• This manual is not a substitute for consultation with an appropriate specialist.
• The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.

Updated: July 2006

Vancouver Cancer Centre tel: 604.877.6136
Fraser Valley Cancer Cetre tel: 604.930.2098
Cancer Centre for the Southern Interior: 250.712.3919

Find patient information about mouth cancer​.

For Patients Receiving Chemotherapy for Any Malignancy

Approximately 40 percent of patients receiving chemotherapy will experience oral complications. The majority of patients with leukemia and those who receive a bone marrow transplant will develop oral com­plications. Research shows, however, that fewer problems develop when oral disease is eliminated, when an oral prophylaxis is performed prior to the initiation of chemotherapy and when excellent oral hygiene is maintained throughout therapy.

For Patients Receiving Radiation Therapy to the Oral Cavity and/or Salivary Glands

Radiation therapy to the head and neck, which includes the salivary glands and/or the oral and pharyngeal tissues, may result in acute side effects that include taste loss, mucositis, infection and decreased sali­vary flow. Long-term, permanent side effects may include xerostomia, "radiation caries," trismus, soft tissue breakdown and failure to heal, and osteoradionecrosis (ORN).

Objectives

The objectives of an oral/dental program for the cancer patient are to:

1. Improve and maintain oral hygiene in order to reduce the risk and severity of oral complications.
2. Eliminate oral infection and prevent potentially fatal systemic infections of dental origin.
3. Prevent, eliminate or control pain in the oral cavity.
4. Maintain or improve oral status and prevent destruction of the dentition.
5. Assist with maintaining adequate nutrition.
6. Provide reconstruction and/or rehabilitation following surgical procedures.
7. Prevent or reduce the incidence of bone necrosis secondary to radiation of jawbones.
8. Improve quality of life.

​Updated: May 2003

Oral Manifestations of Chemotherapy

Complications arise from the direct cytotoxic effects of chemotherapeutic agents on oral tissues and/or from the indirect effects of myelosuppression. Oral manifestations are related to the drug protocol (type of drugs, dose and duration), the patient's mucosal integrity, and oral and systemic status. The reactions are often highly individualized.

Mucositis and Ulceration

The gastrointestinal mucosa (GI), because of its high cellular turnover rate, is highly susceptible to the toxic effects of many chemotherapeutic agents. Inflammation and ulceration of the mucosal lining of the mouth, pharynx, esophagus and the entire CI tract may occur. The patient may experience pain, nausea, vomiting and diarrhea. Medications commonly associated with mucositis include: bleomycin, cytarabine (Ara-C), dactinomycin, daunorubicin, doxorubicin (Adriamycin), 5-fluorouracil (5-FU) and methotrexate. Other agents may also be cytotoxic.

Infection

Many drugs induce leukopenia, which can result in an increased risk of infections. The usual clinical signs of inflammation (redness, pain, swelling, heat) may not be present during periods of significant immunosuppression.

If pain is present, the symptomatic areas of possible infection (operculum, periodontal pockets or mucosal ulcerations) should be cultured if the patient develops a fever of unknown origin. Infection may be caused by organisms usually found in the mouth such as candida species, herpes simplex, streptococci and staphylococci. Infections may also be caused by opportunistic organisms not commonly found in the mouth such as aspergillus, mucor, gram-negative bacilli and coliform bacteria. Candidiasis may have the typical appearance of soft white plaques or present as generalized erythematous painful tissue. Angular cheilosis is a common candida-related oral manifestation. Oral infections may lead to systemic infection or sepsis and can be life threatening.

Neurotoxicity

The patient may present with constant, deep pain that is often bilateral and frequently mimics toothache (odontalgia), but no odontogenic or mucosal source can be found. This phenomenon may occur after the administration of drugs such as vincristine and vinblastine.

Xerostomia

Patients may complain of decreased or thickened saliva. The duration of xerostomia is associated with the length of therapy, other prescribed medications and the health of the patient. Xerostomia may result in a lowered pH, alterations in the constituents of the saliva, and it may lead to rampant dental caries. A dry mucosa is more susceptible to pain, infections and irritation.

Taste Alteration

Transient alteration in taste is common after the administration of some chemotherapeutic drugs.

Bleeding

Reduction of platelets (thrombocytopenia) and other clotting factors during periods of bone marrow suppression are the major causes of bleeding. Transfusion of platelets and/or clotting factors in conjunction with topical agents may be necessary for control.

Dental Developmental Abnormalities

Chemotherapy administered during dental development in childhood may cause shortened or malformed roots, enamel defects, disturbance in crown development and eruption.

​Published: May 2003

Oral/ Dental Evaluation and Treatment Plan

The objective of pre-chemotherapy dental treatment is to eliminate existing infection and to manage potential sources of infection and sites of trauma. The evaluation should include oral hard and soft tissue examination, including periodontal evaluation and necessary radiographs.

Treatment and Maintenance of Teeth

Patients with hematologic malignancies may be immunosuppressed and thrombocytopenic prior to administration of chemotherapy. Dental treatment should be scheduled in consultation with the oncologist.

For all patients, eliminate any area of infection or irritation, such as teeth with fractures, fractured restorations, advanced carious lesions, pulpal or periapical involvement, periodontal inflammation, pericoronitis, or ill-fitting prostheses.

Orthodontic bands should be considered for removal if highly stomatotoxic chemotherapy is expected to be administered. The decision should be made in consultation with the oncologist. Institute periodontal disease control measures that include plaque control, and if possible, a full dental prophylaxis. Patients who continue to maintain excellent oral hygiene throughout therapy may have fewer complications.

