Download Oral Health Maintenance in Head and Neck Cancer Patients

Earn
3 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.
Oral Health Maintenance in
Head and Neck Cancer Patients
A Peer-Reviewed Publication
Written by Kathryn Gilliam, RDH, BA
Abstract
Many head and neck cancer patients are not treated in large
cancer centers that have dental oncologists as a part of the
cancer care team. They are being treated in smaller cancer
centers or private oncology practices where there may not
be a focus on oral health. These people are coming to their
regular dental offices for care, often with side effects of their
cancer treatment. Standards and protocols are detailed for
use in a general dental practice. This course consolidates
current recommendations into specific protocols that are
easily implemented in the general dental practice. The goal is
to give dentists and dental hygienists the confidence to treat
head and neck cancer patients effectively and with concern
for the whole person who is in need of special care at this
vulnerable time.
Educational Objectives:
At the conclusion of this educational activity participants will
be able to:
1. Recognize common oral complications resulting from radiation therapy, chemotherapy, and other cancer treatments.
2. Identify when it is considered safe to treat a patient
undergoing cancer treatment.
3. Develop an individual plan for treatment of various oral
complications to assist in the supportive care of the patient
undergoing cancer therapy.
4. Recognize the dental professional’s responsibility to protect
the oral health of the patient undergoing treatment for head
and neck cancer and the need to be an advocate for oral care
during this critical time in the patient’s life.
Author Profile
Kathryn Gilliam, RDH, BA, has presented courses based
on her passion for the early detection of oral cancer and
care for patients undergoing cancer treatment, as well as
lectures about periodontal inflammation and the connection
to systemic illness. Her articles have appeared in General
Dentistry, RDH, Dental Economics, Dentistry Today, AGD
Impact, and Modern Hygienist. For additional information,
Kathryn may be reached at [email protected]
Author Disclosure
Kathryn is the founder of PerioLinks, an education and
coaching company focused on the vital links between
oral and systemic health. Kathryn Gilliam, RDH, BA, has
no commercial ties with the sponsors or providers of the
unrestricted educational grant for this course.
Go Green, Go Online to take your course
Publication date: Aug 2016
Expiration date: July 2019
Supplement to PennWell Publications
PennWell designates this activity for 3 Continuing Educational Credits
Dental Board of California: Provider 4527, course registration number CA# 03-4527-14008
“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to
(10/31/2019) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third
party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the
required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
products or services discussed in this educational activity. Heather can be reached at [email protected]
Educational Disclaimer: Completing a single continuing education course does not provide enough information to
result in the participant being an expert in the field related to the course topic. It is a combination of many educational
courses and clinical experience that allows the participant to develop skills and expertise.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Registration: The cost of this CE course is $59.00 for 3 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
Educational Objectives
At the end of this self-instructional educational activity,
the participant will be able to:
1. Recognize common oral complications resulting from
radiation therapy, chemotherapy, and other cancer
treatments.
2. Identify when it is considered safe to treat a patient
undergoing cancer treatment.
3. Develop an individual plan for treatment of various
oral complications to assist in the supportive care of
the patient undergoing cancer therapy.
4. Recognize the dental professional’s responsibility
to protect the oral health of the patient undergoing
treatment for head and neck cancer and the need to be
an advocate for oral care during this critical time in the
patient’s life.
Abstract
Many head and neck cancer patients are not treated in large
cancer centers that have dental oncologists as a part of the
cancer care team. They are being treated in smaller cancer
centers or private oncology practices where there may not
be a focus on oral health. These people are coming to their
regular dental offices for care, often with side effects of their
cancer treatment. Standards and protocols are detailed for
use in a general dental practice. This course consolidates
current recommendations into specific protocols that are
easily implemented in the general dental practice. The goal
is to give dentists and dental hygienists the confidence to
treat head and neck cancer patients effectively and with
concern for the whole person who is in need of special care
at this vulnerable time.
Introduction
The majority of articles or continuing education courses
dealing with cancer begin with statistics. Statistics certainly have a place, but they can also overshadow the fact that
every number actually represents an individual person: a
person who may be afraid, a person who may be in pain, or
a person who may be looking to you, a healthcare provider,
to offer relief. This course is intended to prepare you to offer aid to the people in your practice who are undergoing
some of the most traumatic experiences of their lives and
who are literally fighting for their lives.
A few of those statistics
Every year, 1.2 million Americans are diagnosed with
some form of cancer. In 2013, there were 41,380 people diagnosed with oral and pharyngeal cancer and 7,890 people
died of head and neck cancer.1 Head and neck squamous
cell carcinomas, which include cancers of the oral cavity,
oropharynx and larynx, are the sixth most common cancers
worldwide with 633,000 cases diagnosed each year, resulting in 355,000 deaths annually.2
Although overall US cancer death rates continue to decline, the incidence of HPV-related oropharyngeal cancers
are increasing according to a 2013 annual report on the
status of cancer in the United States.3 Studies indicate that
the majority of head and neck cancer patients will suffer
from at least some oral complications of their radiation and
chemotherapy treatments.4
Part of the team
As dental healthcare providers, it is our obligation to provide assessment, prevention and treatment to minimize the
negative effects of cancer therapy, improve the quality of
life and possibly save the life of the head and neck oncology
patient.
The emotional impact of a cancer diagnosis and treatment options and decisions can overwhelm the cancer
patient and family. It is natural to want to begin cancer
treatment without delay. Dental concerns seem minimally
important compared to the life and death magnitude of
cancer. The dental team must become part of the cancer
care team to assist the patient and family through the maze
of treatment coordination so that dental concerns can be
addressed and the potential negative oral effects of cancer
treatment can be prevented or minimized.
