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ORAL HEALTH

IN

CANCER THERAPY
A GUIDE FOR HEALTH CARE PROFESSIONALS

DENTAL
ONCOLOGY
EDUCATION
PROGRAM
Conference Participants
Ericka Arciniega RDH, BS Michelle Lindsay DDS Terry Rees DDS, MSD
UT Health Science Center Children’s Medical Center Baylor College of Dentistry, TAMHSC
San Antonio, Texas Dallas, Texas Dallas, Texas

Mark Chambers DMD, MS Maria Perno McKenzie RDH, MS Matthew Rees MD


UT MD Anderson Cancer Center American Dental Hygiene Association Rutherford Hospital
Houston, Texas San Francisco, California Rutherford, North Carolina

Dorothy Chesley RN, PhD Jayne McWherter RDH, MEd Sterling Schow DMD
Nurse Oncology Education Program UT Houston Dental Branch Baylor College of Dentistry, TAMHSC
Austin, Texas Houston, Texas Dallas, Texas

Lynn Collins RN Denise Moyer RDH, BS Nancy Shreve MS, RN


Oncology Nurses Society UT Health Science Center Harris Methodist Hospital
Dallas, Texas San Antonio Texas Dallas Texas

Patricia Daley DDS Preeti Naik DDS Virginia Sicola PhD, RN


VA North Texas Health Care System VA North Texas Health Care System Veterans Administration Hospital
Dallas, Texas Dalla,s Texas Amarillo, Texas

Gretchen Gibson DDS, MPH Carol Nguyen RDH Sol Silverman MA, DDS
VA North Texas Health Care System UT Health Science Center University California
Dallas, Texas San Antonio, Texas San Francisco, California

Kerry Harwood RN, MIN Donna Owen PhD, RN, AOCN Charles Stiernberg MD
Duke University Medical Center Texas Tech School of Nursing UT Health Science Center
Durham, North Carolina Lubbock, Texas Houston, Texas

Steven Isaacson MD Athena Papas DMD, PhD, FACD Paul Stubbs DDS
Columbia University Tufts University School of Dental Medicine Private dental practice
New York, New York Boston, Massachusettes Georgetown, Texas

Harris Keene DDS Steven Parel DDS Bela Toth DDS, MS


UT Houston Dental Branch Baylor College of Dentistry, TAMHSC UT MD Anderson Cancer Center
Houston, Texas Dallas, Texas Houston, Texas

Sandy Kilkuts DMD, FAGD Mark Pigno DDS Robert Triplett DDS, PhD
Academy of General Dentistry UT Health Science Center Baylor College of Dentistry, TAMHSC
Princeton, New Jersey San Antonio Texas Dallas, Texas

Captain Janice Kitchens USAF NC Major Cameron Pimperl MD Mike Webb DDS
Wilford Hall Medical Center Wilford Hall Medical Center Baylor College of Dentistry, TAMHSC
San Antonio Texas San Antonio, Texas Dallas, Texas

William Kohn DDS Jacqueline Plemons DDS, MS Michael Weiner MD


Centers for Disease Control and Prevention Baylor College of Dentistry, TAMHSC Columbia University
Atlanta, Georgia Dallas Texas New York, New York

Jan Lewin PhD Leonor Ramos RDH


UT MD Anderson Cancer Center Wilford Hall Medical Center
Houston, Texas San Antonio, Texas

COVER DESIGN BY GRADY BASLER


Oral Health
in
Cancer Therapy
Editors
K Vendrell Rankin DDS
Baylor College of Dentistry, TAMHSC

Daniel L Jones PhD, DDS


University of Texas Health Science Center San Antonio

Contributing Editors
Charles E Conklin DDS
Carilion Dental Center, Roanoke, VA
Catherine M Flaitz DDS, MS
University of Texas Health Science Center, Houston
Carl W Haveman DDS, MS
University of Texas Health Science Center San Antonio
Connie C Mobley PhD, MS
University of Texas Health Science Center San Antonio
Spencer W Redding DDS, MEd
University of Texas Health Science Center San Antonio

Editorial Assistants
Dana Ly
Scott Warren
Baylor College of Dentistry TAMHSC

COPYRIGHT 1999, TEXAS CANCER COUNCIL


ACKNOWLEDGEMENTS
The Dental Oncology Education Program convened Consensus Conference ’99, Oral Health in
Cancer Therapy, February 9 - 11, 1999. A diverse group of healthcare professionals involved in
cancer care was assembled to provide perspective and expertise in developing guidelines for the
management of oral health.

The personal and financial commitment of the following individuals and organizations was piv-
otal to the success of the conference.

DOEP Program Assistant

Grady L. Basler

Group Facilitators

Catherine M. Flaitz DDS, MS


Douglas Mitchell DDS
Daniel L. Jones PhD, DDS
K. Vendrell Rankin DDS
Spencer W. Redding DDS, MEd

Observers

Phillip Bonner, DDS


Rita May MEd

Field Testing
Denise Moyer RDH
Leonor Ramos RDH

Sponsoring Organizations

Texas Cancer Council


Baylor College of Dentistry, Texas A&M Health Science Center
American Cancer Society, Texas Division
Wilford Hall Medical Center

National Sponsor

Oral Health Education Foundation

Supporting Organizations

Pfizer, Inc
MGI Pharma, Inc.
Zila, Inc.
Enamelon, Inc.
Table of Contents
INTRODUCTION .....................................................................................................................................................1
GOALS OF THIS GUIDE ....................................................................................................................................................1
THE CANCER TREATMENT TEAM .....................................................................................................................................2
STAGES OF CANCER THERAPY .........................................................................................................................................2

CANCER THERAPIES ............................................................................................................................................3


HEAD AND NECK RADIATION ...........................................................................................................................................3
CHEMOTHERAPY ............................................................................................................................................................4
BONE MARROW AND PERIPHERAL STEM CELL TRANSPLANT ..............................................................................................5
HEAD AND NECK SURGERY ..............................................................................................................................................6

PRETREATMENT....................................................................................................................................................7
PRETREATMENT OBJECTIVES ..........................................................................................................................................7
CONSULTATIONS .............................................................................................................................................................7
DENTAL ASSESSMENT ......................................................................................................................................................7
ORAL HYGIENE ..............................................................................................................................................................8
FLUORIDE THERAPY .......................................................................................................................................................9
PRETREATMENT PROCEDURES .........................................................................................................................................9

DURING CANCER THERAPY ............................................................................................................................12


HEMATOLOGIC GUIDELINES ..........................................................................................................................................12
AHA ANTIBIOTIC PROTOCOL ........................................................................................................................................12
ORAL HYGIENE ............................................................................................................................................................13
MOUTHRINSES .............................................................................................................................................................14
MUCOSITIS MANAGEMENT ............................................................................................................................................15
TOPICAL ANESTHETICS /OCCLUSIVE RINSES ...................................................................................................................16
INFECTIONS .................................................................................................................................................................17
FUNGAL MEDICATIONS ..................................................................................................................................................18
ANTIVIRAL AGENTS ......................................................................................................................................................19
NEUROTOXICITY ..........................................................................................................................................................19
GROWTH FACTORS .......................................................................................................................................................19
HANDLING OF SECRETIONS DURING CHEMOTHERAPY .....................................................................................................19
NUTRITION ..................................................................................................................................................................20
HEAD AND NECK SURGERY ............................................................................................................................................21

FOLLOWING CANCER THERAPY ...................................................................................................................22


CHEMOTHERAPY ..........................................................................................................................................................22
HEAD AND NECK RADIATION .........................................................................................................................................22
XEROSTOMIA MANAGEMENT .........................................................................................................................................24
PILOCARPINE ...............................................................................................................................................................25
SALIVA SUBSTITUTES /MOISTURIZERS ............................................................................................................................26
TOPICAL FLUORIDES ....................................................................................................................................................27
DIRECT RESTORATIVE MATERIALS FOR XEROSTOMIC PATIENTS .......................................................................................30
PRODUCTS FOR XEROSTOMIA MANAGEMENT ..................................................................................................................32
DRUGS THAT MAY EXACERBATE XEROSTOMIA ................................................................................................................33
BONE MARROW AND PERIPHERAL STEM CELL TRANSPLANT ............................................................................................33
HEAD AND NECK SURGERY REHABILITATION ..................................................................................................................35
ORAL CARE IN PEDIATRIC ONCOLOGY ......................................................................................................38
BACKGROUND ..............................................................................................................................................................38
PRETREATMENT ...........................................................................................................................................................38
ORAL CARE DURING CANCER THERAPY .........................................................................................................................39
ORAL CARE FOLLOWING CANCER THERAPY ...................................................................................................................40
LATE SEQUELAE OF PEDIATRIC CANCER THERAPY ..........................................................................................................40

REIMBURSEMENT FOR CANCER-RELATED ORAL CARE.......................................................................42


INTRODUCTION ............................................................................................................................................................42
SOURCES OF PAYMENT ..................................................................................................................................................42
GOALS AND INITIATIVES ...............................................................................................................................................44

SELECTED REFERENCES ..................................................................................................................................45


INTRODUCTION With the increasing trend in outpatient management, including cancer therapy,
every health care professional is a potential and integral part of the cancer
treatment team that once existed solely within the hospital environment. This
guide is offered as an aid to health care providers in collegial efforts to maintain
oral health prior to, during and following the treatment of cancer.

Oral complications of cancer therapy are the result of:

• Surgical removal of anatomical structures of the head and neck


• The effect of chemotherapeutic agents on bone marrow
(myelosuppression) and direct cytotoxic effects on the cells lining the
oral cavity
• Tissue changes associated with total body radiation and therapeutic
radiation to the head and neck
• The body’s response to allogeneic bone marrow transplant and
associated immunosuppressive drug therapy
• Side effects of adjunctive pharmacological preparations (other than
anti-neoplastic drugs)

GOALS OF THIS GUIDE • Heighten awareness of the effects of cancer therapy on oral health.

• Heighten the awareness of the effects of oral health on the efficacy of


cancer therapy

• Provide health care professionals with oral health care guidelines for
cancer patients

• Emphasize the importance and provide guidelines for palliative oral


health care

• Promote the maintenance of oral health following cancer therapy

• Provide information to health care professionals on support issues


associated with oral health care

INTRODUCTION 1
THE CANCER TREATMENT TEAM An interdisciplinary team can provide comprehensive management of the cancer patient in-
cluding the evaluation and treatment planning considering the overall patient health, tumor
site and stage, tumor biologic status, and cultural/socioeconomic status. To provide optimal
therapy, a functional, communicative, interactive team is critical to the successful manage-
ment and outcome of the cancer patient. Assessment and education is crucial and should be
performed by team members as appropriate in all stages of cancer therapy.

STAGES OF CANCER THERAPY

PRETREATMENT The pretreatment cancer period includes the period of time from the medical diagnosis and
hospital admission to the initiation of the chemotherapy, bone marrow transplant condition-
ing therapy and/ or radiation therapy. If circumstances allow, the pretreatment period is the
optimal time to institute an oral hygiene/and or fluoride regime, restore or remove diseased
dentition and eliminate potential oral sources of infection and trauma.

DURING CANCER THERAPY Cancer treatment usually lasts approximately 30-45 days after chemotherapy induction, bone
marrow transplantation, and/or radiation treatment. This period, defined by significant
myelosuppression and immunosuppression, is a consequence of aggressive cancer treatment.
Therefore, only emergent and palliative oral care is routinely provided during treatment. Oral
hygiene continues to be of paramount importance during this phase. It is important to remem-
ber that some individuals receive chemotherapy for several years, depending on the type of
cancer and the protocol used. Every series of chemotherapy may result in the cycle of
myelosuppression and immunosuppression.

POST CANCER THERAPY The post-treatment cancer period includes long-term follow-up of the patient and ranges
from one year to a lifetime. Patients should be closely monitored for recurrence of cancer as
well as the increased possibility of a second primary. The chronic sequelae of bone marrow
transplantation may necessitate the management of chronic graft versus host disease. Meticu-
lous oral health care for individuals who have received therapeutic radiation to the head and
neck is crucial for the life of the individual.

This document represents a compilation and distillation of the proceedings of the Oral Health in Cancer
Therapy conference. It is a product of the editorial board, and as such does not necessarily represent the
opinion of any individual conference participant, institution, or sponsoring organization. The scientific
literature on the definitive management of oral sequelae of cancer therapy is in many instances equivocal,
and occasionally controversial. The following guidelines are offered based on the existing literature, clinical
evidence and sound clinical judgement. All health care professionals are encouraged to use appropriate
referral to other providers when necessary and to maintain constant communication within the patient’s
cancer treatment team.

2 INTRODUCTION
CANCER THERAPIES

HEAD AND NECK RADIATION


Therapeutic radiation to the head and neck can result in both immediate and long-term oral
complications. Oral sequelae are related to the site and total radiation dose and fraction rate.
Head and neck tumors are commonly treated with 5000-7000 cGy over a 4-7 week period.
Hodgkin’s and non-Hodgkin’s lymphoma require less radiation (approximately 3000-4500
cGy) than other solid tumors of the head and neck.

Side effects of head and neck radiation Although ionizing radiation results in the early death of cancer cells, it also concurrently
damages or kills normal cells, resulting in both short- and long-term debilitating side effects.

Mucositis – Occurs as the result of early cell death in the epithelial basement membrane. The
clinical manifestation of mucositis usually begins within the second week of radiation therapy
and subsides slowly several weeks after radiation therapy is complete. Mucosa in the radia-
tion field may remain thin and atrophic, and minimal trauma may result in ulceration.

Hypogeusia/dysgeusia - Permanent taste loss may occur at >60 Gy. Below this level, recov-
ery usually takes several months. Both mucositis and decreased saliva flow may contribute to
taste alteration.

Dentinal hypersensitivity – a result of lowered pH and resultant demineralization of enamel,


combined with mechanical forces opening dentinal tubules.

Xerostomia - Radiation effects on salivary glands result in atrophy of the secretory cells,
particularly the serous cells, as well as vascular damage and connective tissue changes. The
degree of xerostomia (loss of salivary function) is related to radiation field and radiation
dose. Serous glands degenerate at a faster rate than mucous glands, resulting in saliva that is
more acidic, ropy and does not flow readily. The normal functions of saliva are compromised,
which can result in:

• pH buffer capacity reduction (mean pH reduced from 6.45 to 5.48-6.05)


• decreased remineralization capacity
• decreased antimicrobial capacity
• decreased cleansing of the mouth
• taste alterations
• difficulties with:
deglutition
mastication
speech

Dental caries – The concept of dental decay as a transmissible, microbial disease is funda-
mental to the understanding of the etiology of the extensive dental disease (radiation caries)
seen in head and neck radiation patients. Radiation induced atrophy of salivary gland tissue
leads to a decrease in quality and quantity of saliva, reducing the antimicrobial, cleansing and
remineralizing effect of the saliva. In the absence of daily fluoride treatment and proper oral
hygiene maintenance, there can be rapid destruction of the dentition.