Provide oral hygiene instruction, including use of an extra-soft nylon-bristle toothbrush and dental floss, and arrange for ongoing supervision of hygiene during cancer therapy.

Review dietary recommendations to limit highly cariogenic foods without compromising adequate caloric intake.

Additional Needs of Children

Evaluate the dentition and estimate exfoliation time of primary teeth. Remove mobile primary teeth as well as those expected to be lost during the chemotherapy.

Consider removal of gingival opercula if there is a clinical risk for entrapment of food debris and/or nidus for infection, particularly if the area has previously been symptomatic.

Published: May 2003

The most appropriate time to schedule dental treatment during chemotherapy is after patients' blood counts have recovered, usually just prior to their next scheduled round or course of chemotherapy. If oral surgery is required, it should be scheduled to allow 7-10 days of healing prior to the anticipated date of bone marrow suppression. It is imperative that the dentist seek consultation with the oncologist prior to any dental procedure, including prophylaxis. Blood work should be ordered the day before the dental treatment to document hematologic status.

Important Information Includes:

Clotting Factors

Hemorrhage may be a complication when the platelet count is <50,000/mm³ or with abnormal clotting factors (PT, PTT, fibrinogen).

Absolute Neutrophil Count*

Risk of infection and septicemia is high when the absolute neutrophil count is <1,000/mm³. Patients receiving immunosuppressive chemotherapy will usually reach their "nadir" (the lowest blood counts) 7-14 days after initiation of therapy.

Dental treatment can be performed after the neutrophil count has begun to rise from the nadir and has reached a level of 1,000/mm³ or above. If a dental procedure is necessary and the neutrophil count is less than 1,000/mm³, the oncologist must be consulted concerning antibiotic coverage. Extensive invasive oral procedures should not be performed if the absolute neutrophil count will be <1,000/mm³ within 10-14 days of the oral procedure.

Normal Complete Blood Count

* Absolute Neutrophil Count – total WBC x (% "Segs" + % "Bands")

Indwelling Central Venous Catheter

Some patients are given chemotherapy through a catheter placed in a major vein. Because catheters may become colonized with bacteria that enter the blood during dental procedures, it is recommended that these patients receive the American Heart Association endocarditis prophylactic antibiotic regimen prior to an invasive dental procedure, including dental prophylaxis. Physician consultation is recommended.

Oral Hygiene Care

Excellent oral hygiene must be maintained. An oral hygiene program must be individualized for each patient and modified throughout therapy according to his or her medical status.

To foster compliance the patient must understand the risks of septicemia from poor oral hygiene. The patient should be taught a very gentle but effective toothbrushing technique.

During periods of neutropenia and/or thrombocytopenia (ANC < 1000/mm³ and/or platelet count of <50,000/mm³) optimum plaque control measures may necessitate gentle oral lavage, increased baking soda-saline rinses, toothbrush bristles softened in hot water or the use of a super-soft toothbrush. Sponge Toothettes, gauze and/or cotton tipped applicators do not adequately remove plaque and should be supplemented with other measures. Dipping a sponge Toothette in chlorhexidine rinse may increase effectiveness. Regular toothbrushing and flossing should resume as soon as possible. Toothbrushes should be changed frequently and/or disinfected in chlorhexidine. During periods of severe neutropenia, the patient should also be cautioned about eating crunchy or sharp foods that may damage friable oral tissues. Toothpicks should not be used.

Alcohol-based mouthwashes and full-strength peroxide solutions or gels should not be used due to their drying and irritating effects. Use of all diluted peroxide solutions should be limited to the removal of adherent debris; long-term use may disrupt the normal oral flora. Peroxide solutions are acidic and, if used, should be followed by a neutralizing rinse, such as a bicarbonate water solution.

The prophylactic use of chlorhexidine rinse may be helpful in suppressing bacterial colonization but should not replace mechanical removal of plaque with a toothbrush. The patient should be monitored closely and evaluated regularly to determine the benefit of the rinse versus the risk for irritation and/or drying of tissues.

The mouth may be rinsed with a baking soda-saline solution and followed by a plain water rinse several times a day. The solution is prepared by mixing 1-2 tsp(s) of baking soda and 1/2 tsp of salt with one quart of water. The salt may be eliminated according to patient preference. This solution may be put in a disposable irrigation bag and hung overhead to allow the solution to flow through the mouth. The solution must not be swallowed.

Patients who experience frequent emesis should be encouraged to rinse thoroughly with a baking soda and water solution. Brushing the teeth without first neutralizing the gastric acids in the mouth may result in etching of the enamel.

Edentulous patients must not wear dentures while they sleep or when their dentures irritate ulcerated mucosal tissues. Dentures must be brushed daily with a denture brush and soaked in an antimicrobial cleanser or mild detergent. An effective soaking solution for dentures without metal parts is made by mixing one-teaspoon chlorine bleach, two teaspoons Calgon water softener and one cup of water. After brushing and soaking, the dentures should be rinsed well and stored in clean water or a fresh chlorhexidine solution. Edentulous patients should cleanse their tongue and oral tissues with gauze or a soft toothbrush.

Measures for the prevention of tooth demineralization are required only when xerostomia persists for longer than six weeks. It is recommended that a 1.1% neutral pH sodium fluoride or 0.4% unflavored stannous fluoride be brushed on the teeth or applied in custom-made gel applicator trays. A neutral pH fluoride gel should be used by patients with porcelain crowns. Acidulated fluoride should not be used (refer to page 9 for gel application directions).

Routine Dental Care

Routine dental care may be provided as the patient's hematologic status permits.

