Special Care
Instructions for
Cancer Patients
Pamela
Sandow, D.M.D.
University
of Florida
College of
Dentistry
Clinic - (352)273-6740
Office
- (352)273-6775
How to
Use Custom Fluoride
Carriers (Trays)
1. At bedtime, remove partial or
full
dentures from the mouth. Brush teeth
thoroughly with soft toothbrush and regular toothpaste.
Floss teeth by sliding the floss up and down
each side of each tooth. Note: It is very important to remove all food and
plaque from between teeth before using fluoride.
Food and plaque can prevent the fluoride from
reaching the surface of the tooth.
2. Place a thin
ribbon of the fluoride gel into each upper and lower fluoride tray so
that each
tooth space has some fluoride. Either
0.4% stannous fluoride (Gel Kam) or 1.1% sodium
fluoride (Prevident) may be used. The
fluoride can be spread into a thin film that coats
the inside of the
trays, by using a cotton-tipped applicator, finger or toothbrush.
3. Seat the trays on
the upper and lower teeth and let them remain in place for
5 minutes. Only a
small amount of fluoride should come
out of the base of the trays when they are placed, otherwise, there may
be too
much fluoride in the trays.
4. After 5 minutes, remove the
trays and
thoroughly expectorate (spit out) the residual fluoride. Very
Important - do not rinse mouth, drink or eat for at least 30
minutes after fluoride use.
5. For
head and neck
radiation patients, begin using fluoride in the custom trays no longer than one week after
radiotherapy is completed. Repeat
daily for the rest of your life!! Remember
that tooth decay can occur in a
matter of weeks if the fluoride is not used properly.
Care for
Fluoride Carriers (Trays)
1. Rinse and dry the
trays thoroughly after each use. Clean
them by brushing them with a toothbrush and toothpaste.
2. Occasionally, the
trays can be disinfected in a solution of sodium hypochlorite (Clorox)
and
water. Use one tablespoon of Clorox in
about one-half cup of water. Soak them
for about 15 minutes.
3. If the trays
become covered with hard water deposits, soak them in white vinegar
overnight
and brush them the next morning.
4. Do not boil the
trays or leave them in a hot car as they may warp or melt.
How to Use
Brush-on Fluoride
(bone
marrow transplant
patients)
Daily
fluoride (1.1% sodium fluoride or 0.4% stannous fluoride) helps teeth
resist
tooth decay caused by xerostomia (dry mouth). Radiation
therapy to the head and neck area, total body
irradiation,
chronic graft vs. host disease and/or some medications can cause dry
mouth that
can lead to tooth sensitivity or decay. Compliance
with the following fluoride regimen will
greatly reduce the
risk of tooth problems after cancer therapy.
1. The best time to
use fluoride is at bedtime.
2. Remove partial or
full dentures from the mouth.
3. Brush teeth
thoroughly with a soft toothbrush and regular toothpaste.
Floss teeth by sliding the floss up and down
each side of each tooth. Patients with
low white blood cell and platelet counts may be instructed to avoid the
use of
floss while blood counts are low. A
supersoft toothbrush, such as the one made by Biotene,
can usually be used without causing the gums to
bleed. Note: It
is very important to remove all food and
plaque from between teeth before using fluoride.
Food and plaque can prevent the fluoride
from reaching the surface of the tooth.
4. Place a thin
ribbon of the fluoride gel onto your toothbrush. Either
0.4% stannous fluoride (Gel Kam) or 1.1% sodium fluoride
(Prevident) may be used. Thoroughly
brush the fluoride into all
surfaces of the teeth, especially where the tooth meets the gum tissue. A 1.1% sodium fluoride dentrifice, such as
Prevident 5000, may be used instead of regular toothpaste in one step.
5. Allow the fluoride
to remain on the teeth for 5 minutes.
6. After 5 minutes, thoroughly
expectorate (spit
out) the residual fluoride. Very
Important -
do not rinse the mouth, drink or eat for at least 30 minutes after
fluoride use.
7. Bone marrow transplant patients
should
begin using fluoride soon after being admitted for the transplant. Repeat daily for as long as you
have natural
teeth remaining!!
8. Custom fluoride
trays may be fabricated before or after the bone marrow transplant. Patients with sensitive teeth, active decay
or a history of radiation therapy to the head and neck areas should
have
fluoride trays before the bone marrow transplant.
How to
Use Brush-on Fluoride
(head
and neck radiation
patient)
1. The best time to
use fluoride is at bedtime.