CANCER THERAPIES 3
The effects of radiation on bone, periosteum, connective tissue, and vascular epithelium gen-
erally develop over time and include suppressed osteoblastic activity, decrease in cell num-
bers, disorganization of bone remodeling, hypovascularity, and increased fibrosis. Smaller
blood vessels are more sensitive than large vessels. Initially, there is a periarteritis and endar-
teritis that progresses to intimal thickening, fibrosis, and loss of endothelium. This results in
narrowing and possible obliteration of the lumen, reducing the blood supply to all tissue
within the radiation field.

Trismus - fibrosis of the masticatory muscles and TMJ capsule, usually occurring 3-6 months
after radiation therapy, with unpredictable frequency and severity. It is accentuated by some
surgical resections.

Loss of periodontal attachment – increased tooth loss and greater periodontal attachment
loss over time in teeth included in high-dose radiation fields.

Osteoradionecrosis (ORN) – is a result of the irradiated bone’s inability to undergo effective


healing due to local hypovascular, hypocellular and hypoxic changes, and the risk of ORN
increases over time. ORN is confined primarily to the mandible while ORN of the maxilla is
rare. Pretreatment dental management should strive to eliminate or reduce the possibility of
subsequent foci for ORN. Patients who have undergone head and neck radiotherapy should
always be considered to be at higher risk for ORN.

Nutritional deficiency – caused by the effects of mucositis, xerostomia, hypogeusia, and loss
of appetite that can make eating a pleasureless and painful chore. Symptoms may include
rapid weight loss, dehydration, nutritional stomatitis, and secondary oral infection, specifi-
cally candidiasis.

CHEMOTHERAPY

Direct cytotoxic effects Chemotherapeutic agents affect the rapidly dividing cells of the target tumor and the lining
epithelium as well as the oral ecology and the vascular, inflammatory and healing response of
the oral cavity. These alterations may result in mucositis and ulceration of the oral mucosa.
Mucositis is marked by inflammation and ulceration of the mucosal lining of the mouth,
pharynx, esophagus, and GI tract due to the direct cytotoxic effects on the epithelial cells. It
may be exacerbated by secondary infection with bacteria, fungi and viruses. In severe cases
it may prevent oral intake due to severe pain. These denuded surfaces may also serve as an
entry portal for organisms to the systemic circulation.

Indirect effects of myelosuppression Chemotherapeutic agents also target the hemopoietic cells of the bone marrow heightening
the risk of infection due to a decrease in the number of neutrophils (neutropenia = neutrophil
count <1,000/mm3) and immunosuppression.

Bacterial infection - Localized odontogenic infection may be difficult to diagnose in neutro-


penic patients since swelling is often not present. These infections will be more prone to
spread to other body sites because of the loss of neutrophil activity. Between 25% and 54%
of cases of septicemia in neutropenic cancer patients may originate from oral infection. In-
fections in the oral cavity are associated with oral ulcers, periodontal disease, pulpal disease
and sinus infections. Infection is a common cause of morbidity and death in patients receiv-
ing chemotherapy for treatment of acute leukemia.

Viral infection - Herpes simplex virus type 1 (HSV-1) reactivation has serious local implica-
tions due to pain, impaired hydration and nutrition. It most commonly occurs as a component
of chemotherapy mucositis resulting in multiple oral ulcerations involving any intraoral and
perioral soft tissue surfaces. Since these patients are expected to develop mucositis second-
ary to their chemotherapy, HSV reactivation may be overlooked as an etiologic component.
Mucositis complicated by HSV reactivation tends to be more severe and last longer. In
leukemia and bone marrow transplantation patients, reactivation of HSV occurs in 50-80%
of HSV seropositive patients. Prophylactic acyclovir offers effective control and is com-

4 CANCER THERAPIES
monly used in bone marrow transplant patients. However it is not routinely used in patients
on cancer chemotherapy. These patients should be evaluated closely for HSV reactivation.
The systemic consequence of HSV infection is the disruption of the mucosal barrier, allow-
ing a portal of entry for commensal oral microorganisms which can lead to sepsis. Herpes
varicella zoster virus (VZV) cytomegalovirus (CMV), Epstein-Barr virus (EBV), human her-
pesviruses (HHV-6, 7, 8) as well as community respiratory viruses, although much less com-
mon than HSV, have also proven problematic during the course of chemotherapy.

Fungal infection - Candidal infections of the oral mucosa are common in patients undergo-
ing chemotherapy and can cause a burning or scalded sensation, distort taste and interfere
with swallowing. Spread to the esophagus or systemic dissemination is a serious consequence.
Systemic fungal infection is a common cause of infectious death in neutropenic patients,
because established systemic infections may be difficult to recognize and can prove difficult
to treat.

Thrombocytopenia - Decreased platelet number is a common complication in patients on


chemotherapy. Patients are at risk for postoperative bleeding with dental surgery when the
platelet count is below 50,000/mm3. Spontaneous mucosal bleeding can occur when the
platelet count is below 20,000/mm3. The oncologist should be advised of the potential for
bacteremia and/or bleeding associated with proposed dental procedures during chemotherapy.

BONE MARROW
PERIPHERAL STEM CELL
TRANSPLANT
With bone marrow/peripheral stem cell transplant (BMT/PSCT), the bone marrow is de-
stroyed by intensive-dose chemotherapy or radiation therapy, or a combination of both. Bone
marrow may be replaced by bone marrow or stem cells from either the patient or a donor. In
some cases transplantation is used to replace bone marrow that is either diseased or defective.
Alternatively, it may be given as a rescue after high-dose chemotherapy that would poten-
tially be lethal. Diseases typically treated with BMT/PSCT transplant are leukemia, aplastic
anemia, myelodysplasia, myeloma, lymphoma, breast cancer, and in some cases of ovarian
cancer.

Types of transplant Autologous transplant

The patient’s own bone marrow and/or peripheral blood stem cells are removed and pre-
served. Associated oral complications are those related to chemotherapy and neutropenia.
Overall transplant-related mortality rate is approximately 2%.

Allogeneic transplant

Bone marrow and/or peripheral blood stem cells are donated by a family member or a HLA
(Human leukocyte antigen) matched individual. Associated oral complications include those
from chemotherapy and related neutropenia and graft-versus-host disease (GVHD). Overall
transplant-related mortality rate is approximately 25% in related individuals and 40-60%
with an unrelated donor.

Syngeneic

Bone marrow and/or peripheral blood stem cells are taken from an identical twin. Associated
oral complications are those from chemotherapy and related neutropenia. GVHD and oppor-
tunistic infections occur less frequently than with allogeneic transplants. Overall transplant-
related mortality rate is approximately 2%.

CANCER THERAPIES 5
HEAD AND NECK SURGERY

Goals of extirpative surgery • The primary goal of any head and neck cancer surgery is the complete removal of
tumor.
• Secondary goals include the preservation of functional and cosmetic status

Goals of surgical reconstruction • Maintenance or restoration of the quality of life should remain the benchmark of
any reconstructive surgery and prosthetic rehabilitation
• Restoration of dentition and supporting structures
• Maintenance of oral and lip competence
• Preservation or restoration of chewing and swallowing
• Prevention of aspiration
• Preservation or restoration of speech
• Protection of vital structures
• Restoration of cosmetic status

Types of reconstruction Soft tissue reconstruction

The reconstructive choice depends on extent and anatomic location of the defect, patient
factors (prior radiation therapy, etc.) and end results desired, and may include:

• Healing by secondary intention


• Primary closure
• Skin grafts
• Local and regional flaps
• Free tissue transfer

Osseous reconstruction

The reconstructive choice depends on extent and anatomic location of the defect, patient
factors (prior radiation therapy, etc.) and end results desired, and may include:

• Alloplastic materials (e.g., synthetic bony materials)


• Allogeneic bone (e.g., cadaveric bone)
• Autologous bone
Nonvascularized
Vascularized

6 CANCER THERAPIES
PRETREATMENT

PRETREATMENT OBJECTIVES • Eliminate sources of intraoral trauma and infection (calculus, sharp teeth, ill-fitting
prosthesis/appliances, anything that could cause intraoral trauma)
• Obtain impressions of teeth to fabricate custom trays for trauma protection and/or
fluoride delivery, as indicated
• Obtain appropriate radiographs to establish baseline dental evaluation and identify
pulpal, periapical and/or periodontal pathology that require immediate attention
• Complete periodontal charting to establish baseline dental evaluation and identify
periodontal problems that are likely to interrupt cancer treatment
• Restore advanced carious lesions and fractured restorations
• Address dental limitations to adequate nutrition

CONSULTATIONS
The dental professional should provide the oncology team with the following information:

• Dental treatment/management plan and timeline


• Unresolved oral health issues that may interrupt or complicate cancer regime
• Unresolved oral health issues that may significantly effect patient comfort during
therapy
• Anticipated oral complications

The oncology team should provide the dental professional with the following information:

• The patient’s current health history and the cancer diagnosis


• Palliative or curative therapy regimen
• Patient prognosis
• In the case of chemotherapy, the anticipated number of treatment cycles and agents to
be administered
• Route of administration (Patients with a vascular access device may require antibiotic
premedication for dental treatment)
• Current blood data with special attention to the white blood cell count and
differential, the absolute neutrophil count and the platelet count
• In the case of radiation treatment, the cumulative dose and site of delivery should be
reviewed
• In the case of bone marrow transplantation, the type of transplant should be reviewed
• Anticipated timing of side-effects

DENTAL ASSESSMENT

All patients should receive a dental evaluation prior to radiation therapy to the head and neck,
chemotherapy, or bone marrow/stem cell transplant. It is particularly important to obtain an
evaluation if the patient has:

• Not seen a dentist within one year


• Bleeding gums
• Loose teeth
• Ill-fitting dentures
• Periodontal disease
• Orthodontic brackets, bands or fixed arch bars (retainers)

PRETREATMENT 7
Dental history • Previous, current and anticipated oral hygiene practices
• Continued alcohol and/or tobacco use
• Patient motivation, expectations and compliance potential
• Physical limitations to oral hygiene
• Nutritional status

Examination • Review dental history of previous oral trauma and history of


mucocutaneous disease, such as herpes simplex, aphthous stomatitis and candidiasis
• Complete a head and neck examination, including lymph node palpation
• Conduct an intraoral examination, including dental, periodontal and soft tissue
findings and oral hygiene status. Document all existing restorations and evaluate for
tooth mobility, sensitivity and vitality. In addition, identify sources of potential or
existing irritation
• Record vertical dimension opening
• Measure and record salivary function/flow rate
• Obtain a panoramic radiograph and bitewing radiographs as basic screening films
Additional radiographs should be taken as indicated by clinical findings
• Establish a diagnosis for all hard and soft tissue lesions documented.
• Provide standard oral hygiene instructions emphasizing managing plaque control during
cancer treatment
• Coordinate a treatment plan with the patient, family and oncologist, emphasizing
treatment of emergent or acute oral disease, and elimination of teeth with
questionable long-term prognosis

ORAL HYGIENE

Ideally, the patient’s oral hygiene routine should be performed 3-4 times a day or within 30
minutes following meals and at bedtime. As the severity of oral complications increase, oral
hygiene becomes increasingly important. Oral hygiene prior to the application of topical
local medications for oral infections and/or ulcerations renders the medication(s) more effec-
tive.

Brushing • Brush slowly with gentle placement, no pressure


• Avoid trauma
• Use super soft brush: Biotene®, Oral Swab® (foam brushes are not recommended)
• Non-tartar control, non-peroxide, flavor-free, fluoride toothpaste or children’s
toothpaste
• Electric toothbrushes and water irrigation devices are not recommended during
neutropenia

Toothbrush care • Use two toothbrushes and alternate brushes


• Rinse in chlorhexidine or bleach, then with water and dry
• Replace toothbrush frequently

8 PRETREATMENT
Denture care • Removable appliances should not be worn during treatment, if possible
• Dentures should always be removed at night
• Routine denture care:
Always keep appliance in solution when not in the mouth
Clean daily with denture brush
Soak appliance overnight in commercial cleanser or water
• Antifungal therapy alternatives:
Bleach (1 tsp bleach in 8 oz water) for 30 minutes and rinsed thoroughly
Nystatin
Chlorhexidine

FLUORIDE THERAPY

Xerostomia associated with therapeutic radiation to the head and neck is permanent and
usually progressive. It is imperative to communicate the importance of lifelong fluoride therapy
to the patient and family. Ideally, the patient should be started on fluoride therapy prior to
radiation treatment. This may take the form of fluoride gel carriers, brush-on gel, or fluoride
rinses. Fluoride therapy and education should be repeated and reinforced following therapy.

PRETREATMENT PROCEDURES

Bone marrow Oral hygiene and dental recommendations should be related to the prescribed conditioning
peripheral stem cell therapy and coordinated with the transplant physician. Immediacy and extent of treatment
transplant should be determined by consultation between dentist and transplant physician as dictated by
state of disease, immunocompetency, and goals and expected outcome of therapy. If the pa-
tient is neutropenic the need for prophylactic antibiotics with invasive dental treatment should
be discussed with the medical oncologist. If the patient has been on recent chemotherapy or
in the unfortunate circumstance that the BMT conditioning therapy has begun, a broad spec-
trum antibiotic should be considered because of a shift in the patient’s oral flora towards
more gram negative organisms. Options would include ticarcillin plus clavulanic acid or
piperacillin plus tazobactam.

Graft vs host disease prophylaxis Acute GVHD occurs within 100 days of allogeneic stem cell transplant in 18 - 70% of trans-
plant recipients.

• Systemic prevention:
Match histocompatible donor and recipient bone marrow

• Supportive care
Infection prevention and/or treatment
Parenteral hyperalimentation
Immunosuppressive prophylaxis

• Post-transplant administration of methotrexate (MTX), cyclophosphamide,


antithymocyte globulin (ATG), prednisone, cyclosporine (CSP), or combinations of
MTX and CSP with or without prednisone. This drug regime also prevents graft
rejection

PRETREATMENT 9
Endodontics • Conventional root canal therapy should be accomplished as a single procedure for
carious teeth with pulpal involvement confined to the tooth.
• Teeth outside the radiation field with necrotic or infected periapical tissue should
receive root canal therapy.
• Extract apically involved teeth within the radiation field.
• Teeth with periapical radiolucencies that have been previously treated endodontically
should be assessed for clinical signs and symptoms of current infection

Infection prophylaxis All patients with positive antibody titers to herpes simplex virus should receive acyclovir
prophylaxis with oral capsules (200 mg tid) or infusion (250 mg/m 2 q 8h) if oral intake is
disrupted during or after transplant. This typically begins with conditioning chemotherapy
and continues through neutropenia. Some patients may be treated multiple times after trans-
plant or put on indefinite prophylaxis as recurrences are common.

Many centers employ fluconazole prophylaxis to prevent or lessen fungal infections with
BMT. Typical therapy is 400 mg per day oral medication beginning with conditioning che-
motherapy and continuing through neutropenia. Infusion with a similar dose may be used
with compromised oral intake.