The prevention and management of oral complications
of cancer therapy is a topic addressed in many articles but
acknowledged to be lacking in evidence-based research.5
This course is intended to compile the best evidence-based
information and present practical clinical knowledge for
the dental healthcare provider who is increasingly being asked to care for head and neck cancer patients in the
general dental setting. There is a tendency to defer to the
oncologist, but not all oncologists are focused on the importance of a dental health evaluation before the start of
cancer treatment, or the importance of supportive dental
care during and after cancer treatment. That is why it is
crucial for the general dental team to recognize its place on
the cancer patient’s care team and to effectively care for the
head and neck cancer patient and family before, during and
after cancer therapy.
Three phases of dental care of the head and neck
cancer patient
1. Assessment before the start of cancer treatment
2. Supportive management during cancer treatment,
including management of oral complications
3. Maintenance treatment following the conclusion of
cancer treatment
Pre-treatment assessment
The most important dental visit for a patient diagnosed
with any type of cancer is the pre-cancer treatment dental
assessment. Poor oral health has been associated with an
increased incidence and severity of oral complications.
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This has influenced an aggressive approach to stabilizing
oral health as much as possible before the start of cancer
treatment.6
According to the National Cancer Institute, most oncologists assert that delay in treatment is the main reason
they do not refer their patients for a pre-treatment dental
evaluation.7 It is crucial, therefore, that general dental
teams commit to seeing newly diagnosed cancer patients
as soon as possible. Since time is critical for these patients,
and generally not as urgent for other patients in our practices, an office policy regarding immediate scheduling
for pre-treatment assessment of cancer patients is recommended.
The focus of the pre-treatment examination is to
determine the oral health status and to initiate necessary
interventions that may reduce oral complications during
and after cancer therapy.8 Ideally, any dental treatment
performed should be scheduled to allow a minimum of 14
days of healing before the start of oncology treatment.
Goals of pre-treatment dental examination
• Provide prompt identification of existing infections or
other problems.
• Improve the likelihood the patient will tolerate the
optimal schedule and dosage of cancer treatment.
• Prevent, eliminate or reduce oral pain.
• Minimize oral infections that could lead to potentially
fatal systemic infections.
• Reduce the risk and severity of oral complications.
• Prevent or minimize complications that compromise
nutrition.
• Prevent or reduce a later incidence of bone necrosis.
• Preserve or improve oral health.
• Improve quality of life.
Pre-treatment assessment
The pre-treatment assessment should include the following:
• Identify and treat sites of low grade and acute oral
infections
– Caries
– Periodontal disease
– Endodontic infection
– Mucosal lesions (If the patient has a history of
recurrent herpetic ulcers, discuss with the oncologist
the benefit of prescribing a prophylactic systemic
antiviral regimen that the patient will continue
throughout the oncology treatment.)
• Establish a schedule for dental treatment and begin
at least 14 days before the start of cancer therapy to
allow for healing. Postpone elective procedures until
after the cancer treatment is complete and the oncologist clears the patient.
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•
•
•
•
•
•
•
•
•
•
Perform necessary oral surgical procedures at least
14 days before the initiation of radiation treatment.
Radiation patients, especially those with head and
neck cancer, may only be able to have dental surgery
during this pre-treatment phase due to the potential
for osteoradionecrosis following irradiation of bone.
In adults, extract teeth that may pose a future
problem or are non-restorable to prevent later
extraction-related osteoradionecrosis.
In children, extract loose primary teeth and teeth that
are expected to exfoliate during later treatment.
Eliminate potential sources of oral trauma and
irritation such as orthodontic bands and brackets,
ill-fitting dentures, and other appliances. Orthodontic
appliances should be removed before the start of
cancer treatment if highly stomatotoxic chemotherapy
is planned or if the appliances will be in the field of
radiation.
Before starting head and neck radiation, identify
and treat all potential oral problems in the field of
radiation. Request the planned area description and
illustrations from the radiation oncologist. Common
head and neck radiation fields are described and
illustrated in the monograph, Oral Health in Cancer
Therapy.9
Educate the patient regarding the critical nature of
impeccable oral hygiene.
–Establish a written home care plan for the patient
and supply necessary implements, if possible.
– Recommend a power toothbrush and demonstrate
its proper usage.
– Demonstrate proper flossing technique and the
proper use of other interproximal cleaning devices.
Fabricate custom fluoride trays and prescribe 1.1%
neutral pH sodium fluoride gel aimed at prevention of
demineralization and caries.
–Be sure trays cover all tooth structures without
irritating gingival or mucosal tissues.
–Instruct the patient to use custom fluoride trays
for five minutes a day beginning before the first
radiation session and continuing indefinitely.
Advise the patient to avoid alcohol and tobacco
during cancer treatment.
Schedule the patient for oral health maintenance procedures every 8 to 12 weeks during cancer treatment,
as blood counts allow.
–Following active radiation treatment, see the patient
every 6 to 8 weeks for prophylaxis or periodontal
maintenance procedures.
–Gradually, as the patient’s health stabilizes, increase
the time interval to three months.