2. Remove
partial or
full dentures from the mouth.
3. Brush teeth
thoroughly with soft toothbrush and regular toothpaste.
Floss teeth by sliding the floss up and down
each side of each tooth. A supersoft
toothbrush, such as one made by Biotene,
can usually be used without causing the gums to hurt or bleed. Note: It is
very important to remove all food and plaque from
between teeth
before using fluoride. Food and
plaque
can prevent the fluoride from reaching the surface of the tooth.
4. Place a thin
ribbon of the fluoride gel onto your toothbrush. Either
0.4% stannous fluoride (Gel Kam) or 1.1% sodium fluoride
(Prevident) may be used.
Thoroughly brush
the fluoride into all surfaces of the teeth, especially where the tooth
meets
the gum tissue.
5. Allow the fluoride
to remain on the teeth for 5 minutes.
6. After 5 minutes, thoroughly
expectorate (spit
out) the residual fluoride.
Very
Important -
do not rinse mouth, drink or eat for at least 30 minutes after
fluoride use.
7. Head and neck radiation
therapy patients should
begin using fluoride no longer than one week after radiation therapy is
completed. Repeat daily for as
long as you have natural
teeth remaining!!
Dental
Examination Before
Bone Marrow Transplant
WHY:
The purpose of a
dental examination before the bone marrow transplant is to identify
potential
sources of oral infection that can lead to bacteremia (bacteria in the
blood). It is important to prevent or
eliminate dental infection before chemotherapy or other
medications that
lower the ability of the body to fight infections.
Severe gum disease, tooth decay, tooth
abscesses and poor oral hygiene can lead to pain and/or bacteremia
before,
during and after chemotherapy.
WHEN:
The dental
evaluation should be performed as soon as possible after a
diagnosis
requiring chemotherapy that can potentially lower the blood counts. Xrays of the mouth and a clinical examination
can usually be performed without causing any bleeding or trauma. If the dentist finds a dental problem that
requires attention, he or she should call the medical oncologist and
coordinate
any dental care, including cleaning of teeth, at a time when the blood
counts
are at an acceptable level. Usually,
dental care can be safely performed about three to four days before a
round of
chemotherapy. Leukemia patients should
be in remission before elective dental procedures are performed. If a patient is aware of a dental problem or
has not had routine dental examinations, the medical oncologist should
schedule
a dental evaluation as soon as possible to identify and/or treat
potential
dental problems (if the blood values are at acceptable levels.)
WHERE:
The
patient may go to his or her regular dentist to have a check-up before
chemotherapy begins or even during chemotherapy, as long
as the dentist is aware that the oncologist should be consulted
before any dental procedures, that could cause bleeding, are performed. Bitewing Xrays, panoramic Xrays and
clinical examinations are usually safe procedures when blood counts are
low. A dental problem, if present,
should be identified early in treatment so that it can be treated when
the
blood counts have recovered. If the
patient does not have a family dentist, oral surgeons (associated with
most
hospitals) can often perform the prechemotherapy dental evaluation when
requested by an oncologist.
ORAL
CARE DURING THE BONE
MARROW TRANSPLANT
It is extremely important to keep the
mouth clean and healthy during the bone marrow transplant procedure to
help
reduce the risk of infection and bleeding. Some
research has shown that mouth sores are less severe
in people with
excellent oral hygiene. A
professional
dental cleaning 1-2 weeks prior to being admitted to the hospital for
the bone
marrow transplant, is highly recommended. Following
are some suggestions for reducing oral
complications during
the transplant.
1. The medical
oncologist will prescribe antiviral and antifungal medications, when
appropriate. These medications are
usually very effective in lowering the risk of viral and fungal
(thrush)
infections in the mouth as well as in other areas of the body. Fewer infections in the mouth results in less
pain and better nutrition.
2. Toothbrushing
should be performed at least twice daily. Supersoft
toothbrushes* are available that will not
cause bleeding if
used appropriately. Brushing should be
done in a gentle, circular motion. To
be thorough, brush teeth in a systematic fashion to
include all
surfaces of every tooth. Flossing and
the use of a normal toothbrush are not recommended when the platelet
count is
lower than 50,000. The use of a
water-irrigating device, on a low setting, is a good way to eliminate
food
between teeth without causing bleeding.