Infection Control

Culture all suspicious lesions for infection (bacterial, fungal and/or viral). Prescribe treatment in cooperation with the oncologist. Exfoliative cytology or ELISA may be performed for rapid identification of the herpes virus. If positive, acyclovir may be administered to prevent progression of the lesions. For fungal infections, patients should be aware that topical antifungal agents are efficacious only when in contact with the lesions and are used for the prescribed time period. Use of a sugar-free antifungal should be considered if extended use is necessary or if the patient is caries-prone.

Orthodontic Bands

If bands are not removed prior to chemotherapy, soft wax or a plastic mouthguard may cover them during periods of oral inflammation or ulceration.

Dental Management – Following Chemotherapy

At the completion of all planned courses of chemotherapy, closely monitor the patient until all side effects of therapy have resolved, including immunosuppression. The patient may then be placed on a normal dental recall schedule. Since these patients may need to undergo additional myelosuppressive therapy if they relapse in the future, it is very important to maintain optimal oral health.

Children should receive close lifetime follow-up, with specific attention to growth and development patterns.

Published: May 2003

Radiation therapy is associated with a variety of side effects that vary according to total dosage, rate of radiation delivery, fraction size, field of radiation, radiation source, previous surgical intervention and individual patient status. Patients receive radiation therapy to the oral cavity and/or salivary glands for the treatment of tumours in the oral cavity, oropharynx, nasopharynx, larynx and salivary glands, and for the treatment of lymphomas and leukemias. Patients may undergo radiation therapy for 3-7 weeks with a total dose ranging from 3,000 to >7,000 centigray (cGy), depending on tumour type and location. Hodgkin's and non-Hodgkin's lymphomas require less radiation than other solid tumours of the head and neck.

Taste Loss

Alteration and loss of taste may begin with the first 200-400 cGy. After three weeks of therapy, it takes 500-8,000 times normal concentrations of taste stimulant to elicit a normal taste response. Taste acuity levels usu­ally return to normal 2-4 months following completion of therapy, if adequate saliva is available.

Xerostomia

Salivary gland acini within the field of radiation may be permanently destroyed during therapy. Saliva is reduced in volume and altered in consistency. Reduction is dependent upon the total dose of radiation, degree of salivary gland involvement in the field of radiation, and individual patient variables. Flow may be reduced 50% by the end of the first week, and further reduction in volume (up to 100%) may occur. The sali­va produced is more mucinous and acidic, and it may distribute less easily throughout the mouth. Salivary gland tissue does not recover from radiation damage, although some patients may perceive an improvement in salivary output over time.

Mucositis

The mucosa becomes edematous, erythematous, pseudomembranous, and sometimes ulcerated. Pain varies considerably in severity and may be intensified by certain foods. The patient may develop problems in swallowing and speaking. Mucositis usually occurs after the second week of radiation therapy. The lips, buccal mucosa, soft palate, borders of tongue and floor of mouth are at greater risk of mucositis. Severe symptoms usually resolve within six weeks following completion of therapy.

Infection

Secondary infections are common. While candidiasis is most common, all bacterial, mycotic and viral organisms may cause infections.

Nutritional Deficiency

Eating difficulty caused by xerostomia, mucositis and dysphagia may lead to nutritional compromise and dehydration.

Dental Demineralization/"Radiation Caries"

Rapid demineralization and breakdown of tooth structure may occur following radiation therapy. The process may be recognized early after treatment. The teeth need not be in the direct field of radiation thera­py. Demineralization results when the parotid and/or submandibular/sublingual glands are included in the field of radiation. A diminished supply of saliva, particularly of resting flow from the submandibular/sub­lingual glands, deprives the oral cavity of the protective components of saliva and the tooth structure of the calcium and phosphate ions necessary to maintain the hydroxyapatite content of enamel and dentin. Although some patients do not clinically appear to be xerostomic after radiation therapy, they may experi­ence a change in the quality of their saliva, leading to rapid dental demineralization. Even a 25% decrease in saliva may result in dental breakdown.

Trismus

Spasms and/or fibrosis of the muscles of mastication and temporomandibular joint may develop when the muscles and/or TMJ are in the field of radiation. This may impair saliva circulation and interfere with oral hygiene procedures and dietary intake.

Soft tissue necrosis/Osteoradionecrosis (ORN)

Soft tissue and bone necrosis may develop because tissues within the field of radiation become hypovas­cular, hypoxic and hypocellular. This process may be spontaneous or result from trauma, leading to non-healing soft tissue and bone lesions, and necrosis. Trauma may result from tooth extraction, invasive peri­odontal procedures and intraoral prosthetic appliances. The mandible is much more susceptible to ORN than the maxilla. The non-healing bone may become secondarily infected.

Developmental Maxillofacial Deformity

Children who receive radiation therapy to facial bones and developing dental structures may experience altered craniofacial growth and tooth development. The degree of deformity depends on the dose of radia­tion therapy and the age of the child at the time of therapy.

Long-Term Effects of Radiation Therapy

Although patients receiving radiation therapy will experience dramatic resolution of the acute effects following the completion of treatment, the long-term effects are progressive and significant. Fibrosis of tissues and hyalinization of blood vessels contribute to decreased perfusion of tissues that intensifies with time.

Published: May 2003

Pre-radiation therapy dental appointments should establish a dentition that the patient will be able to maintain for the rest of his or her life. The evaluation should consider the patient's previous interest in oral health, as well as current motivation to comply with a rigorous and lifelong preventive oral health program. The financial commitment of the preventive measures and the costly reality and complications of non-com­pliance should be strongly emphasized.