Nutrition • Nutritional status evaluation


• Height and weight
• Dietary intake and supplement use
• Biochemical indicators of protein status:
Albumin
Transferrin
Immune status
• Clinical signs of nutrient deficiency

Oral and Maxillofacial Surgery • Consider extraction for:


• Partially erupted third molars
• Pericoronitis
• Non-restorable fractured teeth
• Unresolved periapical lesions
• Teeth that lie within the radiation field
• Advanced periodontal disease

• Extractions should be performed with minimal trauma


• For extractions allow sufficient healing prior to initiation of therapy:
• Radiation therapy: Minimum of 14 days, 21 days optimally
• Chemotherapy: 3-5 days in the maxilla
5-7 days in the mandible
7-10 days for third molars

10 PRETREATMENT
Periodontics • Remove orthodontic bands and appliances that may cause trauma to oral mucosa
• If bands are not removed, soft wax/plastic mouthguards may be used to cover them
during periods of oral inflammation or ulceration

Orthodontics • Pretreatment prophylaxis and/or scaling and root planing is recommended for all
patients
• Teeth with 4-6 mm periodontal pocketing should be evaluated for extraction
• Extract teeth which display:
Advanced bone loss
Excessive mobility
Purulence or excessive bleeding on probing

Prosthodontics • Discontinue use of removable prosthodontic appliances during therapy


• Avoid using denture adhesives
• Clean removable prostheses well

If the oral health of the individual scheduled to receive cancer therapy cannot be
stabilized in order to eliminate serious risk of infection from the oral cavity and
significant risk of mortality, cancer therapy should be delayed until the oral health
issues can be satisfactorily resolved.

PRETREATMENT 11
DURING CANCER THERAPY

HEMATOLOGIC GUIDELINES The chemotherapy cycle alone or as conditioning therapy for bone marrow/stem cell trans-
plantation consists of cytotoxic drug administration followed by a rest period for healthy
tissue recovery prior to repeated drug administration. An important clinical implication of
this format is that peripheral white blood cell counts change dramatically during the course
of this cycle. Appropriate timing of dental procedures during chemotherapy is critical. The
risk of infection and septicemia is greatest when the patient’s neutrophil count reaches their
“nadir” (the lowest blood count). This occurs at approximately 7-10 days after therapy. If
dental treatment is performed, it should be immediately preceded by consultation with the
oncologist and documentation of the patient’s hematological status. Treatment should only
be performed if the absolute neutrophil count (ANC) has recovered and reached a level of
1,000/mm3 and the platelet count and function are adequate. Surgical procedures should be
scheduled to allow 7-10 healing days prior to the next cycle of cytotoxic drug administration.

• Absolute Neutrophil Count (ANC) should be equal to or greater than 1,000/mm 3


• Platelet count should be equal to or greater than 50,000/mm 3
• Clotting factors (PT, PTT, fibrinogen) should be normal
• Invasive dental procedures should not be performed if the ANC is expected to be
less than 1,000/mm3 within 10-14 days of the procedure

AHA ANTIBIOTIC PROTOCOL

If chemotherapy is being delivered through a vascular access device (central venous catheter,
osteoport), the patient should receive the American Heart Association endocarditis prophy-
lactic antibiotic regime prior to invasive dental procedures.

Amoxicillin Adults: 2.0g


Children: 50 mg/kg P.O. 1 hour prior to procedure

Alternatives to penicillin

Clindamycin Adults: 600 mg


Children: 20 mg/kg P.O. 1 hour prior to procedure

Cephalexin Adults: 2.0 g


or Children 50 mg/kg P.O. 1 hour prior to procedure
Cefadroxil

Azithromycin Adults: 500 mg


or Children: 15 mg/kg P.O. 1 hour prior to procedure
Clarithromycin

12 DURING CANCER THERAPY


ORAL HYGIENE

Patients should participate in the fullest oral hygiene protocol they can tolerate. Pain and/or
edema of oral cavity often prevents patients from continuing oral care during the peak of
mucosal injury. The indication for mechanical removal of plaque is dependent on the patient’s
blood count and presence of oral ulceration.

General guidelines • Continue pretreatment oral hygiene regime


• Fluoride gel applications in xerostomic patients should begin as soon as mucositis
resolves
• Use previously fabricated custom mouthguards to reduce trauma during therapy

Brushing • Continue brushing as per prior instructions


• Monitor patient for trauma and potential hemorrhage during granulocytopenia
(<500/mm3) thrombocytopenia (<40,000 mm3) or mucosal sensitivity.
• Bone marrow transplant: Oral care when platelet count < 20,000 mm3 or
ANC < 500 mm3
• Discontinue brushing and flossing
• Use cotton swabs, gauze sponges and chlorhexidine rinses
• Use sponge dipped in chlorhexidine to remove plaque

Flossing • Use waxed or tape floss - slides more easily and less likely to damage soft tissue
• If patient has not been flossing, now is not the time to start
• If patient has good dental health, maintain flossing above the dental papilla through
out therapy

Frequent rinsing • Should be used in conjunction with, and not in place of oral hygiene regimen
• Cleans and lubricates tissues
• Prevents crusting
• Treats mucosal wounds
• Hydrates and irrigates mucosal tissues
• Soothes sore gingiva and mucosa
• Removes debris
• Prevents accumulation of debris and bacteria

DURING CANCER THERAPY 13


Mouthrinses

COMPOSITION /INSTRUCTIONS FOR USE USES/FUNCTIONS DISADVANTAGES

Neutral rinse 1/4 tsp salt May be used during mucositis


1/4 tsp baking soda Neutralizes acids after emesis
1 qt. H2O Dissolves thick, mucinous salivary
Use q 2 hours until soreness, nausea or secretions
ropy saliva contraindicate. Soothing to irritated tissues
Switch to 1/2 tsp. soda and 1 qt. water or Dislodges debris
water only, if necessary.
Should not be swallowed

Saline rinse 1/2 tsp. salt Not damaging to oral mucosa


8 oz water Helps reduce mucosal irritation
Increases moisture in mouth
Removes thickened secretions and
debris
Recommended for treatment of
leukemic gingivitis and head and neck
radiation

Calcium phosphate Rinse QID or q 1 hr for mucositis Remineralization No published study on


(Caphasol®) mucositis

Chlorhexidine Rinse with 15-30 cc for 1 minute TID Used in presence of poor plaque May alter oral flora
Can be used as a mouthwash and gargle control, signs of inflammation or May delay healing
but should not be swallowed decreased salivary flow Contains alcohol
Allow 30 min before other oral hygiene Effective topical agent Stains both teeth and
procedure Has potent broad-spectrum antimicro- restorations
Rinsing with water intensifies unpleasant bial activity Toothpaste and nystatin
taste Effective at low concentration reduce its effectiveness
Should not replace dental evaluation/ Minimal absorption from the GI tract Promotes bacterial
treatment Results in fewer febrile days (pseudomomas) growth
An alcohol-free, aqueous 2% solution can Unpleasant taste
be compounded by the pharmacist
Can be applied locally with cotton swab

Hydrogen peroxide Not recommended for use as daily rinse Helpful in periodontal infections when May delay wound healing
Should be diluted 1:4 if used anaerobic microorganisms are involved Cause demineralization
Do not use in the presence of blood clots, May promote emesis
as this may promote bleeding Causes dry mouth, thirst
Use to cleanse wounds prior to secondary and discomfort
medication/rinse Promotes fungal growth
Use for 1-2 day maximum Unpleasant taste
Should be followed by therapeutic rinses

14 DURING CANCER THERAPY


MUCOSITIS MANAGEMENT

Numerous systems have been proposed to grade the severity of mucositis in an effort to
standardize the reporting of clinical findings. To date, no single scale is universally accepted
for reporting mucositis. The scale developed by the National Cancer Institute according to
common toxicity criteria is:

0 None
1 Painless ulcers, erythema, or mild soreness
2 Painful erythema, edema, or ulcers, but patient can eat solids
3 Painful erythema, edema, or ulcers, but patient cannot eat solids
4 Requires parenteral or enteral support

General guidelines • Mucositis is common with bone marrow transplant, when chemotherapy is combined
with radiation therapy, when chemotherapy is given to treat leukemia, and when
chemotherapy is given to treat GI cancer
• Severity of chemotherapy-induced mucositis is related to degree of neutropenia.
Mucositis will be most severe at the nadir (lowest) of the neutrophil count
• Virtually all radiation therapy patients who receive over 5000 cGy of radiation
develop mucositis
• Hydrogen peroxide can be used for debridement of ulcerated areas but should be
avoided as a part of a daily rinse
• Although there are conflicting results, chlorhexidine used prophylactically, may help
reduce chemotherapy-induced mucositis. It does not appear to be helpful with
radiation mucositis
• Any removable prosthetic appliances should be removed during mucositis
• Suspicious oral lesions should be evaluated for Candida by Gram stain or KOH
preparation
• Unless previously ruled out, or if the patient is receiving acyclovir prophylaxis, all
chemotherapy-induced mucositis lesions should be cultured for HSV
• It appears that HSV reactivation is not a significant factor in radiation mucositis.
• Use topical anesthetics and/or systemic pain medication for pain control

Topical analgesics • Provide temporary pain relief, but may intensify and prolong mucositis
• May cause burning discomfort
• May increase oral trauma during mastication
• May increase nausea
• May provoke choking in conjunction with food

Dietary management • Suggest non-acidic, bland foods with high moisture content:
Custard
Puddings
Cream soups
Smooth, mildly seasoned casseroles
Soft cooked eggs
Ice cream and milk shakes
• Encourage patients to vary the diet as much as possible to increase and sustain interest
in eating
• Consider consultation with a registered dietician (RD) if oral intake is severely com
promised

Lip care • Moisturize for comfort, especially in the presence of fever or mouth breathing
• Lip status affects nutrition
• Lip moisturizers should be water or lanolin based lubricant

DURING CANCER THERAPY 15


Topical Anesthetics/Occlusive Rinses

COMPOSITION /INSTRUCTIONS FOR USE USES/FUNCTIONS DISADVANTAGES

Viscous lidocaine Rinse (30 sec. and spit) or apply topically Soothes oral mucosa Risk of aspiration
Do not eat following application May promote emesis
Consider dilution Potential for toxicity and
systemic absorption

Hurricaine® Apply as needed for pain Onset in 30 seconds Short duration relief
20% Benzocaine 15 minutes duration May promote emesis
topical gel No systemic absorption

1-2-3 Mix 1.5 ml - 50 mg/ml injectable diphenhydramine Combination of topical Diphenhydramine extends
45 ml - viscous xylocaine 2% analgesic and coating effect therapeutic effect, but may be
45 ml - magnesium aluminum hydroxide deleted due to alcohol content
Swish and hold 5ml in mouth for 30 seconds Composition may vary
Use up to 4 times a day
Small amount may be swallowed

Orahesive® Hold against oral site for 1-2 minutes Provides immediate relief Unpleasant sensation
Can remain in place for an average of 18 hours Thin dressing that forms
Relief up to 30 hours depending on location protective coat
and application technique Not harmful if swallowed

Zilactin B® 7.5 g tube Provides protective coating Mild burning pain with
Apply prn for up to 3 hours application
Dry affected area and isolate until gel sets

Lortab ® “R” elixir Begin with 1 tsp 30 minutes before meals and Acts as analgesic and antitus- Possible side effects:
gradually increase dose to 4 tsp as needed sive to relieve pain associated drowsiness
1 tsp. of Lortab contains: with esophagitis mental clouding
12.5 mg hydrocodone bitartrate Contains alcohol mood changes
120 mg acetaminophen Dosage of other pain medica-
7 % alcohol tions may require adjustment

Sucralfate 10 cc, gentle swirl, QID or q2 hours if not Cytoprotective effect Contains sugar, so long term
(Carafate®)) swallowed Useful against oral mucositis use can increase caries risk
Mixture must be refrigerated and shaken well Anti-ulcer drug Coats mucosa, therefore may
before use Prevents the colonization of mask infections, so patient
Allow 30 minutes after oral hygiene care micro-organisms, reduces pain requires constant monitoring
before using Nonirritating and non-
Sucralfate suspension: dehydrating
8 crushed sucralfate tablets,
40 ml sterile water,
3 Ensure VariFlavor Pacs®
10 ml sterile water
Add water to 120 ml.
Swish and hold 1 tsp in mouth for 30 seconds

Prostaglandins Topical use of PGE2 tablets 0.5 mg/day QID in Reduction in local inflamma- Not effective prophylactically
radiation or chemotherapy- induced mucositis tion without affecting circulat- against mucositis in BMT
Lozenge form available ing levels of PG’s patients
Causes less severe stomatitis
and less pain
Protects oral mucosa from
injury

16 DURING CANCER THERAPY


INFECTIONS

Radiation therapy patients are at risk for candidal infections, and BMT and chemotherapy
patients continue to be at risk for recurrent infections throughout their neutropenic period.
Patients should be taught to monitor themselves for infection and to contact a healthcare
professional immediately if signs appear. The signs of infection include:

• fever
• chills
• shivering
• diarrhea

Bacterial Infections Early identification and treatment of infections leads to a decrease in the severity of stomati-
tis and helps control pain. If the patient is already on prophylactic broad spectrum antibiot-
ics, identification of the bacterial source may be problematic. If possible, identify the source
of infection and select appropriate antimicrobial agents to effectively manage bacterial infec-
tions.