Important: Always
disinfect the toothbrush before each
use. Soak toothbrush in a fresh
solution of Clorox and water (1 tbs. Clorox per 1/2 cup water) or wash
with an
antimicrobial soap containing chlorhexidine. Thoroughly
rinse the toothbrush after disinfection and
before placing it
in the mouth. Change toothbrush weekly.
Hint:
The bristles of the
supersoft toothbrush will become
even softer if held under warm
water before use.
Hint: It
is a
good idea to gently brush the tongue, palate and gums with a
supersoft
toothbrush on a daily basis in order to remove harmful germs.
Hint:
If a
particular brand of toothpaste burns or irritates the mouth, try a
toothpaste
that is specially made for children or people with dry mouth.*
3. Some people with
gum disease may be asked to rinse with a mouthrinse containing 0.12%
chlorhexidine. It is best to use the
mouthrinse 2-3 times daily after meals and at bedtime.
4. Saline or
saltwater and baking soda rinses (1 tsp. salt and 1 tsp. baking soda in
one
quart of water) may be used throughout the day to sooth the sore and
dry
mouth. When using mouthrinses, be sure
to stagger their use throughout the day, allowing at least one hour
before
another mouthrinse. Using several
different
mouthrinses at one time will reduce their effectiveness.
5. To ease the pain
of mouth ulcers, rinse with viscous lidocaine about 15 minutes before
eating. Some pharmacies can also make
flavored lollipops with medications that have a numbing effect to use
before
eating. Eat small bites and chew
thoroughly when using these numbing medicines to reduce the risk of
choking.
6. Keep mouth and
lips well lubricated with a water-based lubricant*.
Petroleum jelly repels water and is not
recommended for use.
7. When the mouth is
sore, remove dentures and leave them out until the mouth heals. All full dentures and partial dentures should
be disinfected before each use with a soap or rinse containing
chlorhexidine. Dentures without metal
may be soaked daily in a fresh solution of Clorox and water (1 tbs.
Clorox to
1/2 cup of water). Rinse the dentures
well before placing them back in the mouth.
*Biotene
supersoft toothbrush, mouthrinse without alcohol,
water-based lubricant (Oral Balance) and toothpaste are specially made
for
people with dry and sore mouths. They
can be obtained through most pharmacies and are over-the-counter. The manufacturer of these products is Laclede
, 15011 Staff Court,
Gardena, CA
90248,
1-800-922-5856.
ORAL
CARE AFTER THE BONE
MARROW TRANSPLANT
1.
The use of daily fluoride is strongly
recommended (see fluoride instructions) for patients experiencing the
following:
-radiation to the
head and neck areas
-total body
irradiation
-allogeneic
(sibling or unrelated donor) transplants
-long-term
chemotherapy
-dry mouth
-active tooth
decay
-tooth
sensitivity to cold
2.
If the platelet count is greater than 50,000,
brushing can be accomplished with a soft-bristled toothbrush (never
medium or
hard). Daily flossing is also
advised
if the platelet count is adequate.
3.
If the platelet count is greater than
50,000, dental cleanings, fillings, root canals and extractions can
usually be
safely performed as long as these procedures are coordinated and
approved by
the medical oncologist. If emergency
dental care is needed when the platelet count is below 50,000, a
platelet
transfusion may be necessary prior to the dental procedure.
4.
If an indwelling catheter is present, it may
be necessary to take a dose of antibiotics one hour prior to any dental
procedure that may cause bleeding. The
dentist providing the care should provide the
prescription for
the antibiotic. (Note to health care
professionals: The American Heart
Association’s regimen for SBE prophylaxis may be used
in these situations.)
CYTOLOGIC
SMEAR
Indications:
suspected
herpetic lesions, candidiasis, leukoplakic lesions that rub off,
erythematous
lesions (Persistent erythematous lesions should be biopsied.)
Technique:
1.
Using a pencil, label the frosted end of a
microscope slide with the patient’s name.
2.
Remove cells from the oral mucosa with a
Cytobrush or tongue blade and
spread them evenly on the microscope
slide.
3.
Repeat procedure on a second microscope
slide.
4.
Spray the slides lightly with a fixative.
(Aquanet hairspray works well.)
5.
Submit both slides to the pathologist with a
provisional diagnosis.
GUIDELINES FOR DENTAL EXTRACTIONS
BEFORE HEAD AND NECK
RADIATION THERAPY
At
the University
of Florida Oral Oncology Clinic,
recommendations for dental extractions prior to the initiation of
radiation
therapy include but are not limited to the following list of factors. Extractions prior to head and neck radiation
are often recommended to reduce the risk of osteonecrosis of the jaws
after
radiation.