All hopeless and questionable teeth (i.e. teeth with furcation involvement or advanced periodontitis, or teeth that are impacted, nonessential or nonrestorable), implants with questionable prognosis, root fragments and other bone pathology within the field of radiation should be removed prior to radiation. Since osteoradionecrosis has been reported to develop in irradiated jaws as late as 25 years following radiation therapy, serious consideration must be given to the extraction of any teeth that may be a problem in the future. Total odontectomy, followed by alveoloplasty or alveolectomy should be performed on patients with minimal potential for maintaining adequate oral hygiene, a significant percentage of non-restorable teeth and/or severe periodontitis.

Oral Surgery

Extractions and surgery, with tension-free primary tissue closure and antibiotic coverage, should be performed to allow at least 14 days of healing prior to initiation of radiation therapy. The precise time interval depends upon the extent of surgical insult and the philosophy of the treatment center.

Pre-prosthetic surgery, including removal of interfering tori and exostoses, should be performed at this time since additional surgical procedures are contraindicated on irradiated bone.

Prosthodontic Evaluation

Proper evaluation of existing removable prostheses is essential. The patient should leave appliances out of the mouth as much as possible during the period of therapy, especially if mucositis develops. New prosthe­ses should not be constructed for at least 3-6 months following radiation, depending upon the integrity of the mucosa, severity of xerostomia and surgical scarring.

Temporomandibular Disorders

Patients with temporomandibular disorders can experience increased complications during and after radi­ation therapy to the head and neck. Conservative management should be planned at the time of the pre-­therapy evaluation.

Additional Needs of Children

Evaluate the dentition and estimate the exfoliation of primary teeth. Remove mobile teeth. Remove gingival operculum if there is a risk for entrapment of food debris or infection.

Tobacco Cessation

Patients who use tobacco should be advised to quit. Response to radiation therapy is improved in individ­uals that do not smoke. Facilitation in the quitting process may involve referral for cessation counseling or to a support group and, when appropriate, nicotine replacement therapy.

Dietary Counseling

Analyze and modify the patient's daily dietary habits to eliminate highly cariogenic foods and drinks without compromising adequate caloric intake. Aggressive use of over-the-counter medications high in sugar content should be discouraged.

Treatment and Maintenance of the Teeth

Provide periodontal care, including prophylaxis and home care instruction.

Perform high priority restorations and eliminate sites of irritation.

Remove orthodontic bands if they are within the field of radiation.

To prevent demineralization of tooth structure, "radiation caries," the minerals normally provided by saliva must be replaced on a daily basis for the rest of the patient's life. The presence of fluoride ions enhances the teeth's ability to uptake calcium and phosphate ions; therefore, fluoride gel, and on occasion a calcium phosphate remineralizing gel, should be applied to the teeth in custom gel-applicator trays.

Several days before the initiation of radiation therapy, patients should begin their daily five-minute application of a fluoride gel. Acceptable fluoride gels include a 1.1% neutral pH sodium fluoride or a 0.4% stan­nous fluoride (unflavored). A neutral pH fluoride should be used by patients with porcelain crowns. Fluoride rinses do not provide adequate fluoride coverage of teeth to prevent demineralization.

Custom Gel-Applicator Trays

Custom gel-applicator trays are fabricated on a vacuform machine using a flexible vinyl mouthguard material. The trays should completely cover all tooth structure. The edges should be tapered to reduce bulk­iness and should be smoothed with either a rag wheel or felt cone or it can be flamed. To prevent the risk of soft and/or hard tissue necrosis, the trays must not irritate the gingival or mucosal tissues.

The adaptation of the trays to cervical margins of the teeth should be checked and modified from time to time, as this thermoplastic material will gradually lose intimacy of fit.

Patient Instruction for Gel Application

1. Brush and floss teeth thoroughly.
2. Place a thin ribbon of fluoride gel (or calcium-phosphate remineralizing gel) in each gel tray.
3. Place the gel trays on teeth and leave in place for approximately five minutes. If the gel oozes from the tray, too much gel has been used.
4. Remove the trays from the mouth and expectorate excess gel. Do not rinse mouth. Rinse trays thoroughly with water.
5. Do not eat or drink for 30 minutes following applications.

*Many people find it convenient to apply fluoride while showering or bathing.

​ Published: May 2003

Dental Treatment

Restorative treatment not accomplished prior to radiation therapy may be performed during the first two weeks of radiation or until the patient begins to experience mucositis.

Infection Control

Ulcerations and dry, friable tissues may easily become infected. Culture suspected infections and prescribe treatment in cooperation with the radiation oncologist. Fungal infections should be treated with a topical antifungal agent, preferably one without sugar.

Dietary Counseling

Guidance in food selection should be offered in order to maintain the patient's nutritional status and to control caries.

Trismus

When the muscles of mastication are in the direct field of radiation, instruct the patient to exercise the muscles three times daily by opening and closing the mouth 20 times as far as possible without causing pain. Opening against gentle pressure generated by placing the hand against the midline mandible may also be helpful. This exercise may lessen the degree of trismus experienced by the patient.

Patient Home Care

Excellent oral hygiene must be maintained. The teeth should be brushed with an extra-soft nylon bristle toothbrush after each meal and at bedtime. Dental floss should be used daily. If the oral tissues become painful, the mouth may be rinsed with a topical anesthetic before brushing. Softening the toothbrush in hot water before use may be helpful. Plaque may be wiped from the oral tissues with gauze moistened in a bak­ing soda-saline solution. Water irrigating devices should be used only on the lowest setting. Sharp objects should not be put in the mouth.