Advise the patient to report any adverse oral effects
immediately so appropriate measures can be insti-
3
Table 1: Treatment with possible complication percentage 10
Treatment Regimen
Anticipated Percentage
of Complications
Adjunctive chemotherapy
10
Primary chemotherapy
40
Hematopoietic stem cell transplantation* where myeloablative conditioning regimens** are used
80
Head and neck radiation therapy to
fields involving the oral cavity
100
*Transplantation of blood cells that give rise to all other blood cells derived from bone marrow,
peripheral blood or umbilical cord blood
**Administration of high doses of chemotherapy or radiation therapy prior to bone marrow
transplantation causing severe myelosuppression
Table 2: Radiation induced oral complications
Complication
Acute
Chronic
Mucositis (mucosal inflammation
and ulceration)
X
X
Pain
X
X
Xerostomia (salivary gland
dysfunction/dry mouth)
X
X
Dysgeusia (taste dysfunction)
X
X
Infections
X
X
Dental caries
X
X
Dehydration and malnutrition
(anorexia)
X
X
Osteoradionecrosis (ORN)
X
X
Dysphagia (swallowing difficulty)
X
X
Trismus (mucosal fibrosis and atrophy)
X
Soft tissue necrosis
X
Dysphasia (speech disorders)
X
Psychosocial effects
X
tuted to ameliorate symptoms before they become so
acute as to interfere with cancer treatment.
Supportive dental care during cancer therapy
During the course of cancer treatment, the dental team must
maintain communication with the oncology team. Consult
with the oncologist before any dental procedures, including
routine prophylaxis or periodontal maintenance procedures.
Ask the oncology team for the patient’s blood count after each
appointment, which will determine when and if a patient can
safely tolerate dental treatment. When the patient’s health is
too fragile for dental procedures, supportive care can come in
the form of home care recommendations and psychological
and emotional support.
The type of treatment the patient is receiving will determine the likelihood of experiencing oral complications
(Table 1.)
Radiation therapy
Radiation therapy is used routinely in the treatment of
head and neck cancers. It may be used as the primary treatment or as adjuvant therapy following surgery. It may be
used alone or with chemotherapy.
Radiation therapy is generally given once a day, five
days a week. The radiation schedule is called “fractionation.” For advanced tumors, more aggressive schedules to
intensify treatment are used and this is called accelerated
fractionation or hyperfractionation.
Most tumors of the head and neck are squamous cell
carcinomas, which require high doses of radiation. Radiation doses for cancer treatment are measured in a unit called
a gray (Gy), which is a measure of the amount of radiation
energy absorbed by 1 kilogram of human tissue. Different doses of radiation are needed to kill different types of
cancer cells.
Oral complications of radiation therapy are related to
the site radiated, the total radiation dose, the fractionation
schedule, and integration with other therapies such as chemotherapy.
Negative oral consequences of radiation treatment
All patients who have undergone radiation therapy for
cancer are at risk for oral complications, but head and
neck cancer patients are a particular challenge regarding oral complications. The oral side effects of head and
neck radiation are more predictable, more severe and
can lead to permanent tissue changes. These changes
can put the patient at a greater risk for serious chronic
conditions than the oral complications typically associated with chemotherapy, which are usually of a shorter
duration and usually less severe than those of radiation
therapy.11
The effects of tumorcidal doses of radiation on oral tissues can cause a plethora of short and long term negative
side effects that impair the quality of life. Radiation side
effects are divided into acute and chronic types.
Acute effects develop during the early phases of radiotherapy and continue into the immediate post-treatment
period. Chronic effects can manifest from weeks to years
after radiation treatment. The acute effects range from
uncomfortable to intensely painful, but generally resolve
in time. However, the severe and acute toxic effects on the
oral mucosa can result in the need for treatment schedules
to be modified so that oral lesions can resolve.12 In cases
of severe oral involvement, the patient may no longer be
able to continue with cancer treatment. Discontinuation of
therapy can be life threatening.
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Chemotherapy
The use of combined chemotherapy and radiation is now
considered standard for most locally advanced tumors of
the head and neck. The toxicities of the combined therapy
are essentially the same as with radiation alone, but develop
more rapidly and are typically more severe when they reach
the maximum level of drug dosage.13
The goal of chemotherapy is to eradicate the rapidly
growing tumor cells. Unfortunately, chemotherapy is also
toxic to other rapidly growing cells, such as those of the
bone marrow, hair and mucosa of the gastrointestinal tract,
including the oral cavity.
Negative oral consequences of chemotherapy
• Direct cytotoxic effects of chemotherapy
–Mucositis and ulceration of the lining of the oral
mucosa.
• Indirect cytotoxic effects of chemotherapy
–Myelosuppression (condition in which bone
marrow activity is decreased, resulting in fewer red
blood cells, white blood cells and platelets) results
in anemia (below normal red blood cell count),
thrombocytopenia (below normal platelets), and
leukopenia (below normal white blood cells).
–Decreased platelet count is common in patients on
chemotherapy. Patients are at risk for postoperative
bleeding with dental surgery when the platelet
count is below 75,000/mm3. Spontaneous mucosal
bleeding can occur when the platelet count is below
20,000mm3.
–Advise the oncologist of the potential for bacteremia
and/or bleeding associated with proposed dental
procedures during chemotherapy.
• Infection
–Infections in the oral cavity are associated with
oral ulcers, periodontal disease, pulpal disease,
pericoronal disease and sinus infections.
–Fungal infections are also increased in these
patients.
Management of oral complications of head and
neck cancer therapy
Mucositis
Oral mucositis is a common debilitating complication of
cancer therapy, occurring in about 60% of patients. Oral
mucositis describes inflammation of oral mucosa resulting from chemotherapeutic drugs or ionizing radiation.
Mucositis typically manifests initially as erythema, with
ulceration developing later.
Acute mucositis results from the loss of squamous epithelial cells because of the radiation induced death of basal
cells. This results in a decrease of epithelial cells. As therapy
continues, cell regeneration often cannot keep up with the
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Table 3: Recommendation based on lab values 14
Lab Values
Neutrophils (Absolute
Neutrophil Count)
Recommendation
Obtain from CBC or from oncologist.
