Oral and Dental Management After Cancer Therapy

Routine systematic oral hygiene is important for reducing incidence and severity of oral sequelae of cancer therapy. The patient must be informed of the rationale for the oral hygiene program as well as the potential side effects of cancer chemotherapy and radiation therapy. Effective oral hygiene is important throughout cancer treatment, with emphasis on oral hygiene beginning before treatment starts.[1]

Management of patients undergoing either high-dose chemotherapy or upper-mantle radiation share selected common principles. These principles are based on baseline oral care (refer to the list of suggestions for Routine Oral Hygiene Care below) and reduction of physical trauma to oral mucosa (refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy below).

Routine Oral Hygiene Care

• Toothbrushing.  [Note: Electric and ultrasonic toothbrushes are acceptable if the patient is capable of using them without causing trauma.] 
• Soft nylon-bristled brush (two to three rows).
  • Brush 2 to 3 times daily with Bass sulcular scrub method.
  • Rinse frequently.
  • Foam toothbrushes:
    • Use only when use of a regular toothbrush is not feasible.
    • Use with antimicrobial rinses when routine brushing and flossing are not possible.
    • Brush teeth 2 to 3 times a day.
    • Rinse frequently.

   

• Dentifrice:
  • Patient preference, as tolerated.
    • (Note: Non–mint-flavored products are typically better tolerated than mint-flavored products when oral mucositis or oral graft-versus-host disease [GVHD] is present).

  • Fluoride recommended.
  • Use 0.9% saline or water if toothpaste causes irritation.

   

• Flossing:
  • Once daily.
  • Atraumatic technique with modifications as needed.

   

• Bland rinses:
  • Varieties:
    • 0.9% saline.
    • Sodium bicarbonate solution.
    • 0.9% saline plus sodium bicarbonate solution.

  • Use 8 to 12 oz of rinse, hold a mouthful, and expectorate until total volume is used; repeat every 2 to 4 hours or as needed to ameliorate discomfort.

   

• Fluoride:
  • 1.1% neutral sodium fluoride gel.
  • 0.4% stannous fluoride gel.
  • Brush on gel for 2 to 3 minutes.
  • Expectorate and rinse mouth gently.
  • Apply once a day.

   

• Topical antimicrobial rinses:
  • 0.12% to 0.2% chlorhexidine oral rinse for management of acute gingival lesions.
  • Povidone iodine oral rinse.
  • Rinse, hold 1 to 2 minutes, and expectorate.
  • Repeat 2 to 4 times a day, depending on severity of periodontal disease.

   

Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy [1]

• Minimize denture use during first 3 weeks posttransplant.
  • Wear dentures only when eating.
  • Discontinue use at all other times.

   

• Clean twice a day with a soft brush and rinse well. 
• Soak in antimicrobial solutions when not being worn. 
• Perform routine oral mucosal care procedures 3 to 4 times a day with the oral appliances out of the mouth. 
• Leave appliances out of mouth when sleeping and during periods of significant mouth soreness. 
• Dentures may be used to hold medications needed for oral care (e.g., antifungals). 
• Discontinue use of removable appliances until oral mucositis has healed. 
•  Remove orthodontic appliances (e.g., brackets, wires, retainers) before conditioning.
•  

Considerable variation exists across institutions relative to specific nonmedicated approaches to baseline oral care, given limited published evidence. Most nonmedicated oral care protocols use topical, frequent (every 4–6 hours) rinsing with 0.9% saline. Additional interventions include dental brushing with toothpaste, dental flossing, ice chips, and sodium bicarbonate rinses. Patient compliance with these agents can be maximized by comprehensive overseeing by the health care professional.

Patients using removable dental prostheses or orthodontic appliances have risk of mucosal injury or infection. This risk can be eliminated or substantially reduced prior to high-dose cancer therapy. (Refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy.)

Dental brushing and flossing represent simple, cost-effective approaches to bacterial dental plaque control. This strategy is designed to reduce risk of oral soft tissue infection during myeloablation. Oncology teams at some centers promote their use, while teams at other centers have patients discontinue brushing and flossing when peripheral blood components decrease below defined thresholds (e.g., platelets <30,000/mm³). There is no comprehensive evidence base regarding the optimal approach. Many centers adopt the strategy that the benefits of properly performed dental brushing and flossing in reducing risk of gingival infection outweigh the risks.

Periodontal infection (gingivitis and periodontitis) increases risk for oral bleeding; healthy tissues should not bleed. Discontinuing dental brushing and flossing can increase risk for gingival bleeding, oral infection, and bacteremia. Risk for gingival bleeding and infection, therefore, is reduced by eliminating gingival infection before therapy and promoting oral health daily by removing bacterial plaque with gentle debridement with a soft or ultra-soft toothbrush during therapy. Mechanical plaque control not only promotes gingival health, but it also may decrease risk of exacerbation of oral mucositis secondary to microbial colonization of damaged mucosal surfaces.