The mouth must be kept as moist and clean as possible to reduce development of infection and pain. Over-the-counter alcohol-based mouthwashes and full-strength peroxide should not be used due to their drying and irritating effects. Long-term use of diluted peroxide solutions may disrupt the normal oral flora.

The mouth should be rinsed with a baking soda-saline solution frequently throughout the day, followed by a plain water rinse. The solution may be prepared by mixing 1-2 tsp(s) of baking soda and 1/2 tsp of salt with one quart of water. Salt may be eliminated according to patient preference. This solution may be put in a disposable irrigation bag and hung overhead to allow the solution to flow through the mouth. The solution must not be swallowed.

Daily fluoride gel applications in custom gel-applicator trays should continue unless pain from mucositis becomes significant. As soon as the mucositis resolves, the patient should resume daily gel application.

Patients should not wear removable prostheses if any irritation, mucositis or ulceration develops. Some radiation oncologists request that the patient not wear dentures throughout the entire therapy period. Dentures should be cleansed daily and soaked in an antimicrobial denture-soaking solution. When out of the mouth, they should be stored in clean water that is changed daily. Denture adhesives should not be used.

Suggestions for symptomatic relief of xerostomia and mucositis pain should be offered to the patient.

​Published: May 2003

Dental Recall/Restorative Treatment

Following completion of all radiation therapy and resolution of the acute oral side effects, the patient should be placed on a dental recall schedule at intervals appropriate to the maintenance of excellent oral sta­tus. A typical recall frequency for prophylaxis and home care evaluation may be every four to eight weeks for the first six months following radiation therapy. The frequency of recall visits should be adjusted accord­ing to the needs of the individual patient.

Perform restorative dental procedures as needed. Consideration should be given to the use of glass ionomer and resin-bonded restoration of remineralized tooth structure. The prophylactic bonding of sealant resins to remineralized tooth structure may be beneficial. (See next section on remineralizing gels). For the pediatric patient, consideration should be given to restoration with stainless steel crowns.

Control of Demineralization/Patient Home Care

Patients may believe that, over time, saliva levels have recovered. However, it is well documented that the quantity and/or quality of saliva is typically permanently compromised and never recovers to normal val­ues. Therefore fluoride gel applications must be continued at a frequency sufficient to maintain tooth mineralization. This may require lifelong daily application(s) of either a 1.1% neutral sodium fluoride or a 0.4% stannous fluoride. A neutral pH fluoride should be used by patients with porcelain crowns.

For patients with early or persistent enamel breakdown, remineralization of teeth may be achieved by reg­ular application of a calcium phosphate remineralizing gel in gel-applicator trays. Applications are made after tooth cleansing procedures have been completed. In the severely xerostomic patient, these procedures should be completed after every meal and before retiring to bed, in addition to a daily fluoride application. Frequency can rarely be reduced because xerostomia is usually lifelong. Patients with enamel breakdown, but who demonstrate compliance with oral hygiene procedures and gel applications, may need a dietary analysis to assist with the elimination of cariogenic foods or oral medications. Chlorhexidine products may help control cariogenic bacterial plaque.

Continue assistance with the palliative management of xerostomia and the identification and treatment of oral infections.

Monitor patient for evidence of trismus. Encourage daily jaw exercises.

Prosthodontics

Prosthodontic appliances may be constructed after the mucositis has resolved and integrity of the oral tis­sues has been reestablished. Appliances must be carefully adjusted to prevent tissue irritation and the initiation of soft or hard tissue necrosis. Some patients may never re-acquire the ability to tolerate a tissue-borne prosthe­ses because of friable tissues and xerostomia.

For the comprehensive management of major dental breakdown, or of significant prosthetic need, referral to a maxillofacial prosthodontist with experience in the treatment of cancer patients is indicated when possible.

Oral Surgery

Invasive surgical procedures involving exposure of irradiated bone should be avoided if at all possible, due to risk for osteoradionecrosis. If tooth extraction is unavoidable, extreme caution must be exercised. Conservative surgical technique, antibiotic coverage for at least two weeks post-operatively, and the use of hyperbaric oxygen therapy for tissue preparation may all be essential to assure complete healing. Alternatives to tooth extraction include coronal amputation and root canal therapy

Children

Following radiation therapy to the craniofacial and dental structures, children should be closely monitored by a dental specialist in growth and development.

Published: May 2003

Bone marrow transplantation (BMT) for the treatment of leukemias, aplastic anemias, lymphomas and some solid tumours is becoming more common. Intensive chemotherapy with or without total body irradiation is administered to eliminate malignant cells and immunosuppress the patient. Following the intensive therapy, the bone marrow is restored by infusing bone marrow or peripheral blood stem cells (PBSC) into the patient through a central venous catheter. The dental team plays a significant role in the management of these patients because pre-existing dental disease may lead to significant infections during and after the transplant, thus compromising the success of the procedure and possibly resulting in sepsis and death.

Types of Transplants

Autologous - the patient's own bone marrow and/or PBSC are removed and preserved;

Allogeneic - bone marrow and/or PBSC are donated by a family member or individual identified through a computer data bank. Techniques are used to match the cell-surface markers to reduce the risk of complications and graft-versus-host disease;

Syngeneic - bone marrow and/or PBSC are taken from an identical twin.

Oral Complications

During initial phases of the transplant, the patient is at risk for developing significant oral sequelae, including oral mucositis and ulcerations, hemorrhage, infections (fungal, viral and bacterial) and xerostomia. The acute oral complications begin to resolve when engraftment is achieved and the hematologic status begins to improve. The initial intensive therapy may result in immunosuppression for up to one year post-BMT.

