Download HERE - Side Effect Support

Patient Name:
Address:
City:
State:
Zip:
Cancer Diagnosis:
Date of Diagnosis:
Finish Date of Radiation Therapy:
Continued Dental Needs:*
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*The
following evidence based practices were referenced for dental needs and
considerations:
-American Cancer Society Head and Neck Cancer Survivorship Care Guideline 22
March 2016
-National Comprehensive Care Network 2016
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3 month recall cleaning and exam for one year then reevaluate needs/risks
Routine dental x-rays per ADA recommendations
Rx 5,000ppm fluoride gel for tray use OR brush-on gel
use daily for LIFE OR
3x/year fluoride varnish
Supersaturated calcium phosphate rinse 2x daily for
mild to moderate xerostomia
AM/PM management of xerostomia with a continuum
of support with gels, lozenges, and sprays, and frequent
sips of water
Monitor for early signs of ORN
Perform a thorough Oral Cancer Screening at all recall
appointments
Additional Dental Considerations:*
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After consultation with this patient’s Radiation
Oncologist the following has been determined:
Teeth charted in Red:
High risk >____cGy
Yellow: Mod risk ____cGy
Green: Low risk ____cGy
Please contact this patient’s treating physician for
proposed dental treatment including extractions,
dental implants, or procedures involving bone in areas
highlighted in red and yellow to make a collaborative
dental treatment plan.
Chemotherapy port placement will require antibiotic
prophylaxis
Remineralizing toothpaste
Trismus and range of motion exercises
Tobacco cessation education
Self-evaluation education
CAMBRA EXTREME RISK: for patients with minimal or
no salivary function
Fluoride protocol
Super saturated calcium phosphate rinse
Xylitol gum/mints/ candy 5 exposures daily
Sealants or Preventive Resin Restorations (PRR) for deep
pits and fissures
Chlorhexidine .12% 10mL rinse one minute daily for one
week each month
Contact Information:
Treating Physician:
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Treating Dentist:
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Created by: Jennifer Brown, RDH
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