• Bacitracin - 500 units/gm (Polysporin®, Betadine Brand First Aid Ointment®)


Apply a thin film 2-3 times a day
Cleanse area before applying, especially if crusted

• Neomycin - 3.5mg/g (Neosporin®)


Apply a thin film 2-3 times a day

• Vancomycin (Vancocin®, Vancomycin®)


For Gram positive bacterial infections
Potential toxicity

• Gram negative bacteria are often resistant to penicillin and cephalosporins


Trimethoprim (Bactrim DS®, Proloprim®, Trimpex®, Septra DS®)
Sulfamethoxazole (Urobiotic®, Bantanol®)

Fungal Infections • Treat infections aggressively as oral candidiasis can evolve to esophageal candidiasis
or fungemia (If patients with oral candidiasis complain of sore throat they should be
evaluated for esophageal candidiasis)
• Fluconazole tablets or clotrimazole troches are the most popular therapies
(compliance better with fluconazole due to one time versus five times per day dosing)
• Itraconazole suspension may be used if patient has resistance to fluconazole
• Avoid nystatin suspension due to sugar content and poor patient acceptance
• For treatment of prosthetic appliances see pretreatment strategies for denture care

DURING CANCER THERAPY 17


FUNGAL MEDICATIONS

Fluconazole (Diflucan ®)100 mg tablets


Disp: 8 tablets
Sig: Take 2 tabs on day one and then one tab for 6 to 13 days
(Oral suspension is also available in 10 mg/ml)

Clotrimazole (Mycelex ®) 10 mg troches


Disp: 70 troches
Sig: Dissolve one troche in the mouth five times per day for 14 days

Itraconazole (Sporonox ®) suspension 100 mg/10 ml


Disp: 140ml
Sig: Swish and swallow 200 mg for 7 to 14 days

Amphotericin B (Fungisone ®) suspension 100 mg/ml


Disp: 24 oz bottle
Sig: Apply 1 ml on tongue 4 times per day for 14 days

Ketoconazole (Nizoral ®) 200 mg tabs


Disp: 14 tabs
Sig: Take one tab per day for 14 days

Nystatin (Mycostatin ®) 200 mg oral troches


Disp: 56 troches
Sig: Dissolve troche in mouth four times per day for 14 days

Viral infections • All mucositis lesions should be cultured for HSV unless the patient is already taking
or has been prophylaxed with acyclovir (Zovirax ®)
• Ointments containing acyclovir (Zovirax®) and penciclovir (Denavir®) are probably
not appropriate for these patients as extent of disease requires systemic therapy
• Outpatient treatment for less severe disease: acyclovir capsules
• Inpatient treatment in patients with severe disease: acyclovir IV
• Other options with advantage of better patient compliance but higher cost:
Famciclovir (Famvir®)
Valacyclovir (Valtrex®)
• For acyclovir-resistant viruses, other antiviral agents include:
Foscarnet (Foscavir®)
Brivudin
Brovavir
• Cytomegalovirus (CMV) infection is not uncommon in immunosuppressed
(transplant) patients. Systemic antiviral (ganciclovir) is the treatment of choice

18 DURING CANCER THERAPY


Antiviral agents
Acyclovir (Zovirax ®) 200 mg caps
Disp: 35 caps
Sig: Take one cap five times per day for seven days

Acyclovir (Zovirax ®) IV
Sig: 5mg/kg every eight hours for seven days

Famciclovir (Famvir ®) 500 mg caps


Disp: 14 caps
Sig: Take one cap two times per day for seven days

Valacyclovir (Valtrex®) 500 mg caps


Disp: 14 caps
Sig: Take one cap two times per day for seven days

NEUROTOXICITY
Chemotherapeutic agents may have toxic effect on peripheral, autonomic and cranial nerves.
Drug-induced neurologic disorders may induce oral pain that mimics that of dental or peri-
odontal origin. If this occurs, reassure the patients and administer palliative treatment to
minimize discomfort. These neurological effects usually subside when the course of chemo-
therapy has been completed.

GROWTH FACTORS

Growth factors are a promising area of study for relief and recovery. They include colony
stimulating factors (GCSF and GMCSF), transforming growth factor B (TGFB), and
keratinocyte growth factor (KGF) among others. All are currently in clinical trials to deter-
mine if they can reduce chemotherapy and radiation induced mucositis.

HANDLING OF SECRETIONS
DURING CHEMOTHERAPY
The healthcare provider should be aware that the vomitus, tears and saliva of a patient under-
going chemotherapy contain cytotoxic drugs and should be handled as hazardous waste.

DURING CANCER THERAPY 19


NUTRITION

Malnutrition and dehydration The dietitian should be involved in patient care and evaluation from the onset. Patients should
receive supportive therapy to address malnutrition and dehydration as secondary consequence
of vomiting, loss or alteration of taste, nausea, pain associated with mucositis, ulceration and/
or local infection.

• If ice chips are used, allow them to melt - do not chew


• Eat small frequent meals
• Maintain caloric intake
• Dysgeusia/dysphagia
Intensifying the odors of food can increase the palatability of foods
Increasing concentrations of flavoring ingredients can compensate for sensory losses
Zinc sulfate 220 mg tablets 2 times daily with meals may improve taste sensation
Aspirin or a mixture of aluminum hydroxide, magnesium hydroxide, and oxethazaine
(Mucaine®, Wyeth Laboratories) can be used for gargling to ease dysphagia

Nausea/vomiting • Antiemetics
Ondansetron (Zofran ®) and granisetron (Kytril®) for extreme or persistent nausea
Prophylactic antiemetic administration is effective
• Colony Stimulating Growth Factors
• H2 antagonists for hyperacidity
• Dose modification of chemotherapeutic agent may be necessary
• Relaxation techniques may be used to decrease psychogenic response before chemo
therapy treatment
• Remove dentures during vomiting to decrease gag reflex
• Sugar-free hard candies reduce anticipated nausea and act as a sialogogue to
stimulate saliva in medication-induced xerostomia
• After vomiting, rinse mouth with water, spit out the water, then swallow a few sips of
cool water to clear mouth of stomach acids which irritate the mucosa

Food as therapy • Eat small frequent meals


• Choose nutrient dense foods
• Eat high calorie foods that emphasize protein
• Promote frequency, consistency and balance
• Combine proteins and carbohydrates
• Increase water intake
• Serving suggestions
Softer, cool, or frozen foods - yogurt, milkshakes or popsicles
Soft foods that are easy to swallow - milkshakes, soft fruits, fruit nectars, cottage
cheese, mashed potatoes, macaroni and cheese, et cetera
Puree foods
Use more butter, sauces and gravies in food
Recommend cream not tomato sauces
• Liquid meal replacements
High in protein and calories
Have extra vitamins and minerals
Most contain little or no lactose
• Carnation Instant breakfast with ice cream

20 DURING CANCER THERAPY


Foods to avoid • Cinnamon
• Abrasive foods
Granola
Toast, crackers (rough, coarse, dry foods)
Taco chips, popcorn, nuts and seeds
• Acidic foods
Citrus
Tomato sauces/juices
• Spicy/salty/overly sweet foods
• Foods that require excess chewing
Chewing gum
Raw vegetables
• Desiccants
Alcohol
Mouthwash
• Food temperature extremes
• Foods and beverages with sucrose
• Chewing ice
• Tobacco

HEAD AND NECK SURGERY

Acute Complications • Electrolyte imbalance


• Management and removal of closed suction drainage
• Suture and staple care and removal
• Fibrinous exudate in secondary healing in oropharyngeal sites
• Dehiscence of primary closure sites
• Serous or exudative accumulation in surgical site
• Bleeding
• Infections
• Enteral alimentation (tube feedings)
• Tracheostomy care
• Pain management
• Disorders in speech and swallowing
• Oral management
• Shoulder dysfunction
• Motor and sensory cranial nerve deficits
• Disturbances in a mental status
• Limitations in oral motor function

DURING CANCER THERAPY 21


FOLLOWING CANCER THERAPY

CHEMOTHERAPY

Before next course of therapy

• Emphasize oral hygiene


• Set up for 3 month recall
• Call oncologist to determine adequate hematologic status for dental therapy

After completion of chemotherapy

• Maintain normal dental recall schedule


• Confirm normal hematologic status
• Maintain optimal oral health in the event further myelosuppressive therapy is required

HEAD AND NECK RADIATION

Oral Hygiene • Patient should be placed on 3 month dental recall after the completion of RT
• The importance of oral hygiene and patient education can not be overstated during
long term follow-up
• Evaluate the extent of xerostomia and recommend palliative/preventive measures

Management of Trismus • Compare vertical dimension opening before/after radiation therapy.


• Fashion a device so the patient can measure dimension (e.g., Tongue depressors taped
together)
• Demonstrate rigorous daily opening and closing exercises
• Recommend warm moist heat before and after exercise
• Prescribe anti inflammatory and muscle relaxant drug therapy as needed

Endodontics • Cautious conservative endodontics can be performed if trismus does not preclude
access
• Instrumentation should not violate periapical tissues
• Extrusion of filling material beyond the apex should be avoided
• Caustic agents should be avoided
• Access openings should never be left open
• Strong temporary restorations should be placed
• Periapical radiolucencies may not resolve in irradiated bone
• Periapical surgery should be avoided in irradiated bone

Periodontics In management of periodontal disease, including deep scaling and root planing, it should be
remembered that post radiation patients are at increased risk for ORN and care must be taken
to minimize tissue trauma.

• Flap surgery with or without osseous recontouring should be avoided


• Consistent prophylaxis regimen
• Chlorhexidine rinses for short durations
• Tetracycline 250 mg q 6 hours for 14 days
• Hyperbaric oxygen
• Subgingival irrigation at prophy appointments

22 FOLLOWING CANCER THERAPY


Prosthodontics • Pre-prosthodontic evaluation of salivary function and load bearing tissues
• Evaluate the appearance of mucosa before placement of dentures
• Implants can be considered 12 to 18 months following radiation therapy
• Implant supported prosthesis when possible to reduce tissue trauma

Oral and Maxillofacial Surgery • Pre-extraction hyperbaric oxygen therapy (HBO) increases tissue oxygen saturation
when dealing with irradiated bone to enhance healing especially in mandible)

20 presurgical HBO treatments


Provide perioperative antibiotic coverage
Perform surgery as atraumatically as possible
10 postsurgical HBO treatments

• HBO therapy is now available in many settings outside major medical centers
• Prophylactic preoperative antibiotic coverage is recommended
• Alveolectomy with primary everted closure

Hyperbaric oxygen therapy Protocol stipulates 1 compression/decompression cycle per day five days per week.
Patients are assigned to one of 4 different stages according to the following criteria:

Stage I - If the wound shows definitive clinical improvement after 30 compression/decom-


pression cycles, the patient is given a full course of 60 compression/decompression cycles. If
there is no improvement after 30 compression/decompression cycles, the patient is advanced
to stage II.

Stage II - A transoral alveolar sequestrectomy with primary closure is done and the compres-
sion/decompression cycles are resumed. If healing progresses without complication, a total
of 60 compression/decompression cycles are completed. If there is incomplete healing, the
patient is advanced to stage III.

Stage III - The patient undergoes a resection of the necrotic bone, the margins of which are
determined by the presence of bleeding bone or by TCN fluorescence. Compression/decom-
pression cycles are continued until healthy mucosal closure is obtained or a total of 60 com-
pression/decompression cycles are given. The patient is then advanced to stage III-R. A
patient can enter stage directly if he/she presents with a pathologic fracture, orocutaneous
fistula, or radiographic evidence of resorption to the inferior border. An initial course of 30
compression/decompression cycles are given in these cases.

Stage III-R - Ten weeks after resection, 20 additional compression/decompression cycles


are given and bone graft reconstruction is accomplished from a transcutaneous approach.

FOLLOWING CANCER THERAPY 23


XEROSTOMIA MANAGEMENT

The loss or significant reduction of salivary function and its protective effect results in a
plethora of adverse conditions. These conditions include rapidly progressive dental caries,
candidiasis, dental attrition, demineralization of the tooth surface, difficulty chewing, tasting
and swallowing, burning mucosa, burning tongue, angular cheilosis, denture intolerance, and
bacterial sialadenitis and the possibility of increased periodontal disease. The degree of
susceptibility and severity of these oral conditions appears to be proportional to the degree of
diminished salivary flow. Other conditions xerostomic patients may encounter are nutri-
tional deficiencies due to difficulty eating and insomnia due to an uncomfortably dry mouth.
Of all of the problems to which xerostomic patients are predisposed, rapidly progressive
dental caries is usually the most devastating. Xerostomia leads to the emergence of a highly
cariogenic microflora and a more cariogenic diet consisting of softer, non-detergent foods,
high in carbohydrate content. Additionally, these foods are retained in the mouth longer due
to the decreased salivary clearance. Xerostomic patients may also seek salivary replacement
with a liquid containing sugar that results in a relentless carious process.

Patient Education Xerostomic patients usually do not understand the seriousness of the detrimental effects of
their reduced salivary flow on their oral health. Patient education regarding their increased
susceptibility to the aforementioned problems is essential. They must understand that dietary
changes toward a softer more carbohydrate rich diet coupled with the use of sugar containing
liquids to moisten the mouth or the use of sugar containing salivary stimulants such as gums,
mints and troches will result in the uncontrollable carious destruction of their remaining
teeth. Dietary counseling is of utmost importance. Patients must appreciate the fact that their
diminished salivary flow greatly enhances the cariogenic potential of foods and liquids with
a high content of sugars or carbohydrates. The use of sugar containing liquids such as sug-
ared iced tea, punches, soft drinks, or fruit juices to moisten the mouth must be avoided. A
proprietary mouth-moistening product is preferred over such liquids. If the patient cannot
use one of these products, plain water should be recommended.

Managing subjective symptoms Management of the patient’s subjective symptoms should be addressed following patient
education. A constantly dry mouth is most uncomfortable and annoying. If functioning
salivary gland tissue remains, prescribing a cholinergic agent, such as pilocarpine, may be of
benefit. Stimulation of endogenous saliva production is more desirable than saliva substi-
tutes. It is more convenient for the patient and contains enzymes and immunoglobulins not
available in substitutes. Pilocarpine has long been recognized as a salivary gland stimulant
and has been shown to be effective in treating xerostomia secondary to radiation therapy.
The usual dose is 5 mg - 10 mg three times daily, the maximum daily dose is 30 mg.

Pilocarpine in 5 mg tablets is presently marketed as a systemic treatment for post radiation


chronic xerostomia under the trade name of Salagen®. Pilocarpine is a parasympathetic ago-
nist that has systemic consequences. The salivary and lacrimal glands as well as other secre-
tory glands including gastric, pancreatic, intestinal, sweat glands and mucous glands of the
respiratory tract are stimulated. This can result in a variety of undesirable side effects such as
sweating, nausea, rhinitis, chills, flushing, urinary frequency, dizziness, and asthenia. It can
also effect the tone and motility of smooth muscle as well as cause either increases or de-
creases in the heart rate and blood pressure. Pilocarpine can have significant effects on the
eyes including miosis and blurred vision from temporary paralysis of accommodation. There-
fore, patients should be instructed not to drive at night when taking the drug. It is contrain-
dicated in patients with uncontrolled asthma, acute iritis or narrow-angle glaucoma and should
be prescribed with caution to patients with cardiovascular disease, chronic bronchitis or chronic
obstructive pulmonary disease. It also has potential adverse drug interactions and should be

24 FOLLOWING CANCER THERAPY


prescribed with caution to patients taking beta blockers such as Inderol®. Consultation with
the patient’s physician may be indicated prior to prescribing pilocarpine. Because it can stimu-
late salivary flow, pilocarpine can be very beneficial for xerostomic patients. They may be
able to cease having to frequently sip on water or use mouth moisteners. Patients may find it
particularly beneficial to use 30-60 minutes prior to meals to assist in mastication. However,
pilocarpine is only beneficial if the patient has sufficient functional salivary gland tissue.
Pilocarpine is also available as ophthalmic solutions for glaucoma. These preparations are
much less expensive than the tablet form and have been recommended for xerostomia by
applying the solution to the tongue. It is available in a variety of concentrations. If used as a
10% solution, the patient would be instructed to put 1/2 to 1 cc on the tongue (5 mg - 10 mg
three times per day.) The pharmacist can be asked to provide a 3 cc tuberculin syringe to
measure the liquid.