Graft-Versus-Host Disease (GVHD)

Allogeneic bone marrow transplant patients are at risk for developing acute and chronic GVHD. Associated GVHD oral complications may include mucositis, mucosal atrophy, ulcerations, and oral infec­tions including candidiasis; immune-related complications, including lichenoid reactions, scleroderma and lupus-like changes (limited oral opening and tongue mobility); and xerostomia with secondary rampant dental breakdown. GVHD and its medical management may cause significant immunosuppression.

Oral/Dental Management Prior to BMT

Elimination of all oral sources of infection and irritation is the goal of pre-BMT dental evaluation and treatment. Dental treatment should be scheduled in consultation with the oncologist. If the patient has a central venous catheter, prophylactic antibiotics should be prescribed in consultation with the physician prior to the dental appointment.

If oral surgery is required, at least 7-10 days of healing should be allowed before the anticipated date of bone marrow suppression (eg: ANC of <1000/mm³ and/or platelet count of < 50,000/mm³).

Dental prophylaxis and oral hygiene instruction may have a significant positive impact on the severity of the oral complications. Patients scheduled for total body irradiation and/or allogeneic transplant should be taught an effective toothbrushing technique to apply fluoride gel on their teeth or, if necessary, study models should be made for fabrication of custom fluoride gel‑applicator trays.

It should be remembered that many of these patients will remain immunosuppressed for up to a year and will be at risk during selected post-transplant dental treatment.

​ Published: May 2003

Intensive oral hygiene measures should be continued to ensure adequate plaque control and reduce the risk of rampant dental breakdown and oral infections. Daily fluoride (rinse or gel) may be necessary until salivary function recovers. Most patients conditioned with total body irradiation who do not develop chron­ic GVHD will recover normal salivary function 3-12 months post‑therapy.

Invasive dental procedures should only be planned following consultation with the patient's oncolo­gist and/or the bone marrow transplant center's dentist. Elective procedures should be delayed approxi­mately one year. Patients with chronic GVHD may experience long-term oral and systemic complications and present with difficult dental management problems. Children may experience altered craniofacial growth and tooth development. Post-bone marrow transplant patients and patients on long-term immuno­suppressive drugs are at risk for second malignancies.

Published: May 2003

Palliative Measures for Xerostomia and Pain

There is no one product that has demonstrated complete effectiveness in the relief of xerostomia and pain. A clean, well-hydrated mouth may prevent exacerbation of the complications associated with cancer therapies and may be the most important suggestion for easing these complaints. The following empirical suggestions may be helpful, and an empathetic ear may greatly enhance the patient's comfort.

Measures to Assist the Xerostomic Patient

Dietary Counselling

To aid in swallowing, foods may be softened or thinned with liquids such as skim milk, broth or water. In addition, melted margarine or gravy may be added to foods if fat consumption is not a problem. Foods with some bulk may be easier to swallow than liquids. Dry foods may be dunked in liquids. Alcohol and drinks with caffeine may cause additional dryness. Carbonated beverages with sugar and diet drinks with phosphoric and citric acids should be discouraged.

Saliva Stimulation

The use of a sugarless gum or candy containing xylitol as a sweetening agent or a wax bolus may help stimulate salivary flow. It may also be helpful to keep a cherry pit or small glass bead in the mouth. Sialogogues such as pilocarpine (and anethole trithione, which is available in Canada and Europe) may benefit some patients with residual salivary gland function.

Saliva Substitutes

A trial of a commercial oral lubricant may be suggested for the patient with a dry mouth. Water alone remains a frequently used mouth-wetting agent, although a small amount of glycerine (1/4 tsp) may be added to eight ounces of water to offer longer-lasting relief from dryness.

Palliative Measures for Xerostomia and Pain

Measures for the Palliation of Pain

It is imperative to determine the etiology of pain prior to suggesting palliative measures.

Topical preparation

A variety of topical anesthetic and coating agents are available to palliate painful mucositis.

Analgesics

Systemic analgesics, such as acetaminophen or ibuprofen, may be taken according to product directions. More potent analgesics may be needed.

Dietary counselling

Patients should be aware that irritating foods such as acidic citrus fruits and juices, hot and spicy products and rough-textured foods may cause additional discomfort. Straws may be used to drink liquids. Temporary comfort may be achieved by sucking on ice chips or popsicles. The patient's diet may consist of foods that are easy to chew and swallow such as milk shakes, cooked cereals and scrambled eggs; soft and pureed fruits and vegetables such as apple sauce and mashed potatoes; custards, puddings and gelatins; and high-moisture foods such as sorbets and ices.

Infection control

Early identification and treatment of infections will diminish the severity of mucositis and help control pain.

The following products and practices may increase dryness and pain and should be avoided:

Commercial mouthwashes

Most over-the-counter mouthwashes should not be used because they have a high alcohol content and can dry and irritate the oral tissues. Flavouring and colouring agents also may be irritating. Alcohol-free mouth-washes are available.

Peroxide

Excessive use of hydrogen peroxide 3% and carbamide peroxide 10% are acidic and may be irritating to the oral tissues and disrupt the normal oral flora. When used, hydrogen peroxide 3% should be diluted (one part peroxide to four parts of water or saline) and should be limited to short-term use.

Alcohol and Tobacco Products

Use should be discouraged due to the irritating and carcinogenic effects. Passive smoke may be filtered from rooms with an electronic filtering appliance.