>2,000/mm 3
No prophylactic antibiotics necessary for
dental treatment.
1,000 mm 3 2,000/mm 3
AHA recommendations for prophylaxis
with dental procedures.
<1,000/mm 3
• IV Antibiotics before surgery.
• Consult with oncologist.
• No routine dental procedures.
Platelets
Obtain from CBC or from oncologist
>75,000/mm 3
No support needed for routine dental
treatment.
40,000 mm 3 70,000/mm 3
• Manage with local hemostasis measures, including
– Pressure
–Topical thrombin
–Microfibrillar collagen
–Sutures, etc.
• Consult with oncologist.
• Perform no routine dental procedures.
<40,000/mm 3
• Transfuse platelets.
• Consult with oncologist.
• Perform no routine dental procedures.
rate of cell death, resulting in denudation of the mucosa. In
addition to direct tissue injury, the oral microbial flora is
thought to contribute to radiation induced mucositis.
Symptoms of radiation induced mucositis include intense pain, difficulty swallowing (dysphagia) and resulting
anorexia and difficulty speaking.
Chemotherapy induced mucositis results from the direct cytotoxic effects of the chemotherapeutic agents on the
epithelial cells. Mucositis is common when chemotherapy
is given in high doses and repeating schedules or when
combined with radiation. Mucositis is the primary reason
patients may need to stop chemotherapy.
Clinical signs of oral mucositis are generally seen 5-10
days following the initiation of chemotherapy and last 7-14
days. Severity of mucositis coincides with the degree of
neutropenia (low white blood cell count) and is typically
most severe at the lowest value of the neutrophil count.
Mucositis is usually self-limiting and heals within 2-3
weeks. Resolution of mucositis correlates with recovery of
white blood cells, specifically the neutrophils.
A patient may safely receive dental treatment when
blood counts have begun to recover, usually just before the
next round of chemotherapy. Dental care during cancer
treatment is based on neutrophil and platelet counts. The
absolute minimum blood counts for safe dental care are
1,000mm3 neutrophils and 50,000mm3 platelets. Request
5
Table 4: Mouthrinses 15
Mouth Rinses
Composition
Instructions
Uses/Functions
¼ tsp. salt
¼ tsp. baking soda
1 qt. H2O
Use Q4H
• Omit salt if necessary due to soreness
• Do not swallow
• May be used during mucositis (omit salt
if necessary)
• Dissolves thick, ropy saliva
• Soothing to irritated tissues
• Dislodges debris
• Neutralizes gastric acids following
emesis
Saline
½ tsp. salt
8 oz. H2O
• Reduces mucosal irritation
• Increases oral moisture
• Removes Not damaging to oral tissues
None
• Thickened secretions and debris
• Recommended for treatment of leukemic
gingivitis
Calcium
phosphate
Rinse 4x/day or Q1H for mucositis
Chlorhexidine
Rinse with 15cc - 30cc for 1 minute,
3x/day
• Can be used as a mouthwash and
gargle but not swallowed
• Allow 30 minutes before using other
oral hygiene procedures
• Rinsing with water intensifies
unpleasant taste
• Can be applied locally with a cotton
swab
• An alcohol-free aqueous 2% solution
can be compounded by a pharmacist
Hydrogen Peroxide
• Not recommended for daily use as
a rinse
• Should be diluted 1:4 if used
• May be used to cleanse wounds,
soften and loosen dried blood from
the lips and mouth
• Use for 1 day - 2 days at maximum
• Should be followed by therapeutic
rinses
Neutral
Doxepin (Tricyclic
antidepressant)
25 mg Doxepin in 5 ml water
None
Remineralization
No published studies on mucositis
• Used in presence of poor plaque control,
signs of inflammation, or decreased
salivary flow
• Effective topical agent
• Has potent broad-spectrum antimicrobial activity
• Effective at low concentration
• Minimal absorption from GI tract
• Results in fewer febrile days
• May alter oral flora
• May delay healing
• Contains alcohol
• Stains teeth and restorations
• Toothpaste and nystatin reduce
its effectiveness
• Promotes bacterial (pseudomonas) growth
• Unpleasant taste
Helpful in periodontal infections when
anaerobic microorganisms are involved
• Well tolerated
• May be used daily
• Results of study indicate effectiveness in
significantly decreasing oral mucositis
pain16
the most current blood counts from the oncology team
prior to every dental appointment.
Management of oral mucositis
Thorough bacterial plaque control and consistent hydration can help minimize the severity of mucositis. Recommendations include the following:
• Brush three times daily:
–Extra soft toothbrush
•
•
•
• May delay wound healing
• Causes demineralization
• May promote emesis
• Causes dry mouth, thirst, and
discomfort
• Promotes fungal growth
• Unpleasant taste
• Increased stinging /burning
• Unpleasant taste
• Drowsiness
–Sponge brush dipped in chlorhexidine is effective in
reducing plaque and oral microorganisms. Due to
alcohol content, burning may be a problem.
Use 1.1% neutral sodium fluoride toothpaste.
Floss with a waxed or coated floss to prevent damage
to the soft tissues. Supervision of floss technique is
important, especially during periods of myelosuppression.
Rinse with water or a simple saline solution (1/2 tsp.
salt in 8 oz. water) while brushing and between meals.
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•
•
Over the counter mouthrinses are not recommended
due to alcohol content. (See Table 4 for additional
mouthrinse information.)
Instruct patients not to wear dental prostheses while
receiving chemotherapy. If they must, they should
limit their use and they should not be worn during
times of significant oral soreness.
–Prostheses should be cleaned twice daily with a soft
brush, rinsed well and soaked in an antimicrobial
solution for 30 minutes after cleaning.