Pilocarpine (Salagen ®) Possible adverse effects: Sweating, nausea, rhinitis, urinary frequency, dizziness, asthenia,
miosis
Contraindications: Uncontrolled asthma, narrow angle glaucoma, acute iritis, allergy
to pilocarpine
Precautions: Cardiovascular disease, retinal disease, pulmonary disease,
biliary tract disease, psychiatric disturbances
Drug interactions: Beta blockers and anticholinergics
Dose: 5 mg TID - can increase to 10 mg TID (max daily dose 30 mg) 20
min onset, peak effect at 1 hour, duration of 3-5 hours

Oral moisturizing agents Another method of increasing oral moisture is to recommend a topical agent. Oralbalance® is
a moisturizing gel that adheres to the mucosa and provides symptomatic relief from oral
dryness for several hours. Omni Plaque Fighter Spray ® contains 1.2% poloxamer 407/
dimeticone, an agent that coats and protects the mucosa for several hours, especially when
used at bedtime. Patients may find that using these agents before bedtime negates the need
for pilocarpine, thus avoiding side effects such as sweating during the night. These products
may also be beneficial to patients who wear dentures. Lightly coat the internal surface of the
denture to assist in moisturizing the mucosa and reduce denture irritation.

There are numerous proprietary saliva substitutes available to assist in relieving the symp-
toms of xerostomia. They can be used ad lib as saliva replacement. Some of these products
have a neutral pH and are formulated to assist in the remineralization of the tooth surface
(OraLube®, Salivart®, Glandosane®). Patients should be educated about the benefits of this
type of saliva substitute to encourage their use. However, even after being informed of the
benefits of remineralization and the promotion of a more normal oral flora, when taste, cost
and convenience are taken into consideration, many patients prefer to sip water.

Some saliva substitutes have a low pH value. Tooth enamel will demineralize at a critical pH
of about 5.5. Products formulated for oral use with a pH below 3.0 show distinct erosion of
enamel in vitro. Patients with a decreased salivary flow already have a lower salivary pH,
thus products with a pH below 5.5 may be detrimental to enamel, dentin and cementum.

FOLLOWING CANCER THERAPY 25


Saliva substitutes/Moisturizers Product Manufacturer

Oralbalance® Laclede Research Labs


moisturizing gel, pH 5.5 Gardena, Ca
1.5 oz tube about $5.00 800-922-5856

Omni Plaque Fighter Spray® Dunhall Pharmaceuticals


1.2% poloxamer, pH 7.0 West Palm Beach, FL
18 ml spray bottle about $2.50 800-543-6998

VA Oralube Veterans Administration Medical Center


PH 7.0, 2 ppm F 2002 Holcombe Blvd
4 oz bottle about $1.25 Bldg 110 Room 199
(available to institutions only) Houston, TX 77030

Glandosane® Bradley Pharmaceuticals


mint flavor only, pH 7.0 Kenwood Laboratories
15 ml spray bottle about $7.00 973-882-1505

Moi-Stir Mouth Moistener® Kingswood Laboratories


pH 7.1 Indianapolis, IN
swabsticks or 4 oz spray bottle about $5.00 800-968-7772

Moist Plus® Medical Warehouse


PH 7.0 3 William Way
1/2 oz tube $2 plus postage Stormville, NY 12582
800-969-6945

Saliva Substitute® Roxane Laboratories


pH 6.5 Columbus, OH
120 ml squeeze bottle about $4.50 800-520-1631

Salivart® Gebauer Company


pH 6.2-7.2 Cleveland, OH
30 g or 70 g spray can about $6-8 800-321-9348

MouthKote® Parnell Pharmaceuticals


pH 4.0 Larkspur, CA
2 and 8 oz pump bottle 800-457-4276

26 FOLLOWING CANCER THERAPY


Dental Caries Teeth undergo a natural process of demineralization and remineralization in the oral cavity.
When the localized oral environment favors demineralization over remineralization this re-
sults in a net loss of tooth mineral and an increased incidence of carious lesions. Saliva is
saturated with calcium phosphate and a chronic reduction in salivary flow creates an envi-
ronment conducive to the demineralization of teeth. Topical fluorides have been shown to
alter the local environment to favor remineralization and the lost mineral can be precipitated.
This potential for demineralization combined with the increase in acidophilic organisms such
as mutans streptococci and a more cariogenic diet makes topical fluorides critically impor-
tant for patients with xerostomia. Duraflor® and Duraphat® are fluoride varnishes for in-office
use. They contain 5% sodium fluoride (22.6 mg/ml). They can be used as a cavity varnish
beneath amalgam restorations and as a topical fluoride for the entire dentition. When used as
a topical fluoride treatment, it is placed on all surfaces of the teeth with a small brush. The
teeth should be isolated so that they are dry or slightly moist, but not wet, at the time of
application. The varnish forms a yellowish film on the teeth that should not be removed by
brushing or eating for at least 4 hours. These varnishes may also effective in reducing tooth
and root sensitivity.

Product Manufacturer
Topical Fluorides
DuraFlor® Cavity Varnish Pharmascience Laboratories
5% NaF, 22.6 mg/ml, pH 7.0 Montreal, Canada
800-207-4477

Duraphat® Fluoride Varnish Inpharma Inc


5% NaF, 22.6 mg/ml, pH 7.0 Needham, MS
800-938-5388

PreviDent® Gel Colgate Oral Pharmaceuticals


1.1% NaF gel, pH 7.0 Canton, MA
800-226-5428

PreviDent 5000 Plus® Colgate Oral Pharmaceuticals


1.1% NaF Dental Cream Canton, MA
pH 7.0 800-226-5428

NeutraCare® Oral-B Laboratories


1.1% NaF gel, pH 7.0 Belmont, CA
800-446-7252

FluoriSHIELD® Medical Products Laboratories


1.1% NaF gel, pH 7.0 Philadelphia, PA
800-523-0191

PreviDent® Dental Rinse Colgate Oral Pharmaceuticals


0.2% NaF solution, pH 7.0, 6% alcohol Canton, MA
800-226-5428

Oral-B Anti-Cavity Rinse® Oral-B Laboratories


0.05% NaF, pH 7.0, Alcohol free Belmont, CA
800-446-7252

Reach Act® Mouthrinse Johnson and Johnson


0.05% NaF, pH 5.8-6.6, Alcohol free Skillman, NJ
800-526-3967

Revive® Remineralizing Gel Dental Resources Inc


CaPO4 saturated, 0.05% NaF, pH 6.4 Delano, MN
800-328-1276
FOLLOWING CANCER THERAPY 27
Fluoride Therapy Xerostomia associated with therapeutic radiation to the head and neck is permanent and
usually progressive. It is imperative to communicate the importance of lifelong fluoride therapy
to the patient and family. The daily use of topical fluoride is critical to preventing caries in
xerostomic patients. Neutral sodium fluoride and stannous fluoride products are available for
daily home use. Most 0.4% SnF2 gels have a pH of about 4.7 and the 0.63% SnF2 rinses have
a pH of 2.8-3.5. Without the buffering capacity of saliva, the acidity of these products may
harm the teeth and some restorative materials. The 1.1% sodium fluoride products (5000
ppm fluoride) have a more neutral pH and are highly effective in reducing the incidence of
caries. Prevident 5000 Plus® is a prescription toothpaste containing 1.1% sodium fluoride. It
may be beneficial for those patients who desire additional daily topical fluoride applications,
for non-compliant patients, and for patients with recalcitrant dental caries.

• Although the tray/carrier method of fluoride application is considered an “intensive”


method for caries control in patients with severe xerostomia, some of the intensive
methods such as fluoride rinses/fluoride gel brush-in technique may be effective in
less severely affected patients.

• Fluoride trays/carriers instructions:

1.1% neutral sodium fluoride or 0.4% stannous fluoride in custom tray


Thoroughly brush and floss the teeth with low abrasive toothpaste
Rinse with water
Place a thin ribbon of fluoride gel into the internal aspect of the carriers
Insert carriers into the mouth and onto teeth
Bite the teeth together intermittently to “pump” gel between and around teeth
Leave carriers in place for minimum of 5 - 10 minutes one to two times per day.
Remove carriers and rinse carriers with water
Do not eat or rinse for at least 30 minutes

• Consider daily application of calcium phosphate remineralizing gel (Revive ®) in


custom tray, to assist in remineralization of decalcified lesions

If patients object to the use of fluoride gels, a neutral sodium fluoride rinse containing 0.2%
NaF can be recommended. Another product, specifically formulated to assist the
remineralization process of tooth surfaces, is Revive®. It contains 0.05% sodium fluoride,
sodium phosphate, calcium carbonate and additional electrolytes in a gel having a pH of 6.4.
This product is recommended to fluoride compliant patients who have tooth surfaces exhib-
iting early decalcification (white spots or slightly “sticky” dentin). It may be brushed onto
the teeth and allowed to coat the teeth for 1-2 minutes or used in a carrier in the same manner
as a fluoride gel

All of these fluoride products are used to assist controlling the carious disease process. Den-
tal caries is an infection and should be treated as such. The model described by Anderson,
Bales and Omnell centers on treating the pathological organisms rather than focusing treat-
ment on the carious lesion which results from the infection. Using this model of treating
caries as a disease is helpful in identifying those patients for whom caries control is not
attainable and for whom expensive restorative procedures have an extremely poor prognosis.
A functional dentition cannot be maintained in some severely xerostomic patients and the
most predictable treatment may be complete dentures, possibly supported by implants.

28 FOLLOWING CANCER THERAPY


Dental Restoration When restoring carious lesions in the xerostomic patient, consideration should be given to
the type of direct restorative material placed. Glass ionomer restorations, both conventional
and resin reinforced, have the ability to bond to tooth structure. They also have fluoride
release and the ability to inhibit tooth demineralization in vitro. Multiple clinical studies
have reported a numerical decline in the frequency of recurrent caries around glass ionomer
restorations. Additionally, they have been shown to be fluoride “rechargeable” with topical
fluorides. However, when placed in patients with xerostomia who used a daily application of
a mildly acidic (pH 5.8) sodium fluoride gel, Class V glass ionomer restorations fail due to
wash out and the average time to failure was 8.5 months. The fluoride release from glass
ionomer restorative materials in xerostomic patients who are compliant with the daily use of
a topical fluoride is probably of little benefit.

Class V amalgam restorations have been found to be clinically acceptable in patients who use
topical fluoride daily. However, in low or non-fluoride users, amalgam restorations have
been found to have a high failure rate due to recurrent marginal caries. Therefore, amalgam
may not be the best choice of restorative material for patients who are poorly compliant with
the use of topical fluorides. Resin modified glass ionomers may be more beneficial for these
patients.

Composite restorations have physical properties superior to those of the glass ionomer resto-
rations. Additionally, their wear rates are not significantly affected by a pH of 5.0 compared
to 7.0. Some composites claim to be fluoride releasing thereby theoretically possessing car-
ies inhibiting properties. However, there are no studies substantiating this theory and it is
doubtful that such a small amount of fluoride would be of benefit. Clinical retrospective
studies have found composites to have a clinical longevity one third less than that of amal-
gam, but twice as long as glass ionomer. Therefore, when esthetics is of concern in a patient
who complies with the use of a topical fluoride, a microfilled composite resin is recom-
mended. A microfilled composite in class III and class V preparations is recommended be-
cause a smoother less plaque retentive surface can be obtained as compared to a hybrid com-
posite.

Compomer restorative materials have weaker physical properties than those of composites.
The fluoride release is much less than resin modified glass ionomers and they are poorly
rechargeable. Therefore, they have limited if any indication for use in xerostomic patients.

The flowable composite materials compared to conventional composites have increased po-
lymerization shrinkage, decreased wear resistance and decreased strength. They were origi-
nally designed as pit and fissure sealants and their use as a restorative material has not been
supported by clinical research.

Additional factors to consider when restoring teeth in xerostomic patients are whether to use
a fluoride containing varnish beneath amalgam restorations, a fluoride containing dental bond-
ing agent beneath amalgams or a fluoride containing dental bonding agent beneath compos-
ite restorations. There are few, if any, clinical studies addressing their effectiveness at pre-
venting recurrent marginal lesions. The use of these agents in patients who comply with
topical fluoride use is probably not critical.

Numerous in vitro studies confirm that topical fluorides reduce enamel solubility and con-
tribute to remineralization of enamel. White spot lesions, consistent with decalcification, and
lesions with slight cavitation may not progress in those patients who are compliant with
recommendations for using topical fluoride. Therefore, a conservative approach should be
taken in restoring these lesions until the patient’s compliance with oral hygiene measures has
been established.

FOLLOWING CANCER THERAPY 29


Post Restoration Recommendations

After all active carious lesions have been eliminated and all pits and fissures sealed, an inten-
sive short-term antimicrobial therapy should be administered. Duraflor® or Duraphat® var-
nish should be applied to the entire dentition followed by a 2 week course of a chlorhexidine
rinse twice per day. The last rinse should be done just before bedtime. Studies have shown
that this 14 day regimen will suppress the mutans streptococcus infection below the sensitiv-
ity limit of most caries tests and that this suppression will last between 12 and 26 weeks.
Topical chlorhexidine maintains its substantivity and is effective in preventing caries in
xerostomic patient. Staining associated with chlorhexidine use is seen less frequently in
xerostomic patients.

Patient Recall

Periodic recall is crucially important for these patients. They must initially be recalled every
3 months for examination, prophylaxis, topical fluoride varnish and another two week course
of a chlorhexidine rinse. Such a recall program is essential to success. Patients who remain
caries active or who are found to be caries active at a three month recall are poor candidates
for high cost restorations such as castings, veneers, and fixed partial dentures.

Direct restorative materials for xerostomic patients

Compliant patients Noncompliant Patients


(Re: Fluoride use, diet, meeting appointments)

Class 1 and Class 2 Preparations


Amalgam Amalgam
(fluoride varnish or fluoride dentin
bonding agent may be beneficial)

Hybrid Composite
for esthetically critical areas
(fluoride dentin bonding agent beneficial)

Class III and V Preparations


Microfilled composite Resin modified glass ionomers
(fluoride dentin bonding agent beneficial) (use protective surface coating)

Amalgam for Class V areas


difficult access or difficult isolation
(fluoride varnish or fluoride dentin
bonding agent may be beneficial)

Demineralization without Cavitation


(enamel white spots/sticky dentin surface)
Fluoride varnish twice in one week, Fluoride varnish as often as possible
then every 3-6 months

Daily use of a topical sodium fluoride Expect to restore early

Daily use of Revive® for 2 weeks

Laboratory fabricated restorations


Caries free for 6 months prior to placing Not Recommended
high cost restorations

30 FOLLOWING CANCER THERAPY


Dietary management • Stress value of eating a balanced diet representing variety of food groups
• Encourage combining and sequencing food to enhance mastication, saliva production
and/or oral clearance
• Encourage consumption of water for hydration
• Suggest replacements for fermentable carbohydrates that are nutrient dense and good
source of protein, vitamins and minerals

Candidiasis Xerostomia creates a more acidic oral environment with a concomitant increase in acido-
philic organisms such as mutans streptococci and Candida albicans. A significant correla-
tion between lowered whole saliva and the Candida albicans count has been confirmed. The
patient’s oral mucosa should be carefully examined for signs of infection in the presence of
xerostomia. It may present infrequently in the pseudomembranous form (white curds) or
more commonly is the hypertrophic form (white stria) and/or as the atrophic, erythematous
form (red). Candidiasis should be high on the differential diagnosis when xerostomic pa-
tients complain of a burning mouth or tongue. Intraoral candidiasis may also involve the
commissures of the mouth, angular cheilosis.

