Reader comments on radiation-induced xerostomia.

I wish to offer comments on “RadiationInduced Xerostomia: How Dry Is Your Patient?” by Susan D. Bruce, RN, BSN, OCN (Vol. 8, pp. 61–67). 1. The author cites dysphasia (multiple times) as an effect of xerostomia. Indeed, difficulty with speech can be a problem. However, dysphagia (difficulty swallowing) is never mentioned in the article. Dysphagia is an almost universal early and late effect of xerostomia and can have a significant effect on nutrition and hydration. 2. The author states that pilocarpine (Salagen, MGI Pharma, Bloomington, MN) usually is used after radiation therapy. The reference is dated 1994. Multiple studies demonstrate efficacy of pilocarpine on radiation-induced xerostomia. In addition, some studies have suggested concurrent pilocarpine and irradiation may be more helpful in reducing xerostomia (Johnson et al., 1993; LeVeque et al., 1993; Zimmerman, Mark, Tran, & Juillard, 1997). 3. The author discusses the importance of teaching patients how to perform vigilant oral care and prophylaxis. However, the implications of noncompliance are not outlined clearly. The rationale for intensive, lifelong dental hygiene and surveillance is because patients with xerostomia are chronically at very high risk for dental caries. The most dreaded complication of dental decay in these patients is osteoradionecrosis (ORN). ORN is not reviewed in the article. ORN can lead to nonhealing, necrotic wounds of the mandible and, to a lesser extent, the maxilla that will lead to extensive disability and potentially the need for mandibular reconstruction. Patients most at risk for ORN are those requiring dental extractions after irradiation. Hyperbaric oxygenation, given both before and after postirradiation dental extractions, has been helpful in reducing the risk and severity of ORN (Davies, 1997; DiazArnold & Marek, 2002). 4. Xylitol-sweetened gum has decreased the incidence of dental caries because of its ability to decrease levels of oral streptococci mutans. Bruce attributed this information to Mautner, Maher, and Zampini, but it should have been attributed to Maher (2003). Review of the literature demonstrates multiple references to the efficacy of xylitol and, to a lesser extent, sorbitol in decreasing caries formation (Hayes, 2001; Hildebrandt & Sparks, 2000; Lynch & Milgrom, 2003). The masticatory effect of chewing gum also is helpful in stimulating any remaining functioning salivary acinar cells. Radiation-induced xerostomia, to the degree it occurs, will be permanent. Xerostomia will result in some functional problems that significantly may impact the ability to perform basic functions. As stated in the article, more studies are needed in the management of xerostomia and quality of life in head and neck cancer survivors. Understanding the multiple implications of xerostomia is an important topic for all oncology nurses.