Patients on chemotherapy and radiations

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.
 Mucositis and ulceration
 Pain
 Infection
 Bleeding
 Xerostomia
 Taste alteration
 Neurotoxicity (The patient may present with numbness or
constant, deep pain that is
often bilateral and frequently mimics
toothache but not really dental)

before Chemotherapy
dental treatment:
- Eliminate any area of infection or irritation,
- Remove orthodontic bands if highly stomatotoxic
chemotherapy is scheduled..
- Institute periodontal disease control measures that
include plaque control,
- Provide oral hygiene instruction,
 - Patients should be advised to avoid commercial
mouthrinses with alcohol
- and/or a high sugar content.
- 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

During Chemotherapy
Dental treatment :
scheduled within a few days of the next proposed round or
course of therapy. Generally blood count must be done
infection control:
Culture all lesions for infection (bacterial, fungal and/or viral).
Prescribe treatment in cooperation with the oncologist
Orthodontic band :
If bands are not removed prior to chemotherapy, soft wax or a
plastic mouthguard may be used to protect the oral tissues
from injury during periods of oral inflammation or ulceration
Prevention of dental caries and demineralization
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.

Denture care
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. 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

tooth brushing and flossing

use soft brush , at the time of neutropenia use ultrasoft tooth
brush and no flossing

During Chemotherapy
Mourh rinses
 - Alcohol-based mouthwashes and full-strength peroxide
solutions or gels
- should not be used due to their drying and irritating
effects
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
after 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

Radiation therapy
Potential Oral Manifestations of Radiation Therapy to the
Oropharyngeal and Salivary Gland Region
Acute ______ Chronic
Taste alterations _____ Salivary
gland dysfunction
Salivary gland dysfunction __ Radiation
caries/demineralization
Mucositis/Ulceration/Pain ___
Trismus/TMD
Infection __ Soft tissue
necrosis
Nutritional deficiency/Dysphagia
Osteoradionecrosis
__ Developmental
maxillofacial deformity
Factors that influence intensity and duration of the oral
manifestations
total dosage
rate of radiation delivery
fraction size
field of radiation
radiation source
previous surgical intervention
oral hygiene and dental status
medical and nutritional status of patient
tobacco and alcohol use

Prior to Radiation Therapy

Pre-radiation oral surgery considerations
All hopeless and questionable teeth
- teeth with advanced periodontal disease (especially teeth
with
furcation involvement)
- partially-impacted or soft-tissue impacted teeth
- nonessential, unopposed or nonrestorable teeth
- implants with questionable prognosis
- root fragments
- other pathology (cysts, tumors, etc.)
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.
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. Additionally, removal
of implant
superstructures and skin and/or mucosa closure over the
implant fixtures
should be considered.
Extractions and surgery, with tension-free primary tissue
closure and
antibiotic coverage, should be performed to allow at least 14
day of
heallne prior to initiation of radiation therapy. The precise
time interval
depends upon the extent of surgical insult and the philosophy
of the
treatment center

Treatment and maintenance of the teeth

Provide periodontal care, including oral prophylaxis
Home care instruction: toothbrushing, flossing, implant care
Instructions may need to be adapted to the special needs of
the patient,
especially those patients with limited opening due to disease
and/or
surgical defects
Perform high priority restorations and eliminate sites of
irritation.
Remove orthodontic bands if they are within the field of
radiation

Management Prior to Radiation Therapy

Custom gel-applicator trays
Patient Instruction for Gel Application
The patient should be instructed to perform the following:*
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 5 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

Management During Radiation Therapy

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

Management Following Radiation Therapy

Dental recall/restorative treatment
four to eight weeks for the first six months following radiation
therapy.
Prosthodontic appliances
may be constructed after mucositis has resolved
and integrity of the oral tissues has been reestablished. This
may be six to
eight weeks, or longer, after the completion of all radiation
therapy

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

Control of demineralization
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.
Patients with enamel breakdown, but who demonstrate
compliance with
oral hygiene procedures and gel applications, may need
assessment of
cariogenic flora and a dietary analysis to assist with the
elimination of
cariogenic foods or oral medications. Chlorhexidine products
may help
control cariogenic bacterial plaque, and may enhance
remineralization.
Additionally, regular application of an in-office fluoride varnish,
especially
to exposed root surfaces, may be beneficial.
For those patiens unable to achieve remineralization it may be
necessary
for the patient to regularly apply a calcium-phosphate
remineralizing gel
in gel-applicator trays. Applications are made in addition to the
fluoride
gel and should be done after tooth cleansing procedures have
been
completed.
Patients that are non-compliant with the use of gel applicator
trays may be
able to control caries/demineralization with a high potency
brush-on
fluoride dentrifice (1.1% sodium fluoride

Trismus and Temporomandibular disorder

Patients that undergo radiation therapy to the muscles of
mastication and
the temporomandibular joint may experience severe pain and
limited opening.
Conservative, non-surgical treatment and referral for physical
therapy is
Indicated

Palliation of Xerostomia
The following products and practices may increase dryness
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. Flavoring and coloring agents also may be
irritating.
Alcohol-free mouthwashes are available.
Peroxide:
Hydrogen peroxide 3% and carbamide peroxide 10% are acidic
and excessive use 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

Measures to assist the xerostomic patient include:

Dietary counselin.:
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 anetholetrithione,
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 8 oz of water to offer longer-lasting relief
from dryness.
A burnidifiey in the room, especially at night and in dry
environments
may be helpful

Palliation of Mucosal Pain

Topical preparations;
A variety of topical anesthetic and coating agents
are available to palliate painful~mucositis,
Systemic pain relief;
Systemic analgesics, such as acetaminophen or ibuprofen, may
be needed.
Dietary counseling ;
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 cantrol;
Early identification and treatment of infections will diminish
the severity of mucositis and help control pain