Oral complications of cancer

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Abstract

SIR,-Dr G E Murty and colleagues are of course correct'-we encourage our patients to stop smoking and drinking alcohol not only during radiotherapy and chemotherapy but long term as these habits undoubtedly contribute to the development of multiple primaries in head and neck malignancy.2 Sadly it is our experience that, although patients with bronchial carcinoma almost invariably stop smoking when the diagnosis is confirmed, few of our patients with head and neck malignancies heed the advice. It is undoubtedly true that osteoradionecrosis is not primarily an osteomyelitis but is an ischaemic necrosis of bone which may become secondarily infected when, for example, a tooth is extracted. The technique of interseptal alveolectomy that Mr Hutchison advocates' seems to us to be too invasive to these compromised tissues. To close tooth sockets so as to obtain primary mucosal cover not only does interseptal bone have to be removed but also the buccal and lingual alveolar bone plates must be fractured. This in itself demands considerable healing and remodelling of an already compromised ischaemic bone. Furthermore, in our experience it is very unusual to need to extract more than a single tooth after radiotherapy in these patients. Perhaps this is because we assess the dental state before treatment and extract any doubtful teeth at that stage. We also arrange for regular dental supervision after treatment. Certainly an alveolectomy cannot be performed for single tooth sockets. We cannot agree that presurgical loading with oxytetracycline is illogical. The reason for selecting oxytetracycline is not that it is a broad spectrum antibiotic but because it is chelated to bone and produces high concentrations within the skeleton. The rationale for presurgical loading is that we know of course that the irradiated jaws are ischaemic and so on empirical grounds alone it seems sensible to preload the area with antibiotic before surgery. As stated in our editorial we use metronidazole at the time of surgery and for the immediate postoperative period. What is certainly true is that, in our hands, this regimen has almost completely eliminated cases of symptomatic osteoradionecrosis requiring resection or reconstruction with or without hyperbaric oxygen.