–Patients should use sodium hypochlorite diluted
1:25 with water or chlorhexidine for soaking.
Chapped lips are a common complication of cancer
chemotherapy. The use of lanolin cream or ointment
can provide better lip protection and soothing of
cracked and split lips than a petroleum based product.
Management of mucositis induced pain
It is estimated that 45% - 80% of all cancer patients have
inadequate pain management. Pain may be present in up
to 85% of patients with head and neck cancers at diagnosis. Orofacial pain associated with cancer therapy is a well
recognized adverse effect of treatment and pain due to oral
mucositis is the most frequently reported complaint during
cancer therapy.17
The impact of mucositis pain is profound because it can
interfere with therapy by necessitating treatment delays
and dose reductions that can interfere with cancer cures;
increase cost of care; interfere with oral function, making it
difficult or impossible to eat, drink or swallow; affect mood
or behavior and dramatically diminish the quality of life.
Mucosal pain may persist long after the mucositis resolves, suggesting that chronic symptoms may be related
to tissue changes, including epithelial atrophy and/or neuropathy.18
Topical anesthetics have a limited duration, may sting
on application to damaged mucosa, and may affect taste.
The flavor of topical anesthetics may cause gagging or emesis.
One of the most frequently prescribed treatments for
mucositis pain is “magic mouthwash.” These rinses are
combinations of anesthetics with an antacid coating agent,
an antifungal agent, and sometimes a steroid. A compounded rinse may provide palliative pain control due to
the anesthetic but there is no evidence that they are more
effective than the topical agents used alone.
Many commercial products are marketed for oral mucositis pain but have not been proven clinically effective.
These include mucosal covering agents. Film forming
agents provide a thick adherent barrier over ulcerated mucosa and may reduce pain.
Systemic medications used for mucositis include opioids and non-steroidal anti-inflammatory medications
(NSAIDS). Opioids have been shown to be very effective
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Table 5: Topical anesthetics for mucositis pain management 20
Agent
Formulations
True Topical Anesthetics
Lidocaine
Viscous gel, jelly, ointment, solution,
patches
Benzocaine
Gel, ointment, spray
Tetracaine/Chirocaine
Anesthetic tabs
EMLA
Cream
“Magic Mouth Rinse”
Compounded rinse (Lidocaine, diphenhydramine, Amphogel ± Nystatin)
Antihistamines
Diphenhydramine
Elixir, IV solution
Other agents
Doxepin
Elixir
Benzydamine
Rinse (not available in US)
Benzonatate
Gel caps (open and coat mouth)
Cocaine
Compound 10% solution
Table 6: Non-steroidal anti-inflammatory 21
Drug
Common Name
Paracetaol
Acetaminophen
Propionic acids
Ibuprophen, Naproxen, Naproxen
Sodium, Fenoprophen, Ketoprophen,
Flurbiprophen, Oxaprozin
Meclofenamic acid
Meclomen
Acetic acids
Diclofenac potassium, ,Sulinda, Ketorolac, Etodolac
Nonselective COX-1 and
COX-2 inhibitors
Aspirin, Diflunisal, Choline magnesium
trisalicylate
Selective COX-2 inhibitors
Celecoxib (see FDA alert)
Cox/Lox inhibitor
Lilofelone (under development)
Oxicams
Piroxicam, Tenoxicam, Droxicam,
Lomoxicam, Meloxicam
Table 7: Opioid medications for mild to moderate mucositis pain 22
Drug
Dosage
Codeine phosphate*
15 mg – 60 mg PO/SC/IM q4-6h
Codeine sulphate*
15 mg – 60 mg PO q4-6h
Oxycodone*
15 mg – 30 mg PO q4h
Oxycodone extended release
tabs*
10 mg – 160 mg PO q12h
Hydrocodone*
5 mg – 10 mg PO q4-6h
* Combined with acetaminophen, aspirin, or Ibuprophen, which can be dose limiting
7
Table 8: Opioid medications for moderate to severe mucositis pain
Drug
Dosage
Morphine Oral
10 mg – 60 mg PO
Morphine extended release
15 mg – 30 mg PO q8-12h
Morphine IV, IM
Varies
Hydromorphone
2 mg – 8 mg PO q3-4h; 1 mg - 4
mg SC/IM/IV
Oxycodone*
15 mg – 30 mg PO q4h
Oxycodone extended release*
10 mg – 160 mg PO q12h
Oxymorphone*
10 mg – 20 mg PO q4h
Oxymorphone extended release* 5 mg – 40 mg PO q12h
Oxymorphone*
1 mg – 1.5 mg SC/2.5-5mg SC/
IM/IV q8-12h
Methadone
2.5 mg – 10 mg PO b.i.d. or
t.i.d./10 mg IM
Levorphanol
2mg PO q6-8h
Fentanyl transdermal patch
12 mg – 1,000 mcg/h patch
q72h
Fentanyl Intravenous
50 mg – 100 mcg/kg IV q1-2h
Fentanyl transmucosal**
100 mg – 200 mcg per dose
(titrate q15 min. p.r.n.)
Fentanyl buccal tablet**
100 mg – 800 mcg applied to
buccal gingival
* Combined with acetaminophen, aspirin, or ibuprophen which can be dose limiting
**Transmucosal and buccal fentanyl are used for breakthrough pain; doses can vary and are
customized by prescribing clinician
in pain management for the head and neck cancer patient.
There are two categories of opioid medications: those used
for mild to moderate pain and those used for moderate to
severe pain. Continuous time based dosing is more effective than pain contingent dosing. Extended release formulations are the most popular.19 The use of NSAIDS is
contraindicated where concerns for bleeding due to low
platelet counts are present.