Published: May 2003

The following products are recommended for the prevention or palliation of many of the oral problems associated with cancer therapies.

NB Use of all products should be evaluated for individual patient benefit and should be closely monitored for efficacy. Products that prove to be ineffective or result in additional morbidity should be discontinued and alternative methods sought.

Compliance will be greatly impacted by the patient's perception of need and by the cost and availability of the product.

Bacterial Plaque Control

Ideally patients should use an extra-soft nylon bristle toothbrush and dental floss for mechanical removal of plaque. Sponge Toothettes/ foam sticks and lemon-glycerine swabs available to hospitalized patients may not adequately remove bacterial plaque. If used, a sponge Toothette soaked in chlorhexidine rinse may enhance plaque removal. Patients who suffer from severe oral pain or significant neutropenia may soften their toothbrush in hot water before use, or they may switch to a super-soft, multi-tufted toothbrush. These brushes should be disinfected in chlorhexidine and air dried before reuse.

Chiorhexidine rinses or gels may be used to assist with bacterial plaque control when mechanical methods are inadequate. Chiorhexidine rinses with alcohol that irritate or dry friable tissue should be discontinued, and they should be diluted with water for pediatric patients.

Fluoride Gels

A 1.1% neutral pH sodium fluoride gel or a 0.4% stannous fluoride gel is used for the prevention of caries and/or demineralization of the tooth structure secondary to xerostomia. For patients with long-term or permanent xerostomia, daily application is accomplished using custom gel-applicator trays. Patients with a transient xerostomia may brush the fluoride gel on their teeth daily. Acidulated fluorides should not be used. Fluoride rinses do not provide adequate protection. Patients with porcelain crowns should use a neutral pH fluoride.

Remineralizing Gel

A gel with calcium, phosphate and fluoride can be used in gel-applicator trays in addition to fluoride gel to remineralize early enamel breakdown in severely xerostomic patients.

Saliva Substitutes/ Oral Lubricants

A variety of OTC sprays and gels are available for temporary relief from xerostomia and dry lips. Occlusive lip balms, such as petrolatum, may promote microbial growth. During radiation therapy the patient should follow the advice of the radiation oncologist.

Saliva Stimulants

A prescription for pilocarpine (or anethole trithione, available in Canada and Europe) may benefit patients with residual salivary gland function.

Tobacco Cessation/ Nutritional Information

Materials are available free of charge from the National Cancer Institute (1.800.4.CANCER).

• "How to Help Your Patients Stop Using Tobacco. A Manual for the Oral Health Team"
• "Clearing the Air How to Quit Smoking and Quit for Keeps" (a patient publication)

Oral Care Products

The following solutions are prepared by a pharmacist for relief of generalized oral pain:

Sucralfate Suspension (Ferraro; 1984)

• 8 sucralfate tablets
• 40 ml sterile water
• 3 Ensure Variflavor Pacs dissolved in 10 mi sterile H2O

Stir together. Add H2O to 120 ml. Swish and hold 1 tsp in mouth for 30 seconds.

Palliation of Pain

All palliative pain preparations should be closely monitored for efficacy and re-evaluated if pain persists. Topical anesthetic and protective preparations may be used for isolated ulcerations. The patient should be cautioned that some preparations can anesthetize the gag reflex and lead to aspiration of food. Lack of sensation may result in damage to intact mucosa.

Temporary palliation of pain also may be accomplished with the use of a magnesium aluminium hydroxide antacid mixed with an OTC alcohol-free Benadryl in a 1:1 ratio. The patient is instructed to swish and hold one teaspoon in the mouth to coat and palliate the oral tissues. A small amount may be swallowed.

Benadryl-Lidocaine Solution

Diphenhydramine injectable 1.5 ml 50 mg/ml. Xylocaine viscous 2% 45 ml. Magnesium aluminium hydroxide soin 45 ml. Swish and hold 1 tsp in mouth for 30 seconds. Small amounts may be swallowed.

Published: May 2003

Prior to surgery for the removal of oral structures, a full dental examination should be performed. Radiographs necessary to confirm the status of any remaining natural teeth will be obtained. Impressions are made for study models so that surgical stents can be constructed. These temporary prostheses are inserted and further refined by the prosthodontist at the time of surgery.

The use of a surgical stent in this manner maintains oral function, enhances appearance, and supports and protects skin grafts in the sites of the surgical defect. This approach significantly reduces the duration of hospitalization that would otherwise be required. Regular adjustment of such prostheses is required to accommodate changes in the contour and consistency of adjacent tissues.

The prosthetic rehabilitation of patients whose condition has been altered by a cancer or the treatment for that cancer is also undertaken. This may include the replacement of teeth with partial or complete dentures, and the construction and delivery of prostheses to replace intra- and extra-oral structures removed surgically.

The Department of Dentistry collaborates with other disciplines (ENT, Speech Pathology, Nutrition, Social Work, etc) and Agencies, in order to optimize patient care.

Some non-cancer patients are accommodated in this programme.

Maintenance and Monitoring

The Department maintains a recall programme in order to ensure that the delivery of care following dental assessment has been appropriate to the needs of individual patients. A database is being developed with which dental care can be analyzed.

Finance

The Dental Department will offer any BC Cancer Agency (BCCA) registered patient a dental consultation as required. Care may be provided to BCCA registered patients whose dental needs arise directly from a cancer or the treatment of the cancer. The BCCA will not support the costs of care necessitated by neglect, or resulting from pre-existing dental conditions.