NON-DENTAL
FACTORS
*Radiation
dose
If the radiation
dose to the bone of the mandible and maxilla is less than 5000cGy, then
according to the literature and our experience, there
should be minimal risk of osteonecrosis after
radiotherapy. The radiation oncologist
must give this
information to the dentist prior to the initiation of head and neck
radiation.
*Location
of radiation ports
At the UF Oral
Oncology Clinic, recommendations for dental extractions prior to
radiotherapy
are limited to those areas of the mandible and maxilla that are going
to
receive greater than 5000cGy. The
radiation oncologist must give this information to the dentist prior to
the
initiation of head and neck radiation. If
there are teeth outside of the potential high
dose field of
radiation that are symptomatic or have a hopeless prognosis, they
should be
extracted prior to radiation, if time permits.
*Patient
prognosis
If the prognosis
of the patient is extremely poor or if the tumor is growing rapidly,
the
radiation oncologist may decide that radiation needs to proceed without
delay. After extraction, 2-3 weeks
healing time is recommended before head and neck radiation therapy
begins.
*Patient
age
The younger the
patient, the longer the teeth must be maintained disease free. If dental extractions are required (due to
tooth decay or periodontal disease) in areas that will receive high
dose
radiation, the patient will be at significant risk for osteonecrosis. The risk of osteonecrosis in irradiated areas
is present for the duration of the patient’s life.
There is no “safe” time limit to wait for
extractions or surgery in these areas. Therefore,
the patient needs to be informed of the
potential life-long
risk before radiation therapy is initiated, even if the teeth are very
healthy.
*Patient
finances
If the patient
cannot afford dental care that is required after radiation therapy,
serious
consideration needs to be given as to whether any teeth should remain
in the
proposed high dose field of radiation.
*Patient
compliance
If the patient
has demonstrated lack of motivation in previous dental care and oral
hygiene,
or has a severe dental phobia, serious consideration needs to be given
whether any
teeth should remain in the proposed high dose field of radiation.
GUIDELINES
FOR DENTAL EXTRACTIONS
BEFORE HEAD AND NECK
RADIATION THERAPY
DENTAL
FACTORS
*Radiographs
A panoramic
radiograph should be taken prior to radiotherapy to assess health of
the teeth
and jaws. Patients without teeth should
also have a panoramic film. Other
intraoral radiographs may be necessary.
*Periodontal
disease
Teeth in the
proposed high dose field of radiation should be considered for
preradiation
therapy extraction if periodontal sulcular depths are equal to or
greater than
5mm, if there is furcation involvement, if
they have a history of refractory periodontitis,
tooth mobility, bleeding, or inflammation
of the gums.
*Caries
(tooth decay)
Teeth in the
proposed high dose field of radiation should be considered for
preradiation
therapy extraction if they have deep decay, especially in a patient
that has
numerous areas of tooth decay throughout the oral cavity.
*Root
canals
Teeth having root
canals in the proposed high dose field of radiation should be
considered for
preradiation therapy extraction if they have silver points and/or
evidence of
root canal failure, i.e. pain, swelling or apical radiolucencies.
*Impactions
Impacted teeth,
especially third molars, that will be located in the proposed high dose
field
of radiation should be extracted prior to radiation, if there is
pathology
associated with the teeth or if the teeth have a communication with the
oral
cavity.
*Large
fillings, fractures, occlusal wear
Teeth with large
fillings, fractures or significant occlusal wear should be considered
for
extraction prior to receiving high dose radiotherapy.
*Pain,
apical radiolucency
Teeth that are
painful, have a history of pain, sensitivity to percussion or apical
radiolucency should be considered for extraction prior to receiving
high dose
radiotherapy.
*Unopposed
teeth
Teeth that do not
have contact with a tooth in the opposing arch should be considered for
extraction prior to receiving high dose radiotherapy, if they are in
the
proposed high dose radiation field.
SURGICAL GUIDELINES FOR EXTRACTIONS
PRIOR
TO
HEAD AND NECK RADIATION THERAPY
*Perform
adequate alveoloplasty with extractions to eliminate sharp bony
projections,
tori and to make the patient “denture ready”.
*Achieve
primary closure, if possible. Do not
stretch the mucosal tissue beyond its
physiologic limits.
*It
may be advisable to place the patient on prophylactic
antibiotics for one week after extraction to reduce the risk of
infection.
*Allow
a minimum of 14-21 days of healing prior to the
initiation of radiation therapy.