Adjuvant medications and therapies may be beneficial in
controlling mucositis pain. These include muscle relaxants,
anti-inflammatories, antianxiety medications, antidepressants, anticonvulsants, relaxation, meditation, transcutaneous nerve stimulation, cold/moist heat applications, ice
chips, hypnosis, acupuncture and counseling. A modified
diet consisting of soft and moist foods is beneficial.
Xerostomia (salivary gland dysfunction/
dry mouth)
Radiation of the salivary glands results in atrophy of the
secretory cells and subsequent dry mouth or xerostomia.
The degree of xerostomia is related to the dose of radiation
and the amount of salivary gland tissue in the radiation
field. Although Intensity-Modulated Radiation Therapy
(IMRT) has reduced the severity of xerostomia, it still occurs to some degree in most patients.23
Radiation doses as low as 25 Gy can result in hypofunction of salivary glands and permanent xerostomia
results at doses greater than 35-52 Gy. Serous glands degenerate faster than mucous glands, resulting in thicker
and more acidic saliva. Multiple abnormalities can
occur following degeneration of salivary glands, including impaired antimicrobial capacity and mouth cleansing, taste alterations, and difficulties in oral functions
such as chewing, swallowing and speaking.24 Loss of
salivary function also leads to esophageal dysfunction,
including chronic esophagitis, nutritional compromise,
higher frequency of intolerance to oral medications, increased infections, loss of buffering capacity, reduction
in remineralizing capacity leading to dental sensitivity
and increased susceptibility to dental caries, increased
loss of tooth structure due to attrition, abrasion, and
erosion and increased susceptibility to mucosal injury.
Xerostomia also results in difficulty sleeping due to oral
dryness. It can contribute to emotional challenges such
as social withdrawal and depression.
Management of xerostomia
Managing the oral health of a patient with radiation induced xerostomia is enormously challenging. It requires a
lifelong commitment to impeccable oral care. It is imperative to educate the patient regarding the potentially devastating effects of radiation on the dentition and the mucous
membranes.
Topical management of xerostomia
Unfiltered fluoride containing tap water is the most recommended mouth moisturizer because it is inexpensive and it
delivers some fluoride to help protect the teeth with each sip.
Bottled water doesn’t contain fluoride and should be discouraged. The moisturizing effect of water is short lived. Patients
are encouraged to carry water with them at all times and sip
frequently throughout the day and night.
Commercially available salivary substitutes can also be
used to moisten the mouth. It is preferable to use one with
a pH over 5.1 to prevent demineralization of tooth enamel.
Most commercial salivary substitutes are expensive and
have a short duration of action. Some saliva substitutes
are formulated as viscous gels or are made with a silicone
molecule that has an affinity for mucosa. These products
can be used to coat the oral soft tissues to protect and lubricate them for a longer duration. They may be beneficial
at bedtime.
Over the counter sugar free gums and mints are safe
to use to stimulate any remaining salivary function;
however, xylitol containing items are preferable because
xylitol inhibits the growth of cariogenic bacteria (mutans
8www.ineedce.com
streptococci).25 For those patients with no residual salivary
function, these items will not be tolerated well as they tend
to stick to the tissues and can even irritate or tear the fragile, dry mucosa.
Systemic management of xerostomia
A systemic sialagogue can be prescribed to stimulate salivary flow in a patient who has reduced salivary flow. Sialagogues are available as tablets, capsules, and an ophthalmic
solution that can be placed under the tongue. If there is no
residual salivary function, a sialagogue will be ineffective.26
Prevention of xerostomia induced dental caries
The following requirements must be followed to maintain
the patient’s dentition:
• Avoid moistening the mouth with cariogenic liquids
such as sodas, citrus flavored or carbonated water,
juices, teas, or any other liquid containing sugar.
• Avoid using any liquid with an acidic pH to moisten
the mouth.
• Avoid using foods with sugar to stimulate salivary
flow such as gums, mints, candies, lemon drops, etc.
• Brush teeth after every meal or snack.
• Perform thorough oral hygiene procedures at least
twice a day with a soft toothbrush and fluoride
toothpaste that contains 1,100 ppm – 5,000 ppm
fluoride ion.
• Avoid 0.05% sodium fluoride rinses and 0.63% stannous fluoride rinses for head and neck cancer patients
because low concentration products have not been
shown to be effective in xerostomic patients.
• Use a 1.1% topical fluoride gel daily in custom trays
1. The optimal time to use fluoride trays is immediately before bedtime.
2. Insert both upper and lower trays and bite gently a
few times to “pump” gel between the teeth.
3. Leave the fluoride trays in the mouth for 5-10 minutes.
4. Remove and expectorate the gel several times but
do not rinse.
5. Rinse the trays and allow to air dry.
6. Do not eat or brush teeth for at least 30 minutes.
• Initiate antimicrobial therapy using a 0.12% chlorhexidine rinse. The normal recommendation is to use ½
oz. for one minute twice daily for two weeks. This
will reduce the number of mutans streptococci below
the pathological level for 12-36 weeks for non-cancer
patients. For head and neck cancer patients, however,
rapid recolonization occurs when chlorhexidine is
discontinued. Continuing use of chlorhexidine rinses
is recommended.27
• Use fluoride varnish to protect the teeth against
demineralization and promote remineralization.
www.ineedce.com
Table 9: Management and medications for HSV infections associated
with mucositis 33,34
Management
Culture all lip, palate, and tongue
lesions in HSV-antibody positive
patients unless patient is already
taking acyclovir.
Medication
Serological results are not
helpful in confirming the
diagnosis of HSV-1 during
immunosuppression.