Dental brushing and flossing should be performed daily under the supervision of professional staff:

• A soft nylon-bristled toothbrush should be used 2 to 3 times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus, keeping them free of bacterial plaque. 
• Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma. 
• Oral rinsing with water or saline 3 to 4 times while brushing will further aid in removal of dental plaque dislodged by brushing. 
• Rinses containing alcohol should be avoided. 
• A toothpaste with a relatively neutral taste should be considered because the flavoring agents in toothpaste can irritate oral soft tissues. 
• Brushes should be air-dried between uses. 
• While disinfectants have been suggested, their routine use to clean brushes has not been proven of value. 
• Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use. 

Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. Flossing allows for interproximal removal of dental bacterial plaque and thus promotes gingival health. As with dental brushing, this intervention should be performed under the supervision of professional staff to ensure its safe administration.

The oral cavity should be cleaned after meals:

• If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary. 
• Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals. 
• Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary. 
• Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. 
• Toothettes have limited ability to cleanse the dentition; however, they may be useful for cleaning maxillary/mandibular alveolar ridges of edentulous areas, palate, and tongue. 

Preventing dryness of the lips to reduce risk for tissue injury is important. Mouth breathing and/or xerostomia secondary to anticholinergic medications used for nausea management can induce the condition. GVHD of the lips can also contribute to dry lips in allogeneic transplant patients. Lip care products containing petroleum-based oils and waxes can be useful. Lanolin-based creams and ointments may be more effective in moisturizing/lubricating the lips and thus protecting against trauma.

References

1. Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas’ Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607. 

]]> http://smilewell.wordpress.com/2011/12/07/oral-and-dental-management-after-cancer-therapy-from-the-national-cancer-institute/feed/ 0 drbill http://smilewell.wordpress.com/2011/07/06/does-periodontitis-increase-cancer-risk/ http://smilewell.wordpress.com/2011/07/06/does-periodontitis-increase-cancer-risk/#comments Wed, 06 Jul 2011 12:06:01 +0000 smilewell http://smilewell.wordpress.com/?p=257 ]]>  

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

DOES PERIODONTITIS

INCREASE CANCER RISK?

As evidence mounts linking gum

disease to other serious conditions

such as heart disease and even

premature birth among pregnant

women, dentists and hygienists

have been highlighting the importance

of maintaining the health of

the gums. Not only is it critical to

brush and floss twice daily at

home, patients are strongly encouraged

to undergo professional dental

cleanings to prevent or alleviate

inflammation of the gums

(“gingivitis”). Otherwise, if left

untreated, gum disease may lead to

a more serious condition, chronic

periodontitis. This advanced form

of gum disease can result in bone

and tooth loss. In addition, research

indicates that periodontitis also

increases the risk of developing

head and mouth cancers, especially

in the mouth and throat.

We’ll be happy to answer any questions

you may have on the subject of

gum disease. We offer complete

dental health services for the whole

family. We want to do more than

meet your expectations – we want to

exceed them. We’re located at 1371

Beacon Street, where we make it a

point to get to know you and the specific

needs of your family. It’s important

to us. Please call 617-738-0700

to schedule an appointment. Having

nice looking teeth gives a boost to

health and happiness. Office hours

are Mon.-Thurs. 8am-5pm.

P.S. According to the research

mentioned above, each millimeter

loss of alveolar bone (the ridge of

bone that surrounds the roots of the

teeth) increases the risk of head and

neck cancer fourfold.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

CHOOSING

SUITABLE

REPLACEMENTS

While fluoridated drinking water

has helped ensure that people under

age 50 have an excellent chance

of keeping all their teeth, older

individuals may not be so fortunate.

In fact, the Centers for Disease

Control and Prevention reports that

one-quarter of American adults

over the age of 65 have lost all their

teeth; the National Institute of

Dental and Craniofacial Research

indicates that 58% of Americans

over age 50 have fewer than 21 of

the normal 32 teeth. Missing teeth

lead to poor nutrition as well as a

possible collapse of the vertical

dimension of the lower face. To

avert these potential problems,

dental implants provide the best

functioning, and most naturallooking,

replacements.

If you have any questions about

your chances for replacing lost teeth

through the latest techniques call us

at 617-738-0700. Our recommendations

for dental treatment are always

in the best interest of the patient.

We can provide you with implants,

dentures, bridges and crowns, as

well as general dental treatment for

the entire family. We want you to

look and feel your best. For a happy,

healthy, and good-looking smile, we

urge you to have a check-up soon.

We’re located at 1371 Beacon Street.

Office hours are Mon.-Thurs.

8am-5pm.