No dental costs will be reimbursed retrospectively to outside practitioners. Available funds will be allocated prospectively, taking into account the merits of each treatment plan. A dental examination by an Agency staff member may be required before a proposed treatment plan is approved for funding. The services of BCCA dental consultants are provided without charge to the patients except where unrelated dental needs are to be met.

Enquiries concerning the BC Cancer Agency dental programme may be directed to the Head, Division of Dentistry.

​ Published: May 2003

Important Information for Patients Receiving Radiation to the Head and Neck

What happens to saliva?

There are substances in saliva that aid in the digestion of food and help protect the teeth from tooth decay. Radiation to the head and neck for treatment of cancer does not have a direct affect on the teeth but can change saliva. The saliva may feel thick and sticky or the mouth may feel dry. When this happens the teeth can become painful and cavities can form quickly.

The changes in saliva will appear within a week or two after starting radiation treatment. Your mouth and throat may also become sore. To reduce problems from changes in saliva and soreness in the mouth, it is important to follow instructions given by dental and medical professionals.

How can I reduce problems in my mouth?

Keep your teeth as clean as possible. Many more bacteria and germs can cause tooth decay and infections in a mouth with little to no saliva. Therefore, it is important that you brush with a soft toothbrush and clean between the teeth as instructed by the dental professional at least two times per day. You should also have your teeth professionally checked and cleaned every 3 or 4 months.

Use fluoride in custom gel trays. Studies on the use of fluoride in custom made gel trays show a reduction in tooth breakdown. From impressions taken of your teeth clear plastic custom gel trays are made. Once daily, place a small amount of fluoride gel in each tray. Put enough gel in the tray to cover the teeth. If gel over flows from tray when placed in your mouth, you have put too much gel in the tray. Wear the trays for one minute. After you remove the trays from your mouth rinse them with cool water and let them air dry.

Treatment of sore mouth. Your mouth may become too painful to clean during radiation treatment. If this happens, contact the dental clinic. The staff will help you with methods of dealing with the discomfort by suggesting easier ways to keep your teeth clean. They can also recommend rinses that help relieve pain. Your doctor can also help with this problem.

Care of dry mouth. Most people find sipping water from a bottle is the best method to help moisten their mouth. Chewing sugarless gum or sucking on sugarless hard candies may help stimulate saliva. Avoid frequent eating of soft carbohydrate foods and drinks with sugar or honey as these can cause tooth breakdown. You should brush your teeth after every meal. If you have thick, sticky saliva in your mouth, rinse with a mixture of baking soda, salt and water (1/2 tsp. baking soda, 1/4 tsp. salt, and 500 ml water).

Visit a dentist regularly. Dry mouth can be permanent. How dry depends on the area of radiation, the amount of radiation, and the person. Therefore, the problems caused by dry mouth may also be life long. Regular visits to a dentist are important to help keep your teeth and gums as healthy as possible. Your dental professional will tell you how often you should see them. They will also advise you how to best take care of your teeth and gums. If your teeth become sensitive or you have any concerns with your mouth, you should contact the dental clinic or your dentist.

* To reduce the risk of tooth break-down, continue to use the fluoride in the custom gel carriers. This will be necessary as long as your mouth remains dry. A dentist will advise you if and when you may discontinue their use.

Please contact the dental department if:

1. Your custom fluoride gel try is lost or damaged;
2. The gel makes your gums hurt;
3. The gel tray makes you gag;
4. Your mouth or teeth are painful;
5. If you have any questions about your teeth or mouth.

BC Cancer Agency Dental Clinic
600 West 10th Avenue
Vancouver, B.C. V5Z 4E6
(604) 877-6136

​Published: May 2003

1. American Cancer Society, Cancer facts and figures (request current year). Atlanta, GA

2. National Institutes of Health. Consensus development conference on oral complications of cancer therapies: diagnosis, prevention, and treatment. NCI Monograph No.9 U.S. Public Health Service. Washington, DC U.S. Government Printing Office, 1990.

3. National Institutes of Health. Consensus development conference on oral complications of cancer therapies: diagnosis, prevention, and treatment. (Final conference statement and recommendations) J Am Dent Assoc. 119: 179-183, 1989.

4. National Oral Health Information Clearinghouse, Department OH, Box NOHIC, 9000 Rockville Pike, Bethesda, MD 20892 (a service of the National Institutes of Dental Research, National Institutes of Health).

5. Peterson, DE, Elias, EG, & Sonis, ST (Eds.) Head and neck management of the cancer patient. Boston: Martinus Nijhoff Publishers, 1986.

6. Peterson, DE & Sonis, ST (Eds.) Oral complications of cancer chemotherapy. Boston: Martinus and Nijhoff, 1983.

7. Silverman, S. Oral cancer 3rd ed. Atlanta, GA: American Cancer Society, 1990.

8. Barker, GJ, Barker, BF, Gier RE (1996) Oral Management of the Cancer Patient: A Guide for the Health Care Professional. Biomedical Communications, University of Missouri-Kansas City, School of Dentistry, 650 East 25th Street, Kansas City, MO 64108-2784, pp ii-5

​Published: 28 January 2009

Guideline for the Early Detection of Oral Cancer in BC 2008

At the request of the College of Dental Surgeons of British Columbia, this guideline has been written by a working group of the BC Oral Cancer Prevention Program, which is a multidisciplinary team composed of clinicians and scientists from the BC Cancer Agency.

This guideline is intended to provide guidance about the appropriate use of oral cancer screening techniques and to help dentists make informed decisions about screening for oral cancer in practice. It should be used to facilitate clinical decision-making.

Due to the importance of ongoing research related to oral cancer screening, this guideline will be updated on a regular basis with multidisciplinary input.