and insisting on the acquisition of oral hygiene habits. Basically, the purpose of it is to relieve symptoms using a formula. This includes using lidocaine hydrochloride 1% and chlorhexidine digluconate 0.12%

Patients must drink at least half a litre of water a day to get a good hydration. There is a possibility of cryotherapy, above all in mucositis and occasioned by quimotherapics. There‐

Nowadays, there are saliva substitutes (sprays or gels that temporarily wet the oral mucosa these are palliative) and stimulants (lemon drops, chewing gum with xylitol and sialogogues, among which the pilocarpine is the most important). Pilocarpine is an on-selective cholinergic agonist, which stimulates the salivary secretion. However, in our protocol, it is not recom‐ mended due to its various side effects [64, 65]. We recommend drinking water to hydrate, diet

As saliva decreases, the sense of taste disappears. Thus, a zinc element can be useful for the restoration of protein responsible for the regulation of pores in taste buds. It is also important to drink an abundance of liquids with meals and to slowly chew. This will liberate flavours

As for mucositis, large ulcerations appear in the mucosa of the oropharynx and oral cavity. Curing this disease usually takes three weeks. However, up to two months may pass before they start to subside [15, 56-58, 67]. In terms of management, we must differentiate pain control [68] and functional disability [60, 62, 69] by combining oral solutions (lidocaine hydrochloride

The election of treatment in the first phase of ulceration is to prevent infection. This can be achieved through good oral hygiene and antimicrobial agents, such as clorhexidine mouth‐ wash, povidone iodine and hyaluronic acid gels, which form a film that restructures the epitelio. With these measures, the bacteria colonization in injuries with ulcerous mucositis is

way, the maximum opening can be kept.

184 Updates on Cancer Treatment

mucosa, accompanied by a soft diet and anticariogenic.

before meals to help reduce swallowing pain [56-61].

tips and good oral hygiene

and stimulate saliva [32, 66].

prevented but its apparition is not [70].

fore, patients must thaw ice in their mouths every 30 minutes [62, 63].

1% and chlorhexidine digluconate 0.12%) and a liquid or soft diet.

There are cytoprotective agents that eliminate free radicals acting as antioxidants. In this group, we have amifostine, prostaglandins and sucralfalte. The amifostine is a protector against the xerostomia during the radiotherapy treatment. It reduces its gravity and duration. However, it has multiple adverse effects and so its use is limited [72, 73]. Sucralfate adheres to the walls of the ulcer and constitutes a superficial barrier in the gastrointestinal tract. As a result, the oropharingeo pain is reduced but mucositis is not prevented. Sucralfate has some antibacterial activity so it aids the healing of injuries and stimulates the synthesis of the prostaglandins [74-77].

It is difficult to specify which treatment should be elected as each patient responds differently to radiotherapy. Our experience is that chlorexidine and hyaluronic acid [78] do no aid aggressive injuries. Thus, in different cases of mucositis III and IV, we recommend the use of, topic corticoids, mainly 0.5% Triamcinolone Acetonid, three times a day for three weeks. We also recommend oral rinses or creams, depending on whether the injuries are unique or multiple. The injuries develop favourably but as it is a corticoid, we have to suspend it gradually [79, 80]. Keefe et al. affirm that the high-level mucositis pain can be relieved with potent analgesic such as opiaceous [81].

Furthermore, we reviewed written studies on this subject and found that there are currently no published articles referring to the association between the administration of cortisone and the presence of recurrences in the head and neck. Moreover, if there are references in other locations, such as the prostate or the skin, it remains the treatment of choice [82-84].

Nowadays, there are new therapies (biological response modifiers) conducted in the investi‐ gation phase. These eliminate the mucositis, mainly reducing the minimum development of the mucositis and, specifically, various growth factors. They also contribute to the biological process of mucosity destruction [85]. In this group, we mention palifermine keratinocyte growth factor. In advanced degree cases, this sees reduced mucositis but has secondary effects and thus, its use is restricted [86-88].

Low-energy laser therapy is an effective method for the prevention and management of mucositis. It is used to accelerate the regeneration of tissues and stop swelling and pain [89-92].

It is also important to get a basic medium so that there is no mycosis. Thus, as a preventative measure, we recommend bicarbonate water rinses before meals (dilute a spoonful of bicar‐ bonate in 200 ml of water). Additionally, in the case of candidiasis, the treatment of choice is Nystatin (topical antifungal). Here, we suggest rinsing three times a day, for three minutes over a period of four weeks. Optimal oral hygiene is crucial in order to reduce the risk of oral mucositis [89]. In cases that do not respond to the topical treatment or severe infections, we recommend systemic antifungal such as fluconazole, 150 mg. - daily doses for two weeks [93]. Little can be done to improve the toxicity of the skin, aside from moisturizing several times a day and not covering the area so it does not keep moisture. We also recommend leaving it to air dry.

Patients usually experience weight loss due to difficulties in swallowing caused by mucositis. Taste alterciones causes a loss of appetite and dietary recommendations are necessary.