P.S. Dental implants are rooted

inside the jawbone, which prevents

the bone resorption that causes the

bone underlying lost teeth to

shrink.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

FOODS FOR

THOUGHT

While we have all been told that

eating too much candy is bad for

our teeth, relatively few patients

are aware that seemingly healthy

and nutritious foods such as

raisins and whole wheat bread also

pose potential problems. The fact

is that all carbohydrates break

down into simple sugars, which

then are converted into “plaque”

by bacteria in the mouth. It is this

sticky residue that is primarily

responsible for tooth decay and

gum disease. This risk is increased

when carbohydrate-based foods

such as raisins and whole-grain

breads adhere to tooth surfaces

and collect below the gum line. At

this point, they can pose nearly as

much of a danger to oral health as

caramel in candy bars.

This column has been brought to

you in the interest of better dental

health. We believe in preventive

dentistry. We know that you wish

to receive your general dental care

from a highly trained, caring staff;

therefore, professionalism is very

important to you. Our promise to

you is that our office will provide

you with dental care of the highest

quality available, utilizing the

most modern procedures and an

extremely qualified staff. Please

call 617-738-0700 to schedule an

appointment. We’re located at

1371 Beacon Street. Office hours

are Mon.-Thurs. 8am-5pm.

P.S. To protect your teeth from

the acid in sodas, sip water or

chew sugarless gum to activate

acid-neutralizing saliva, and then

brush your teeth.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

ROOT CAUSE

OF PAIN

When a deep cavity or crack causes

infection that damages a tooth’s

pulp (which contains blood vessels,

nerves, and connective tissue),

severe pain results. If left untreated,

the damage can spread to the surrounding

bone, causing further

problems. For this reason alone,

patients with an infection in the

pulp of a tooth need to undergo

endodontic treatment that involves

drilling to the core of the tooth;

removing the damaged pulp, and

then cleaning, shaping, filling and

sealing the tooth. A “root canal”

procedure derives its name from

the fact that the pulp branches

down each root through canals that

stop just short of the bottom tip of

the tooth. Endodontic treatment

preserves teeth and circumvents the

need to extract them.

Our mission is to use our knowledge

and experience in endodontics

to save teeth that would otherwise

be lost. We are currently accepting

new patients. We provide individual

care to our patients in a comfortable,

professional environment.

If you know of anyone in need of

quality dental care we would appreciate

your referrals. We’re located

at 1371 Beacon Street, where our

purpose is to help people reach and

commit to the highest level of dental

health personally appropriate to

them. Please call 617-738-0700 to

schedule an appointment. Office

hours are Mon.- Thurs. 8 a.m. -

5 p.m.

P.S. Root canal treatment removes

the source of pain caused by an

infected pulp; because the procedure

is performed with local anesthetic,

it does not cause pain.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

ALL-PORCELAIN CROWNS

When it comes to choice of

material for replacement crowns,

porcelain provides the most natural

appearance. Much like natural

teeth, translucent porcelain does

not have a monochromatic

appearance. Instead, it displays

color variation that results from the

internal play of light. Porcelain’s

texture also plays a role in

imparting an organic look to

replacement teeth by breaking up

light reflections. The first

all-ceramic crowns introduced over

a century ago were the porcelainjacket

type. While they offered

superior cosmetic appearance, they

were not thought to be strong

enough to be used on back

(chewing) teeth. More recently,

however, proprietary materials and

processes have been developed for

fabricating all-ceramic crowns out

of solid blocks of material that

combine excellent strength and

beauty.

Crowns are an ideal restoration for

teeth, which have been broken, or

have been weakened by decay or a

very large filling. Our dental

services include crowns, bridges,

dentures, and cosmetic dentistry.

For more information, or to

schedule an appointment, please

call us at

617-738-0700

. It is

important to us that any dental

experience be a positive one for all

patients. For exceptional dentistry

for the entire family, come see us at

1371 Beacon Street.

Office hours

are Mon.-Thurs., 8am-5pm.

P.S. All-ceramic crowns tend to be

more natural looking than

porcelain-fused-to-metal (PFM)

dental crowns, and they give no

indication of the metal edge of their

substructure like PFM crowns do.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

MEDICINE-INDUCED

DRY MOUTH

The medication you’re currently

taking may have such unwanted

side effects as dry mouth, softtissue

changes, gum-tissue overgrowth,

and taste changes. In fact,

the Academy of General Dentistry

reports that up to 400 medications

can contribute to dry mouth. A list

of these prescriptions and over-thecounter

drugs includes antihistamines,

decongestants, painkillers,

muscle relaxants, tranquilizers,

diuretics, and antidepressants, as

well as drugs that treat high blood

pressure, Parkinson’s disease, and

incontinence. Aside from being

uncomfortable, dry mouth can lead

to irritation, inflammation, and

infection of the soft tissues of the

mouth. Anti-seizure medications,

immunosuppressant drugs, and

channel calcium blockers may also

cause “gingival overgrowth”

(enlarged gum tissue). To avert

these potentially serious problems,

consult with the dentist about a

treatment strategy.