Topical ointments are not appropriate, as extent of disease requires
systemic therapy.
IV route of medication is
preferred in cases where
chemotherapy-induced or
radiation-induced Mucositis
impedes oral intake.
Outpatient treatment for less severe
outbreak.
• Rx: Acyclovir 400 mg
capsules
• Disp: 21 capsules
• Sig: Take one capsule three
times per day for seven
days
Inpatient treatment for more severe
disease.
• Rx: Acyclovir IV
• Sig: 5mg/kg every eight
hours for seven days
Options with better compliance but
higher cost.
• Rx: Famciclovir or Valacyclovir 500 mg. capsules
• Disp: 14 capsules
• Sig: Take one capsule two
times per day for seven
days
Option for acyclovir-resistant
viruses.
• Rx: Foscarnet
• Sig: 60 mg/kg IV every 12
hours or 40 mg/kg every 8
hours for 7 days – 21 days
or until complete healing
•
•
Use products that contain calcium and phosphate as
studies show their presence is required in order to reduce demineralization and promote remineralization.
Commit to professional dental examination every
three months the first year and at three to six month
intervals thereafter depending on the oral condition.
Candidiasis
In patients with head and neck cancer who have received
radiation therapy and have resulting xerostomia, the oral
tissues become dry, rough, sticky, and more susceptible to
infection. The most common infection found in patients
with hypo-salivation is candidiasis.
Candidiasis may present as a pseudomembranous form
(thrush), as an atrophic (erythematous) form, often associated with removable dental appliances or less commonly, as
a hypertrophic (white) form.
Candidiasis should be suspected when xerostomic patients complain of a burning mouth or tongue. This infection may spread to involve the commissures of the mouth,
which is described as angular cheilitis or cheilosis.
9
Management of candidiasis
Several antifungal agents are effective against candida albicans. Nystatin solutions are high in sucrose and should be
avoided in dentate dry mouth patients. Antifungal agents
often come in the form of troches or pastilles but neither is
tolerated well by patients with hyposalivation because they
lack sufficient saliva to dissolve them and because they may
cause mucosal abrasion. Topical creams, lozenges or rinses
are preferable.
Systemic antifungal agents are effective and do not
require dosing as often as topical agents, which is important because compliance can be a significant problem for
patients with fungal infections.
possibility of interfering with or termination of the planned
chemotherapy regimen.
Taste alterations caused by chemotherapy usually resolve in three to four weeks following treatment. Dysgeusia
resulting from radiation to the head and neck may begin
to improve in three to eight weeks following radiation
treatment and improvement may continue slowly over the
course of a year. If the radiation resulted in damaged salivary glands, taste sensation may never recover.
Taste alterations and nutritional deficiencies
Management of taste alterations
and nutritional deficiencies
• Keep mouth clean and healthy as much as possible as
a clean mouth may improve taste in some people.
• Ask the oncologist about zinc sulfate supplements,
which may improve taste in some people.
• Rinse with salt and baking soda solution (½ tsp. salt
and ½ tsp. baking soda in 1 cup warm water) before
meals. May help neutralize bad tastes in the mouth.
• Do not eat one to two hours before chemotherapy and
up to three hours following chemotherapy to prevent
food aversions caused by nausea and vomiting.
• Choose foods that smell and taste good, whenever
possible, even if the food is unfamiliar.
• Marinate meats in fruit juices, sweet wines, salad
dressings, or other sauces. This helps with xerostomia as
well*.
• Flavor foods with spices, herbs, citrus fruits, sugar,
and other sauces*.
• Eat a variety of protein sources such as poultry, eggs,
fish, peanut or other nut butters, beans and dairy
products in addition to red meats.
• Use protein drinks to supplement diet when taste
aversions limit nutritional intake. Various flavorings
may be added to these drinks.
• Try sugar free gum, mints and other hard candies
to mask a metallic or bitter taste. Use products with
xylitol to prevent tooth decay.
* It is imperative to advise patients that if they use
sauces and other flavorings and marinades with
sugar, they must be impeccable with their home care
techniques, including the twice daily use of 5,000ppm
neutral sodium fluoride toothpaste and daily use of
1.1% neutral sodium fluoride gel in custom trays. The
risk for dental caries is high and must be considered
when choosing ways to make foods more palatable
and easier to swallow.
Taste alteration (dysgeusia) is a common side effect of cancer chemotherapy.36 Food may taste differently than before
therapy or may have no taste at all. Commonly, patients
complain of a metallic or chemical taste, all food tasting the
same or food tasting like cardboard.
Dysgeusia may reduce the patient’s appetite, leading
to poor oral intake, poor nutrition, poor hydration and the
Osteoradionecrosis
Osteoradionecrosis (ORN) is a rare late effect that occurs
after radiation therapy has been completed. ORN is the
most serious potential complication for the head and neck
cancer patient.37 ORN is irreversible, progressive devitalization of irradiated bone. This condition causes necrotic
Viral infections
Herpes simplex virus type 1 (HSV-1) reactivation happens most commonly in conjunction with chemotherapy
induced mucositis. Since patients receiving chemotherapy
are expected to develop mucositis, the caregiver may overlook HSV-1 reactivation as an etiologic factor in the oral
ulcerations. Mucositis complicated by HSV-1 reactivation is more severe and longer lasting and has serious local implications. The ulcerations may appear in multiple
locations involving any intraoral and perioral soft tissue
surfaces. HSV-1 reactivation can cause severe pain and impaired nutrition and hydration. The systemic consequence
of HSV-1 reactivation is the disruption of the mucosal barrier, creating a site of entry for oral microorganisms, which
can lead to sepsis.
