For Patients Receiving Chemotherapy for Any Malignancy

Approximately 40 per cent 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; and
8. improve quality of life. 

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)

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.

Oral Care Products

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

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

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

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 (CI), 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-FLJ) 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

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.

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