Risk Factors

Patients should be assessed for OM risk factors prior to starting treatment. Risk factors for OM are broadly categorized as treatment-related or patient-related.11 Some data suggest children and older patients are at greater risk for OM.6,13,14

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Other patient factors said to increase the risk of OM include poor oral hygiene; periodontal disease; salivary gland dysfunction/dry mouth (possibly due to other medications); low body mass index; renal and hepatic function; and comorbid diseases, such as psoriasis and diabetes.3,15-17 Certain genetic polymorphisms may also predispose patients to OM.3,11,17 Treatment alone carries such an overwhelming risk for patients undergoing high-dose chemotherapy prior to HSCT or radiotherapy for HNC that the role of patient risk factors is marginalized.11

Several chemotherapy agents predispose patients to developing OM, including 5-fluorouracil (5-FU), bleomycin, busulfan, capecitabine, carboplatin, cisplatin, doxorubicin, etoposide,  ifofsamide, irinotecan, leucovorin, methotrexate, oxaliplatin, paclitaxel, vincristine, and vinorelbine.3,14,18In addition to type of chemotherapy, the drug dose, schedule, route of delivery, and concomitant therapies also affect risk.1 For patients undergoing radiation, risk of OM depends on dose, fractioning, and targeted location.14 Advances in radiation technology have not helped reduce the incidence of OM in patients with HNC.18 However, use of midline radiation blocks or 3-dimensional radiation may reduce mucosal injury.18

Mucosal barriers are the first line of defense against pathogenic invasion. Disruption of the mucosal lining places patients at increased risk of opportunistic infections, which can be life-threatening for some patients.15 Immunosuppressed patients with neutropenia and OM have an especially high risk of potentially life-threatening infection.10 All patients with an elevated risk of OM should be assessed before starting treatment and followed closely during treatment for signs and symptoms of OM and infection.18