There are several antifungal agents effective against Candida albicans. Nystatin products
with a high sucrose content should be avoided. Xerostomic patients may find troches diffi-
cult to dissolve in their mouths. Patient compliance is reduced for any product requiring
multi-dosing compared with a single dose product. Fluconazole is the most appropriate agent
for the vast majority of candidal infections due to its efficacy, safety and patient compliance.
Itraconazole has recently been released as a solution and acts both as a topical and systemic
medication. It contains no sugar (sweetened with sorbitol and saccharin). Itraconazole solu-
tion may be the best alternative for patients whose disease is refractory to fluconazole therapy.

Xerostomic denture wearers can be more prone to recurrent candidal infections. Patients can
use one of the antifungal creams or nystatin powder on the internal surface of their denture to
assist in resolving the infection. The denture can also be treated for 30 minutes with a solu-
tion of one teaspoon of sodium hypochlorite in eight ounces of water daily until the infection
is eliminated.

Beneficial products The Biotene ® products by Laclede Research Laboratories are popular because they do not
burn and irritate the dry mucosa as do many of the more popular toothpastes and mouthrinses.
The Biotene® chewing gum contains xylitol which impedes the growth of mutans streptococ-
cus and can assist in the prevention of caries. Xerostomic patients usually prefer a very soft
toothbrush because of their sensitive gingival tissue. Several brushes with soft bristles are
listed. Additional items popular with xerostomic patients are Glide® dental floss and tape
and Super Floss® due to their ease of use.

Dr. John’s Sugar Free Candies ® may be useful for xerostomic patients who like to try and
stimulate their salivary flow with something sweet. They contain hydrogenated starch hy-
drolysates as sweeteners rather than alcohol sugars and therefore may not cause as much
gastrointestinal distress. These hydrolysates have been shown in vivo to possess a low
acidogenic potential. Their effect on plaque pH is similar to that of sorbitol. Hydrogenated
starch hydrolysate is slowly metabolized to carbohydrates and contains 25% fewer calories
than sugar.

The National Sjögren’s Syndrome Association provides valuable information for coping with
dry mouth. MGI Pharma, makers of Salagen®, and the National Institute for Dental Research
also produce helpful patient information.

FOLLOWING CANCER THERAPY 31


PRODUCT MANUFACTURER
Products for xerostomia management
Biotene® Starter Treatment Pack Laclede Research
Oralbalance® moisturizing gel Gardena, CA
Biotene® Mouthwash 800-922-5856
Biotene® Toothpaste
Biotene® Chewing Gum (xylitol sweetener)
Biotene® Supersoft Toothbrush

Butler® GUM Ultra Soft Toothbrush John O. Butler Co.


Butler® Sensitive Toothbrush Chicago, IL
800-528-8537

Glide® Floss and Tape WL Gore & Assoc. Inc.


Flagstaff, AZ
800-645-4337

Super Floss® Oral-B Laboratories


Integrated floss threader and floss 800-446-7252

Dr. John’s Candies® Dr. John’s Candies


Grand Rapids, MI
616-454-3707

Dry Mouth (Xerostomia) NIDR


Patient Information Brochure PO Box 54793
Washington, DC 20032
301-402-7364

The Comfort Zone MGI Pharma


Patient Information Newsletter Minneapolis,MN
800-562-0679

Sjögren’s Digest National Sjögren’s Syndrome Association


Patient information periodical 5815 N. Black Canyon Hyw
Suite 103
Phoenix, AZ 85015-2200

Fluoride therapy for transient xerostomia Fluoride therapy for xerostomia associated with pharmacotherapy (psychotherapeutics, che-
motherapeutic agents, anticholinergics, narcotics) can be prescribed to prevent demineraliza-
tion and decrease hypersensitivity.

• Home Use
• Neutral (non-acidic) fluoride solution 1/day at bedtime
• Directions:
Brush, floss and rinse before applying fluoride with a second toothbrush
Spit out all the fluoride
Do not rinse, eat or drink for 30 minutes
• Do not use if mouth is highly sensitive or feeling unwell
• Fluoride can irritate the oral tissues and cause nausea.
• If mouth becomes sensitive, discontinue fluoride use
• Office Use
• DuraFlor varnish 5% (in office treatment)
• No brushing, flossing or eating for 4 hours

32 FOLLOWING CANCER THERAPY


Drug Classification Trade Names
Drugs that may exacerbate xerostomia
Anti-asthmatic Theo-Dur, Slo-bid, Slo-Phyllin, Amoline, Phyllocontin
Anticholinergics Donnatal, Lomotil, Banthine
Antidepressants Elavil, Paxil, Prozac, Sinequan, Tofranil, Zoloft,
Antihistamines Actifed, Benadryl, Chlor-Trimeton, Hismanal, Seldane
Antihypertensives Aldomet, Catapress, Capoten, Minipress, Serpasil
Anti-infIammatory Dolobid, Feldene, Motrin, Nalfon, Naprosyn
Anxiolytics Atarax, Ativan, Equanil, Librium, Valium, Xanax
Antiparkinsonian Artane, Cogentin, Lardopa, Sinemet
Antipsychotics Clozaril, Eskalith, Navane, Haldol, Stelazine, Thorazine
Decongestants Dimetapp, Sudafed, Ornade
Diuretics Aldactone, Esidrix, Diuril, Hygroton, Lasix, Maxide
Sedatives Dalmane, Halcion Restoril
Narcotics Lortab, Vicodan, Dilaudid, Percodan

BONE MARROW
PERIPHERAL STEM CELL
TRANSPLANT

Chronic graft-versus-host disease Chronic GVHD occurs after 100 days post-transplantation in 33-44% of allogeneic stem cell
transplant recipients. This can occur in patients who have not experienced acute GVHD. In
chronic GVHD, the host (patient) possesses isoantigens which are foreign to the graft, thereby
stimulating the immunocompetent grafted lymphoid cells to react against the host. Oral mani-
festations occur in 90% of patients with evidence of GVHD in other organs. Oral manifesta-
tions include epithelial atrophy, erythema, ulcerative lesions, lichenoid lesions, and xerosto-
mia. Pain is a common presenting symptom of these manifestations. Appropriate history and
diagnostic testing differentiate the lesions of GVHD from oral diseases with similar clinical
presentation. The patients during this stage are at risk for oral mucositis and xerostomia
following GVHD should continue with oral care protocols twice a day.

Differential diagnosis: The diagnosis of GVHD is based on exclusion of other diseases. KOH
preparation and Gram staining can be performed to exclude fungal infections and cultures
can be used to exclude herpes infection common in immunocompromised bone marrow trans-
plant recipients. Labial mucosa and salivary gland biopsy can assist in diagnostic confirma-
tion of clinical findings and history. Correlation of systemic manifestations of oral changes
should be noted.

• Systemic therapy
• Combination of prednisone and procarbazine, cyclosporine, cyclophosphamide, or
azathioprine
• Average duration of treatment is 24 months. By 4 years post-transplant, 80% of
patients are free of active GVHD and off of immunosuppressive treatment
• Anti-T cell immunotoxin
• Oral therapy
• Rule out opportunistic infections, especially candida and HSV
• Topical corticosteroids (rinses, gels, creams)
• PUVA therapy-oral psoralen plus UVA light therapy
• Systemic steroids
• Adjust cyclosporine dosage
• Pain management
• Soothing mouthrinses containing agents: kaolin and diphenhydramine (benadryl)
• Topical anesthetics (dyclonine, lidocaine, benadryl)
• Oral and/or parenteral analgesics as necessary

FOLLOWING CANCER THERAPY 33


• Xerostomia
• Salivary stimulants - pharmacologic, cholinergic medications
Pilocarpine (Salagen®)
Bethanechol
• Sodium bicarbonate rinses to neutralize oral acidity and minimize thick ropy saliva
(1 tsp / 8 oz. water).
• Artificial saliva and oral wetting agents
• Sugarless chewing gum and sugarless, non-acidic hard candy
• Artificial moisturizing products
• Avoid drying agents
Tobacco, caffeine, alcohol
• Avoid hard foods - raw vegetables (carrots, celery)
• Frequent sips of water. Ice water preferred if patient can tolerate.
• Anti-caries therapy
• Topical fluoride therapy (stannous or sodium) or remineralization therapy-brush on
or in custom carriers
• Dietary management for xerostomia
• Rinsing with water after drinking sweetened beverages or nutritional supplement
• More frequent recall visits to dentists
• Dry lips
• Water or lanolin-based products (avoid petroleum-based products which may mask
infection)
• Topical vitamin E oil, commercially prepared or punctured capsules
• Manage drug-induced gingival overgrowth
• Request transplant physician consider alternative immunosuppressive medications
• Achieve periodontal health
• Train patient to perform effective oral hygiene (regular flossing and toothbrushing)
• Frequent dental prophylaxis
• Other periodontal therapy as necessary
• Opportunistic infections may still occur
• Secondary malignancy
• Oral squamous cell and Kaposi’s sarcoma
• Biopsy suspicious lesions

Opportunistic Infections • Profound impairment of immune function may last six months to one year following
BMT
• Common infections include Candida and HSV
• HSV infection will present atypically, and may potentially involve all intraoral and
perioral soft tissue

Secondary malignancy • Increased risk is related to immunosuppressive drug therapy


• Skin and mucosa are particularly common sites

Drug-induced gingival overgrowth • Cyclosporine is currently the only immunosuppressant with this complication

34 FOLLOWING CANCER THERAPY


HEAD AND NECK SURGERY REHABILITATION

Chronic complications/concerns • Disorders in speech and swallowing


• Limitations in oral motor function
• Motor and sensory cranial nerve deficits
• Infections
• Enteral alimentation (e.g. tube feedings)
• Pain management
• Oral management
• Facial, neck, and shoulder dysfunction
• Disturbances in a mental health
• Fibrosis
• Cosmetic deficits
• Bony exposure
• Aberrations in activities of daily living

Supportive services After the patient and family return home, the primary contact at the treatment center is the
nurse/case manager who may guide local health care providers, patients and/or the families
over the phone or refer to the appropriate professional. Often nurses at the treatment center
can give care instructions over the phone to health care professionals allowing the patient to
remain at home or in his or her hometown.

Speech and Swallowing Tumors of the oral cavity and their treatment can create complex problems including swal-
lowing as well as severe disturbances in speech production. Depending on the location and
size of the tumor and the selected treatment, the ability to masticate, formulate, manipulate
and propel the food bolus during the oral preparatory stage of swallowing may be affected.
Smooth bolus transit and efficient triggering of the swallow reflex which normally occur
during the oral stage may be disrupted or impaired and subsequently affect pharyngeal transit
of the bolus resulting in further problems swallowing and possible aspiration during the pha-
ryngeal phase of swallowing. Furthermore, alterations in structures or limitations in move-
ment as a result of the tumor itself or its treatment often result in imprecise articulation and
decreased speech intelligibility. Therefore, patients with malignant tumors of the oral cavity
should be referred to the speech-language pathologist prior to the initiation of treatment.
Pretreatment evaluation and counseling should establish baseline functioning, provide real-
istic expectations for posttreatment speech and swallowing abilities, reduce fear, ensure pa-
tient responsibility and compliance, and establish continuity of care for maximal success
posttreatment.

Intervention should continue throughout and following the completion of the patient’s cancer
treatment to help maintain and preserve premorbid functioning particularly oral nutrition.
Although not routinely necessary, when indicated, a videofluoroscopic examination of swal-
lowing or modified barium swallow, can assess oropharyngeal function. The presence and
etiology of aspiration can be determined and the effectiveness of treatment strategies to im-
prove the patient’s swallowing can be evaluated. Results allow the clinician to make judge-
ments as to the patient’s ability to take food orally and help identify the most appropriate
swallowing strategies and diet type.

If the patient is treated with radiotherapy alone or in combination with chemotherapy, the
patient will often experience side effects including fibrosis and some degree of functional
impairment. The speech-language pathologist should establish appropriate swallowing exer-
cises and techniques based on thorough examination of the patient’s swallowing abilities.
Continuation of appropriate exercises during and after treatment will help preserve range of
motion and flexibility of the lips, tongue, jaw, larynx, and pharynx for both speech and swal-
lowing.
FOLLOWING CANCER THERAPY 35
Some patients may require the development of an intraoral prosthesis for obturation of a
velopharyngeal deficit or to reshape and augment the contours of a resected hard palate. The
speech-language pathologist is critical in its development. The speech-language pathologist
should be consulted to assist in its design so that speech and swallowing are optimized.

While the goal of any cancer management is first and foremost to eradicate the tumor, head
and neck cancer patients will experience significant treatment-related morbidity that will
have substantial impact on both speech and swallowing and ultimately on their quality of life.
It is therefore critical that functional restoration of speech and swallowing be a primary con-
sideration in the planning process and definitive choice for their cancer treatment. As such,
early referral to the speech-language pathologist is critical for successful functional outcome.

Maxillofacial Prosthetics Frequently, some form of maxillofacial prosthetic treatment is required as part of the reha-
bilitation of head and neck cancer patients, as prostheses are often needed to restore oral
functions such as swallowing, speech, and mastication. In other instances, a prosthesis may
be indicated for cosmetic and psychosocial reasons. Prosthetic devices may also be used to
position or shield facial structures during radiotherapy of head and neck cancer patients. The
overall goal of all maxillofacial prosthetic treatment is to improve the quality of life by re-
ducing the morbidity associated with a particular head and neck condition, or to assist in the
delivery of treatment which benefits a particular head and neck condition.

Hard palate defects Surgical obturators - A temporary prosthesis used to restore the continuity of the hard palate
immediately after surgical resection of a portion or all of the hard palate and/or contiguous
alveolar structures

Interim obturators - A prosthesis that is made after a surgical resection of a portion or all of
one or both maxillae; frequently, this may include replacement of teeth in the defect area.
This prosthesis replaces the surgical obturator that is inserted immediately following the
resection.

Definitive obturators - A prosthesis that artificially replaces part or all of the maxilla and
associated teeth lost due to surgery. It is fabricated after complete healing of the defect has
occurred.