You can rely on us to answer all

your questions about dental treatments

and procedures. We appreciate

the opportunity to provide you

with quality dental care. Our staff is

made up of well-trained professionals

who work together as a team to

provide the highest quality treatment

in a warm, caring setting. We’re

located at 1371 Beacon Street.

Please call 617-738-0700 to schedule

an appointment. Office hours are

Mon.- Thurs. 8 a.m. – 5 p.m.

P.S. Cardiovascular agents, central

nervous system stimulants, and

smoking cessation products can

sometimes leave a bitter or metallic

taste in the mouth or an inability to

taste at all.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

CHLORINATED

POOL WATER’S

POTENTIAL RISK

There is little question that

swimming is a healthy activity.

However, those who frequently

swim or spend prolonged periods

of time in chlorinated pools should

be aware of the potential for tooth

enamel damage. While chlorine is

added to pool water to provide

swimmers protection against

bacteria, using too much chlorine

can lower pH levels in water to the

point where it can erode tooth

enamel. Curiously, brushing teeth

after they are exposed to chlorinated

pool water with low pH (acidic)

may do more harm than good.

Abrading the weakened tooth

enamel with a brush may only

hasten the erosion. Rinsing with

a fluoride product may be

preferable. Consultation with the

dentist can provide a proper

diagnosis and treatment.

Do you spend significant

amounts of time in chlorinated

water? We want you to receive the

highest quality, complete, affordable

dental care. We keep abreast

of all new procedures, and would

like to increase public awareness

of the importance of preventative

oral health care. We’re located at

1371 Beacon Street. Please call

617-738-0700 to schedule an

appointment. Your oral health

requirements, from restorative to

cosmetic considerations, will be

met with the latest technology.

Office hours are Mon.- Thurs.

8 a.m. – 5 p.m.

P.S. Because most sodas and sport

drinks contains acids, it may benefit

teeth to drink them through a straw.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

PLAQUE

DETECTION

Although your teeth may seem

clean, they still may be encrusted

with germ-laden plaque, especially

between teeth and at the gum line.

To detect just how effective tooth

brushing and flossing are in removing

the sticky substance that causes

both tooth decay and gum disease,

patients can undergo a plaque

detection test either at home or in

the dental office. The home version

of the test utilizes special tablets

that contain red dye. Once the

tablet is chewed and mixed with

saliva, the dye is swished around in

the mouth for about 30 seconds.

After a water rinse, the teeth are

examined. Any pink residue on the

teeth indicates remaining plaque,

which poses a threat to teeth and

gums.

We are trained to detect and treat

periodontal disease. We will be

happy to answer any questions you

may have about the health of your

teeth and gums. We will discuss

your particular problem and recommend

the treatment that is right for

you. We’re located at 1371 Beacon

Street, where we feature state-of-theart

treatment procedures for all your

dental needs. Please call 617-738-

0700 to schedule an appointment for

compassionate and gentle dental care.

Office hours are Mon.- Thurs. 8 a.m. -

5 p.m.

P.S. The dentist or hygienist can

perform a plaque detection test in

the office using special fluorescent

solution and an ultraviolet

plaque light.

by William Papadopoulos

D.M.D., C.A.G.S.

www.smilewell.com

MISSING LINK

UNCOVERED

Proline is one of a number of

amino acids that serve both as

“building blocks” of proteins and

as intermediates in metabolism.

What has recently come to the

attention of dentists is the fact that,

in addition to amino acids’ role as

the building blocks of muscles,

tendons, organs, glands, nails, and

hair, proline has been identified as

the amino acid responsible for

making teeth strong and resilient.

Researchers have found proline to

be repeated at the center of proteins

found in tooth enamel, which is the

hardest substance found in the

human body. This new finding may

lay a foundation for future research

that helps dentists replace damaged

parts of the outer-tooth layer with

healthy layers of new enamel.

Let us help you with answers to

your questions about proline. Our

dental team is committed to

performing to his or her highest

ability in order to achieve the

optimum level of care. We believe

that with preventative dental care,

daily brushing and flossing, and a

well-balanced diet, people can

maintain their teeth and gums in

good health well into their later

years. Let’s help you keep that

dazzling smile. Call 617-738-0700

to schedule an appointment. We’re

located at 1371 Beacon Street.Office

hours are Mon.- Thurs. 8 a.m. – 5 p.m.

P.S. Other animals, such as frogs,

do not have proline repeats as

long as those found in humans’

teeth, which causes frogs’ teeth to

be softer than those of humans.