RADIATON
CARIES- WHY DOES IT OCCUR?
Radiation caries
is defined as tooth decay that results from radiation-induced dry mouth
(xerostomia). The increased incidence of
tooth decay in
postradiation patients is caused by radiation to the major salivary
glands and
is not due to radiation of individual teeth. This
means that patients having received radiation to
one or more of the
major salivary glands are susceptible to radiation caries whether or
not teeth
have been included in the field of radiation. Radiation
caries can occur because of the inability of
the saliva to
destroy bacteria that causes tooth decay and its inability to
remineralize the
tooth enamel. The decrease in salivary
flow and salivary pH also contribute to the process of tooth decay.
NOTE: RADIATION
CARIES CAN OCCUR WITHIN WEEKS AFTER RADIATION THERAPY IS COMPLETED.
SUGGESTIONS
TO HELP ALLEVIATE
DRY
MOUTH (XEROSTOMIA) CAUSED BY RADIATION
1.
Use pilocarpine
(Salagen) 5mg, qid, (prescription required.)
2. Try special food
preparation - blended and moist foods are easier to swallow.
3. Use artificial
saliva (available over-the-counter.)
4. Sip plain water
throughout the day (usually preferred over artificial saliva by most
patients.)
5. Try Biotene brand,
over-the-counter, dry mouth products (toothpaste, alcohol-free
mouth rinse and
OralBalance lubricating gel.)
6. Avoid the use of
alcohol-based mouth rinses.
7. Try water and
glycerin (few drops only) mixed in a small aerosol spray bottle.
8. Avoid the use of
tobacco and alcoholic beverages.
ORAL
CARE DURING HEAD AND NECK RADIOTHERAPY
It is extremely
important to keep the
mouth clean and healthy during head and neck radiation, to help reduce
the risk
of oral infection. A professional dental
cleaning prior to radiation is highly recommended. Following are
some suggestions for reducing
oral complications during head and neck radiation.
1.
The radiation oncologist or dentist will
prescribe antiviral and antifungal medications when appropriate. These medications are usually very effective
in lowering the risk of viral and fungal (thrush) infections in the
mouth. Fewer infections in the mouth
results in less
pain and better nutrition.
2.
Toothbrushing should be performed at least
twice daily. Supersoft toothbrushes* are
available that will not cause irritation, if used appropriately.
Brushing should be done in a gentle,
circular motion. To be thorough, brush
teeth in a systematic fashion to include all surfaces of every
tooth.
Flossing is recommended as well as the use of
a water-irrigating device, on a low setting, to eliminate food between
teeth.
Hint:
The bristles of the
supersoft toothbrush will become even softer if held under warm water
before
use.
Hint:
It is a good idea to gently
brush the tongue, palate and gums with a supersoft toothbrush on a
daily basis
in order to remove harmful germs.
Hint:
If a particular toothpaste burns or irritates
the mouth, try a toothpaste that
is specially made for children or people with dry
mouth.*
3.
Saline or saltwater and baking soda rinses (1
tsp. salt and 1 tsp. baking soda to one quart of water) may be used
throughout
the day to sooth the sore and dry mouth. When
using mouthrinses, be sure to stagger their use
throughout the day,
allowing at least one hour before another mouthrinse.
Using several different mouthrinses at one
time will reduce their effectiveness.
4.
To ease the pain of mouth ulcers, rinse with
viscous lidocaine about 15 minutes before eating. Some
pharmacies can also make flavored
lollipops with medications that have a numbing effect (tetracaine) to
use
before eating. Eat small bites and chew
thoroughly when using these numbing medicines to reduce the risk of
choking.
5.
Keep mouth and lips well lubricated with a
water-based lubricant*. Petroleum jelly
repels water and is not recommended for use.
6.
When the mouth is sore, remove dentures and
leave them out until the mouth heals. All
full dentures and partial dentures should be
disinfected before each
use. Dentures without metal may be
soaked daily in a fresh solution of Clorox and water (1 tbs. Clorox to
1/2 cup
of water). Rinse the dentures well
before placing them back in the mouth.
*Biotene
supersoft toothbrush, mouthrinse without alcohol, water-based lubricant
(OralBalance) and toothpaste are specially made for people with dry and
sore
mouths. They can be obtained through
most pharmacies and are
over-the-counter. The manufacturer of
these products is Laclede , 15011 Staff Court, Gardena,
CA 90248,
1-800-922-5856.