Mandibular defects Includes defects resulting from surgical resections of the mandible, tongue, or floor of mouth

Mandibular resection prosthesis - A maxillary and/or mandibular prosthesis delivered after a


mandibular resection to allow the remaining deviated mandibular segment improved occlusal
contact with the maxillary dentition. This can require use of a flange, guide, or occlusal
platform incorporated in the prosthesis to guide the mandibular segment into optimal oc-
clusal contact.

Mandibular reconstruction prosthesis - A prosthesis delivered after a surgery to reconstruct


continuity of the mandible following a mandibular resection.

Palatal augmentation prosthesis - A prosthesis that allows reshaping of the hard palate to
improve tongue-palate contact during speech and swallowing. The prosthesis is necessary in
patients with impaired tongue mobility due to cancer surgery.

36 FOLLOWING CANCER THERAPY


Soft palate defects Speech aid prosthesis - A removable maxillary prosthesis to restore an acquired defect of the
soft palate. A portion of the prosthesis extends into the pharynx to separate the oropharynx
and nasopharynx during phonation and deglutition, thereby completing the palatopharyngeal
sphincter.

Palatal lift prosthesis - A removable prosthesis that aids in velopharyngeal closure by elevat-
ing an incompetent soft palate that is dysfunctional due to cancer surgery.

Facial defects Auricular prosthesis - A prosthesis that replaces the auricular portion of an ear that is par-
tially or totally missing due to cancer surgery.

Nasal prosthesis - A prosthesis that replaces a nose that is partially or totally missing due to
cancer surgery.

Orbital prosthesis - A prosthesis that replaces the contents of the orbital region, including the
eyelids and the eyeball, following cancer surgery.

Ocular prosthesis - A prosthesis that replaces an eyeball following cancer surgery.

Cranial prosthesis - A biocompatible, permanently implanted replacement for a portion of


the skull bones.

Radiation therapy Radiation stent - An intraoral prosthesis designed to position/shield tissues during radio-
therapy of the head and neck regions.

Radiation carrier - A device used to administer radiation to confined areas by means of


capsules, beads, or needles of radiation emitting materials

Head and neck cancer follow-up • Obtain a hospital course or treatment course summary. This should be available from
the appropriate oncologist.

• Determine whether the patient still has cancer, whether additional treatments will be
necessary, and if so where, when, and how many.

• If treatments have been concluded, determine what follow-up will be necessary, how
often, and by whom. As a general rule for the first year “check ups” should be sched
uled once per month for patients who had advanced cancer and once every 2 or 3
months for early cancer. Every case should be judged separately.

• The extent of a checkup depends on the location of the tumor and type of treatment
as well as the original tumor stage. At a minimum, a checkup would include a
comprehensive head and neck examination including fiberoptic nasopharyngoscopy.
Lab tests and radiographic studies will also be a part of the followup but the
frequency of these will be customized to the individual patient.

• The patient may return to their community with a number of difficult sequelae. The
patient may be xerostomic, and have difficulty chewing, swallowing, smelling, or
speaking. There may be a temporary or a permanent tracheostomy in place. While
reconstructive surgery and maxillofacial prosthetics are very good today, they are
never able to restore a patient to a perfect precancerous state in terms of function or
cosmesis.

• The purpose of followup is to provide comprehensive long-term care to the head and
neck cancer patient addressing issues of detection of recurrence, second primary
neoplasm identification, and management of long-term treatment sequelae.
FOLLOWING CANCER THERAPY 37
ORAL CARE IN
PEDIATRIC ONCOLOGY

BACKGROUND

Approximately 8,000 cases of cancer are diagnosed in children annually in the United States
and this disease risk continues to increase each year. The 3 most common cancers diagnosed
in children are leukemia, central nervous system tumors and lymphoma, which accounts for
about 70% of all new cancers seen in this age group. Management of most cancers in children
usually requires multimodality treatments, including chemotherapy, localized or total body
irradiation and surgery. Learning to diagnosis and manage these oral complications is impor-
tant because up to 90% of children with cancer will experience an oral complication. In
addition, the level of the child’s oral health can play an important role in the outcome of any
cancer treatments. Similar to adults undergoing cancer therapy, an immunosuppressed child
is at high risk for septicemia due to oral infections. In addition, the oral status of the young
cancer survivor may be permanently altered by the late effects of cancer therapy. With the
overall 5-year survival rate for the most common pediatric cancers approaching 80%, more
children will seek long-term oral health care from a knowledgeable and concerned dental
team. The following protocol has been adapted from the Guidelines for the management of
pediatric Dental Patients Receiving Chemotherapy, Bone Marrow Transplantation, and/or
Radiation, American Academy of Pediatric Dentistry Reference Manual 1999-2000.

PRETREATMENT
Ideally, all children with cancer should be evaluated by a general dentist/pediatric dentist
shortly after the diagnosis, as part of a pretreatment assessment. A period of 7-10 days prior
to initiation of chemotherapy/radiation offers the best time frame for this evaluation. The
purpose of the evaluation is to identify potential complications and to treat significant oral
diseases. During this time prevention strategies to promote oral health are reinforced. Devel-
oping a relationship with the oncology team is important in order to improve communica-
tions and encourage dental referrals as early as possible.

Although comprehensive oral care is ideal, it is not always possible or even realistic for to a
child who is undergoing cancer treatment. The primary goal is to treat emergent and/or acute
disease in an expeditious and safe manner in order to decrease the risk of oral complications
during active phases of myelosuppression. This treatment should only be provided in consul-
tation with the oncologist and after a careful review of hematologic laboratory studies. Con-
sideration must also be given to antibiotic prophylaxis when indicated.

• Institute pulp therapy as indicated. Pulpotomy and pulpectomy treatment is prefer


able to extraction if no periapical pathology is present. Do not perform direct pulp
capping on primary teeth.

• Extract teeth with acute or chronic infections and periapical pathology. In addition,
remove primary teeth that are close to exfoliation and are likely to be lost during
cancer therapy. Remove residual root tips that are in soft tissue. Ideally, all extractions
should be performed 5 to 7 days prior to the initiation of chemotherapy/radiation.

• Manage all soft tissue lesions conservatively and symptomatically. Conservative


removal of an operculum may be indicated in selected cases when there is a history of
pain, swelling at that site, or if significant inflammation is present despite the
institution of oral hygiene measures.

38 PEDIATRIC ONCOLOGY
• Consider the removal of orthodontic or other appliances, which may cause irritation
to the oral mucosa. Discontinue the use of removable appliances. This is important
when the child will require prolonged dose intensive therapy and mucositis is ex
pected. Limited fixed interceptive appliances, such as a band and loop space main
tainer, may be left in place if there is not significant soft tissue impingement.

• For the pre-cooperative or anxious child, attempt to coordinate dental procedures


with other procedures that require sedation or general anesthesia.

ORAL CARE DURING CANCER THERAPY

Hematologic Guidelines in Pediatrics The following are general hematologic guidelines for the dental management of the child
with cancer. These recommendations may vary depending on the type of cancer, the intensity
of the therapy, concurrent medical problems and the preestablished protocols of the institu-
tion. For these reasons, it is essential that a dentist consult with the oncologist prior to treat-
ment.

Elective Dental Procedures

• Absolute neutrophil count (ANC) should be greater than 1000/mm3


• Platelet count should be greater than 50,000/mm3

Emergency Dental Procedures

Emergency procedures may be performed with any hematologic status to remove sources of
infection, if the treatment is performed in coordination with the oncology service. Platelet
transfusion may be indicated if the values are less than 50,000/mm 3.

Oral Hygiene • Daily toothbrushing and flossing when ANC is greater than 500/mm3 and platelet
count is greater than 20,000/mm3
• Dental hygiene with a moist gauze or spongy toothette only when ANC is less than
500/mm3 and/or platelet count is less than 20,000 mm3. Flossing should be
discontinued during this time

Antibiotic prophylaxis guidelines Prophylactic antibiotic coverage should be provided according to the current American Heart
Association (AHA) recommendations. In addition, there are special situations for the pediat-
ric cancer patient that require antibiotic prophylaxis. Consultation with the oncologist is im-
portant in order to determine which antibiotic should be prescribed and if the period of anti-
biotic use should be extended. Special circumstances for antibiotic prophylaxis include but
are not limited to the following examples:

• Patient has an ANC that is less than 500/mm3 and/or WBC that is less than 2,000/mm3
• Patient has a central venous catheter
• Patient is taking long-term immunosuppressive drugs, such as cyclosporine or
prednisone

PEDIATRIC ONCOLOGY 39
ORAL CARE FOLLOWING CANCER THERAPY

• Provide restorative and periodontal therapy to return the patient to optimal oral health
• Provide symptomatic care for any residual or long-term oral lesions or side effects.
• Restart or initiate orthodontic care if indicated
• Perform oral surgical procedures involving the jaws, following the recommendations
of the radiation oncologist, if indicated
• For the precooperative or anxious child, attempt to coordinate dental procedures with
other procedures that require sedation or general anesthesia
• Place the child on a 3-month recall for the first 12 months after cancer treatment and
6 months thereafter, unless more frequent appointments are needed for control of oral
disease
• At recall visits, review current medications to determine if the child continues to
receive immunosuppressive or myelosuppressive drugs. Determine if the child’s
disease is in remission or if the child is in active treatment for cancer
• At recall visits, review current blood laboratory studies to assess if child’s hemato
logic status has returned to normal. Particular attention should be paid to the WBC,
differential, ANC and platelet count
• Educate the patient and parents about the possible long-term sequelae of chemotherapy
and radiation on the teeth, oral mucosa and craniofacial complex
• Obtain consult from radiation oncologist (as appropriate) prior to surgical procedures
that involve the extraction of teeth, osseous surgery or the removal of intrabon
pathology

LATE SEQUELAE OF
PEDIATRIC CANCER THERAPY
The child patient with cancer may experience long-term sequelae following treatment, simi-
lar to the adult patient. However, unique problems arise in children that are related to abnor-
malities in the growth and development. The severity of the orofacial defects depends on
several factors, including the age of the patient undergoing cancer therapy, the intensity and
duration of the treatment, location of the primary tumor in the head and neck region, surgical
defects from tumor removal and whether chemotherapy, radiation or a combination of treat-
ments were used.

Dental Disturbances • Agenesis of the permanent teeth


• Microdontic teeth
• Developmental enamel defects of hypoplasia
• Abnormal root formation including;
Agenesis of the roots
Short “v-shaped”roots
Narrow, thin, tapered roots
Root dilaceration
• Delayed dental development
• Abnormal eruption
Non-eruption of one or more teeth
Partial eruption of one or more teeth
Ectopic eruption of one or more teeth
Tooth eruption without root formation
Delayed eruption of one or more teeth

Craniofacial growth disturbances • Malocclusion


• Facial growth disturbances (Decreased development)
• Facial asymmetry

40 PEDIATRIC ONCOLOGY
Salivary gland dysfunction • Xerostomia
• Thick ropy saliva

Dental caries • Secondary to xerostomia


• Secondary to enamel defects
• Secondary to diet high in fermentable carbohydrates
• Secondary to chronic use of sucrose-containing medication

PEDIATRIC ONCOLOGY 41
REIMBURSEMENT FOR
CANCER-RELATED ORAL CARE

INTRODUCTION

As cancer treatment shifts from large regional medical centers to local community hospitals,
the availability of community dentists to manage oncology patients is critical to optimum
patient care. Dentists who manage oncology patients must be readily available to provide
evaluations and treatment to interface with medical and surgical therapies. This treatment is
often on short notice, requiring complex treatment planning decisions that consume a great
deal of the dental practitioner’s time and office resources.

The lack of financial resources to support oral oncology care creates barriers which block
patient access to care. Without adequate reimbursement, it is unrealistic to expect commu-
nity dentists to readily accept significant uncompensated care burdens.

SOURCES OF PAYMENT

Self pay – Patients requiring medically necessary oral healthcare related services for their
oncology problems have limited coverage under their medical plans, Medicare and Medicaid
programs. Patients are often faced with paying these bills out-of-pocket. When patients can
not afford these expenses, the provider is placed in the unfortunate position of providing care
or not providing care based on the availability of financial resources. Frequently self-pay
means “no pay” and the uncompensated care burden falls on the practitioner. Quality of
patient care cannot be sustained within this type of operating environment.

Commercial insurance – The majority of commercial insurance carriers exclude medically


necessary dental services from their medical and surgical contracts. In order for payment to
occur, the practitioners will often write letters of justification and appeal on behalf of the
patient concerning the medical necessity of the dental services. This becomes very time
consuming and costly in an active dental practice.

Dental insurance – Many patients have dental benefits provided through their employment.
Dental insurance payments provide significant revenues to most dental practices. However,
most dental insurance plans have associated deductibles and maximum yearly allowances.
Depending on the complexity and scope of oral oncology services required, the practitioner
can still face shortfalls in reimbursement. In addition, many dental insurance carriers will
exclude services such as fabrication of fluoride trays for the prevention of post radiation
tooth decay. Despite the fact that some shortfalls in reimbursements exist, patients with
dental coverage are the practitioner’s best payor source.

Medicaid – Medicaid is a Title XIX program which provides dental benefits for indigent
Americans. Most state Medicaid programs receive the majority of their funding through the
federal government. This has been estimated at between 50-80% of the state’s Medicaid
operating budget. Because states accept federal funding, certain guidelines exist and must be
followed. Federal guidelines require states to provide dental benefits under the Early Peri-
odic Screening, Diagnosis, and Testing Program (EPSDT). States are allowed to determine
eligibility requirements and coverage. The majority of dental funds are spent on children.
However, a very limited number of states have expanded coverage to the adult population.

National studies have shown that most dentists do not participate in state Medicaid programs
because of low reimbursement rate, burdensome paperwork and poor appointment compli-
ance.

42 REIMBURSEMENT
Texas Medicaid - In Texas, a broad range of dental services are covered under reimburse-
ments for Medicaid recipients under age 21. The state of Texas has provided a means whereby
dentists may be reimbursed for a dental related problem which is secondary to a life threaten-
ing medical problem. Guidelines for filing claims can be found in the Medicaid Dental
Services Manual (section #18-40, Doctor of Dentistry “DOD” Practicing as a Limited Physi-
cian). Dentists can receive reimbursement for certain dental services if the dentist is licensed
by the state board, and enrolled in the state’s Medicaid and Medicare program. All claims for
Medicaid recipients over age 21 and falling into this category must have claims submitted on
a HCFA 1500 form using appropriate medical diagnosis (ICD-9) and procedural coding (CPT).
In addition, the dentist must have the services pre-authorized and supporting documentation
from the patient’s physician. Presently only 30% of Texas dentists participate in Texas Med-
icaid Program, which is administered by The National Heritage Insurance Corporation. Ac-
cording to Dr. James Orr, Texas NHIC Dental Director, Medicaid reimbursement rates are
45-50% of the dentist’s usual and customary charges. Texas dentists can enroll in the Medic-
aid Program by contacting provider enrollment at (512) 343-4900.

