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Patient Name: Address: City: State: Zip: Cancer Diagnosis: Date of Diagnosis: Finish Date of Radiation Therapy: Continued Dental Needs:* *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 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:* o o o o o o 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: <Oncology Center> <Address> <Phone> <Email> Treating Dentist: <Address> <Phone> <Email> Created by: Jennifer Brown, RDH <Fax> <Fax>