Medicare - Medicare was established 33 years ago as the nation’s health care plan for the
elderly. Eligibility begins at age 65 or before if disabled. There are basically three ways in
which Medicare pays directly or indirectly for dental services:

Graduate Medical Education Funding (GME) - Hospitals supporting dental residency


training receive direct and indirect medical education funding from Medicare to support their
teaching programs. This payment source is not applicable to dentists in private practice.

Medicare Part A (Hospital Insurance) covers inpatient hospital care, inpatient care in a
skilled nursing facility, home health care and hospice care. Medicare Part A is financed by a
tax on employers and employees, and the money goes into the Hospital Insurance Trust Fund.
For the most part, Medicare Part A does not provide for reimbursement for dentist and physi-
cian services.

Medicare Part B (Medical Insurance) covers doctors services, outpatient hospital services,
and a number of other medical services and supplies not covered under Part A. Part B is
financed through a combination of general tax revenues and premiums paid by Medicare
beneficiaries. The revenue for Part B goes into the Supplementary Medical Insurance Trust
Fund. Part B is administered by private insurance agents called Medicare Carriers. Medicare
has surrendered direct control of the program. To insure standardization and administration
of the Medicare program, the federal government has prescriptive guidelines for carriers to
follow concerning reimbursement issues.

Section 1862 (a) (12) of the Social Security Act excludes dental services from the Medicare
Coverage. Since the enactment of this legislation, Congress has reviewed and amended the
law and the Health Care Financing Administration (HCFA) has made regulatory changes to
provide for certain medically necessary dental hospitalization, examinations and dental re-
lated procedures. Presently, Medicare guidelines allow for payment to dentists for oral ex-
aminations, x-rays, and extractions to prepare the jaws for radiation therapy for Medicare
recipients with head and neck malignancies. In addition, the dentist may be reimbursed for
covered services related to managing oral side effects from cancer therapy such as mucositis,
viral, bacterial and fungal infections. Medicare guidelines also provide coverage for maxil-
lofacial prosthetics and restoration of the supportive structures to support the prosthesis.

REIMBURSEMENT 43
Texas Medicare - The Medicare Part B carrier in the State of Texas is Trailblazers, a subsid-
iary of Blue Cross Blue Shield. Dentists wishing to enroll in the state Medicare program can
contact: The Medicare-Provider Enrollment, P.O. Box 833928, Richardson, Texas 75083.
Telephone (972) 766-2609.

The dentist will need to request a Medicare Enrollment Package, which will include HCFA
Form 855 for provider enrollment. During enrollment, the dentist will have to decide to be
either a participating or non-participating provider. Details concerning the advantages and
disadvantages of each will be provided in the enrollment package. Once enrolled the dentist
will be assigned a Unique Physician Identification Number {UPIN), which will be needed in
order to submit Medicare claims. In Texas, UPIN Directories for referring physicians re-
quired on all submitted claim forms can be obtained by calling (972) 766-7665. On request,
Medicare will also furnish the dentist its participating and non-participating fee schedules for
their region. Dentists must also use ICD-9 and CPT Coding for Medicare claim submission
on HCFA Form 1500. Common Procedural Terminology Manuals (CPT) can be obtained
from: American Medical Association, Order Department: OP O54192, PO Box 10950, Chi-
cago, IL 60610.

The International Classification of Diseases (ICD-9) can be obtained by phone, 1-800-MED-


Shop, or purchased from your local medical bookstore. Another resource for these publica-
tions includes physician colleagues who commonly use this coding system for billing
medical claims.

GOALS AND INITIATIVES

• In order to maximize reimbursement the dentist and billing staff must understand how
to use appropriate medical and procedural coding

• The dentist and billing staff must understand dental coverage issues as outlined in the
Medicare Coverage and Limitation Manual. Copies of this manual are usually
retained by most hospitals providing care to Medicare recipients, or obtained from
your Medicare Carrier. It is important to understand the language of these guidelines
and how to apply it to your specific claim

• A mechanism exists in Texas for dental reimbursement for a limited scope of services
for oncology patients in the Medicaid and Medicare programs. The dentist and bill
ing staff must understand the appropriate billing mechanisms for each in order to
maximize reimbursement

• Individual practitioners, organized dentistry, patient advocacy groups and legislators


must work collaboratively to streamline a very complicated reimbursement process
for Texas Medicaid dentists who are providing services under The Doctor of
Dentistry Practicing as a Limited Physician guidelines

• Individual practitioners, organized dentistry and patient advocacy groups must work
with state legislators to increase state dental Medicaid rates to insure indigent Texans
have access to the most basic of oral health care services

44 REIMBURSEMENT
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Diagnosis, Prevention, and Treatment. National Cancer Institute Monograph Number 9
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(1997).

Oral Complications of Cancer and Cancer Therapy National Cancer Institute PDQ
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Oral Management of the Cancer Patient: A guide for the Health Care Professional.
Barker, GJ, Barker, BF, Grier, RE. Fifth edition (1996).

Periodontal Considerations in Management of the Cancer Patient. Research, Science and


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Busch DB. Radiation and chemotherapy injury: pathophysiology, diagnosis, and treatment.
Critical Reviews in Oncology/ Hematology (1993) 15:49-89.

Mueller BA, Millheim ET, Farrington EA, Brusko C, Wiser TH. Mucositis management
practices for hospitalized patients: National survey results. Journal of Pain and Symptom
Management (1995) 10(7): 511-518.

Scully C, Epstein JB. Oral health care for the cancer patient. Oral Oncology (1996) 32(5):
281-286.

Silverman S. Oral cancer: Complications of therapy. Oral Surgery Oral Medicine Oral
Pathology Oral Radiology Endodontics (1999) 88:122-126.

Singh N, Scully C, Joyston-Bechal S. Oral complications of cancer therapies: prevention.


Clinical Oncology (1996) 8(1): 15-24.

Toth B, Chambers M, Fleming T. Prevention and management of oral complications


associated with cancer therapies: Radiation/Chemotherapy. Texas Dental Journal (1996)
June 113(6): 23-29.

Toth BB, Martin JW, Fleming TJ. Oral complications associated with cancer therapy.
Journal Clinical Periodontology (1990) 17: 508-515.

BONE MARROW TRANSPLANTATION

Barker GJ. Current practices in the oral management of the patient undergoing
chemotherapy or bone marrow transplantation. Support Care Cancer (1999) 7:17-20.

Eggleston TI, Ziccardi VB, Lumerman H. Graft-versus-host disease case report and
discussion. Oral Surgery Oral Medicine Oral Pathology Oral Radiology Endodontics
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Epstein JB, Lunn R, Dip DH, Nhu Le, Stevenson-Moore P. Periodontal attachment loss in
patinets after head and neck radiation therapy. Oral Surgery Oral Medicine Oral Pathology
Oral Radiology Endodontics (1998) 86:673-677.

Epstein JB, Ransier A, Lunn R, Spinelli J. Enhancing the effect of oral hygiene with the
use of a foam brush with chlorhexidine. Oral Surgery Oral Medicine Oral Pathology
(1994) 77(3): 242-247.

Redding SW, Callander NS, Haveman CW, Leonard DL. Treatment of oral chronic graft-
versus-host disease with PUVA therapy. Oral Surgery Oral Medicine Oral Pathology Oral
Radiology Endodontics (1998) 86(2): 183-186.

CHEMOTHERAPY

Patients Receiving Cancer Chemotherapy. American Dental Association, Council on


Community Health, Hospital, Institutional and Medical Affairs (1989).

Borowski B, Benhamou E, Pico JL, Laplanche, Margainaud JP, Hayat M. Prevention of


oral mucositis in patients with high-dose chemotherapy and bone marrow transplantation:
A randomized controlled trial comparing two protocols of dental care. Oral Oncology
(1994) 30(2): 93-97.

EpsteinJB, Schubert MM. Oal mucositis in myleosuppressive cancer therapy. Oral Surgery
Oral Medicine Oral Pathology Oral Radiology Endodontics (1999) 88(3):273-276.

Houston D. Supportive therapies for cancer chemotherapy patients and the role of the
oncology nurse. Cancer Nursing (1997) 20(6): 410-411.

Masayasu I, Yoshiya M, Kakuta S, Nagumo M. Clinical trial of recombinant granulocyte


colony-stimulating factor for chemotherapy-induced neutropenia in patients with oral
cancer. Journal Oral Maxillofacial Surgery (1997) 55: 836-840.

Meraw SJ, Reeve CM. Dental considerations and treatment of the oncology patient
receiving radiation therapy. Journal of the American Dental Association (1998) 129: 201-
205,

Niedermeier W, Matthaeus C, Meyer C, Staar S, Muller R-P, Schulze H-J. Radiation-


induced hyposalivation and its treatment with oral pilocarpine. Oral Surgery Oral Medicine
Oral Pathology Oral Radiology Endodontics (1998) 86: 541-549.

Sonis ST. Mucositis as a biological process: a new hypothesis for the development of
chemotherapy-induced stomatotoxicity. Oral Oncology (1998) 34: 39-42.

Sung EC. Dental management of patients undergoing chemotherapy. Canadian Dental


Association Journal (1995) 23 (11): 57-59.

Sweeney MP, Bagg J, Baxter WP, Aitchison TC, Oral disease in terminally ill cancer
patients with xerosotomia. Oral Oncology (1998) 34:123-126.

HEAD AND NECK RADIATION THERAPY

Head and Neck Cancer Patients Receiving Radiation Therapy. American Dental
Association, Council on Community Health, Hospital, Institutional and Medical Affairs
(1989).

Barker G, Loftus L, Cuddy P, Barker B. The effects of sucralfate suspension and


diphenhydramine syrup plus kaolin-pectin on radiotherapy-induced mucositis. Oral
Surgery Oral Medicine Oral Pathology (1991) 71: 288-93.

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Beumer J, Curtis T, Harrison RE. Radiation therapy of the oral cavity: Sequelae and
management Part 1. Head and Neck Surgery (1979) 1: 301–312.

Beumer J, Seto B. Dental extractions in the irradiated patient. Special Care in Dentistry
(1981) 1(4): 166-173.

Cengiz M, Ozyar E, Ozturk D, Fadil A, Atahan IL, Hayran M. Sucralfate in the


prevention of radiation-induced oral mucositis. Journal of Clinical Gastroenterology
(1999) 28(1): 40-43.

Epstein JB, Emerton S, Guglietta A, Le N. Assessment of epidermal growth factor in


oral secretions of patients receiving radiation therapy for cancer. (1997) Oral Oncology
33(5): 359-363.

Gagesund, M, Tilikids A, Dahllof G. Absorbed dose in the head and oral cavity during
total body irradiation. Oral Oncology (1998) 34:72-74.

Haveman, CW Redding SW. Dental management and treatment of xerostomic patients.


Texas Dental Journal (1998) 115(6) June:43-56.

Jansma J, Vissink A, Spijkervet FLK, Roodenburg JLN, Panders AK, Vermey A, Szabo
BG, Johannes-Gravenmade E. Protocol for the prevention and treatment of oral sequelae
resulting from head and neck radiation therapy. Cancer (1992) 70(8): 2171-2179.

Mealey BL, Semba SE, Hallmon WW. The head and neck radiotherapy patient: Part 2-
Management of oral complications. Compendium Continuing Education in Dentistry
(1994) 15(4): 442-454.

Meraw SJ, Reeve CM. Dental considerations and treatment of the oncology patient
receiving radiation therapy. (1998) Journal American Dental Association 129:201-205.

Spijkervet FLK, van Saene HKF, Van Saene JJM, Panders AK, Vermey A, Mehta DM.
Effect of elimination of oral flora on mucositis in irradiated head and neck cancer
patients. Journal of Surgical Oncology (1991) 46:167-173.

Spijkervet FKL, van Saene HKF, Van Saene JJM, Panders AK, Vermey A , Mehta DM.
Mucositis prevention by selective elimination of oral flora in irradiated head and neck
cancer patients. Journal Oral Pathology Medicine (1990) 19: 486-489.

Spijkervet FKL, van Saene HKF, Panders AK, Verme A, van Pharma JJM, Mehta DM,
Fidler V, Effect of chlorhexidine rinsing on the oropharyngeal ecology in patients head
and neck cancer who have irradiation mucositis. Oral Surgery Oral Medicine Oral
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American Academy of Pediatric Dentistry: Guidelines for the Management of pediatric
Dental Patients Receiving Chemotherapy, Bone Marrow Transplantation, and/or
Radiation. Reference Manual1999-2000. Pediatric Dentistry, (1999) 21(5): 74-75.

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da Fonseca MA. Pediatric bone marrow transplantation: oral complications and
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Deutsch M. The use of pilocarpine hydrochloride to prevent xerostomia in a child treated


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Kennedy L, Diamond J. Assessment and management of chemotherapy-induced mucositis


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18(5): 189-192.

48
About the Dental Oncology Education Program
The prevention, detection and diagnosis of oral cancer, and the successful management of the oral sequelae associated with cancer therapy
can be accomplished only through the collaboration and cooperation of all health care professionals. Multiple individuals, agencies and
groups, at both the local and national level, have educational materials, resource information, personnel, etc. to contribute to this effort. It is
the intent of the Dental Oncology Education Program (DOEP) to identify these resources, to perpetuate and enhance the relationships with
the various societies, agencies, institutions and projects and to disseminate this information to the practicing health care community through
multiple venues. DOEP exists to assist dental professionals in Texas to maximize their effectiveness in this effort and to work collaboratively
with allied health professionals and groups to advance these goals.

DOEP has partnered with: American Cancer Society, UTHSC, San Antonio, UT Houston Dental Branch, MD Anderson Cancer Center,
Texas Dental Association, Physician Oncology Education Program, Texas Medical Association, Nurse Oncology Education Program, Texas
Nurses Association, National Spit Tobacco Education Program, Texas Department of Health Office of Tobacco Prevention and Control,
Texas Comprehensive School Network, Texas Agricultural Extension Service.

Annually the DOEP:

• Provides technical assistance to over 20 entities


• Provides over 7,000 hours of continuing education
• Provides training and educational materials to over 20,000 health care professionals
• Coordinates the donation of over 1,500 hours to cancer education, prevention, screening
• Develops educational materials for distribution to graduate and undergraduate health care professionals

DOEP Projects
• Student fellowships provide undergraduate students the opportunity to participate in cancer and tobacco community education
• Resources and technical assistance made available to individuals and schools
• ADA CERP accredited continuing education programs
• Videos – Examination of the Head, Neck and Oral Cavity
Biopsy Technique
Health Care Professional’s Guide to Oral Cancer
• Resource Guide to publications on oral cancer and tobacco
• Publications
Oral Disease Update (Volumes I – V)
Tobacco Facts for the Clinician
• Website http://dental-outreach.uthscsa.edu/DOEP/

DOEP Headquarters
Texas Dental Association
Box 109
1946 South Interregional
Austin, TX 78704

Tollfree 1-888-443-2439
(512) 443-1308
Fax (512) 443-0953
Texas
Cancer
Council
REFERENCES