In leukemia and bone marrow transplant patients,
prophylactic acyclovir is effective in controlling HSV reactivation and is used commonly in bone marrow transplant
patients. It is not used routinely for patients undergoing
chemotherapy. Those patients should be monitored for
HSV-1 reactivation and treated quickly with acyclovir if
HSV-1 reactivation is suspected.
Other viral infections are problematic during cancer
chemotherapy, including herpes varicella zoster virus
(VZV), cytomegalovirus (CMV), Epstein-Barr virus
(EBV), human herpes viruses (HHV-6, 7, 8) and respiratory viruses.
Management of viral infections
Table 9 contains detailed information on the management
and medication of viral infections.
10www.ineedce.com
soft tissue and bone that fails to heal following surgery or
injury. Most cases of ORN occur in the mandible where
vascularization is poor and bone density is high. Very
rarely, ORN can start in the maxilla.38
Because radiation destroys cancer cells through the
deprivation of oxygen and vital nutrients, it inevitably
destroys normal cells as well, damaging blood vessels and
reducing circulation to the area of the bone. Insufficient
blood supply to the irradiated areas decreases the ability
to heal. Any subsequent infections or injury to the bone
can pose a major risk to the patient. ORN happens most
often following an insult to the bone in the irradiated area
such as; surgery, biopsy, tooth extractions or irritation from
dental appliances.39 Clinically, ORN may manifest as pain,
swelling, reduced mobility of the jaw (trismus), orofacial
fistulas, exposed necrotic bone (sequestrum), fracture and
suppuration (exudate).
Many factors can contribute to the development of
ORN. Any patient receiving more than 40 Gy radiation is
at risk for ORN, but it occurs more often at doses over 60
Gy. Many head and neck cancer patients receive more than
70 Gy radiation therapies. There is increased risk associated with a combination of radiation and chemotherapy. The
location and size of the tumor are also contributing factors.
The immunologic and nutritional health of the patient at
the time of treatment and smoking at the time of treatment
all factor into the risk for ORN.40
Treatment of osteoradionecrosis of the bone is difficult;
therefore, prevention of ORN should be the focus of the
pretreatment assessment. Most cases of ORN respond
to conservative treatment for pain control and long term
oral antibiotic therapy.41 In cases that do not respond well
to antibiotic therapy, local debridement of the infected
bone is an option. Hyperbaric oxygen therapy (HBO) has
proven to be effective by increasing tissue oxygen levels.42
Other adjunctive therapies to manage ORN such as; ozone
therapy, laser therapy, tetracycline-guided debridement
and parathyroid hormone supplementation have been
proposed. Further study is necessary to develop specific
recommendations.
Conclusion
The best treatment for the side effects of cancer treatment
is prevention. The pre-cancer treatment assessment and
dental care appointment are crucial in the prevention of
possible negative oral sequelae of cancer care. The negative consequences that occur despite the best efforts of the
cancer care team can range from mild to severe, acute to
chronic. They can affect the patient physically as well as
emotionally and they can interrupt and even stop the
course of cancer treatment. Negative side effects can affect
the quality of the patient’s life and put that life at greater
risk. Customized treatment plans must be developed to
address the various side effects the patient is experiencwww.ineedce.com
ing and coordination with the oncology team is critical in
managing these negative oral consequences. The overview
presented in this course will make the practitioner aware
of the variety of negative consequences that can occur as a
result of cancer treatment and the recommended management strategies available to care for these patients during
times of pain and suffering.
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Author Profile
Kathryn Gilliam, RDH, BA, has presented courses based
on her passion for the early detection of oral cancer and care
for patients undergoing cancer treatment, as well as lectures
about periodontal inflammation and the connection to systemic
illness. Her articles have appeared in General Dentistry, RDH,
Dental Economics, Dentistry Today, AGD Impact, and Modern
Hygienist. For additional information, Kathryn may be reached
at [email protected]
Author Disclosure
Kathryn is the founder of PerioLinks, an education and coaching
company focused on the vital links between oral and systemic
health. Kathryn Gilliam, RDH, BA, has no commercial ties with
the sponsors or providers of the unrestricted educational grant for
this course.
Online Completion
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Questions
1.Most oncologists cite which of the following as the
reason they do not refer their newly diagnosed patients
for a pre-cancer treatment dental evaluation?
a. Delay in treatment
b. Dental care is a low priority
c. Patients don’t like to go to the dentist
d. None of the above
2.The dental visit which is most important for preventing
or minimizing negative oral consequences of cancer
therapy is:
a. Routine prophylaxis
b. Restorative appointment
c. Pre-cancer treatment dental assessment
d. Pre-cancer treatment surgical appointment
3.The pre-cancer treatment assessment should include
which of the following?
a. Identify and treat sites of low-grade and acute oral infections
b. Perform necessary oral surgical procedures at least 14 days before the initiation of
radiation treatment
c. Fabricate custom fluoride trays and prescribe 1.1% neutral pH sodium fluoride gel
d. All of the above
4.Which of the following is associated with an increased
incidence and severity of oral complications of head
and neck cancer treatment?
a. Autoimmune disease
b. History of tobacco use
c. Poor oral health
d. Advanced age
5.How many days prior to the start of cancer treatment
should dental extractions be performed?
a. 5 – 7 days
b. 7 – 10 days
c. 14 days
d. 28 days
6.How frequently should the head and neck cancer
patient be seen for maintenance appointments during
active cancer treatment (as long as blood counts
allow)?
a. Every 3 – 6 weeks
b. Every 8- 12 weeks
c. Every 3 months
d. Every 6 months
7.Most tumors of the head and neck are:
a. Basel cell carcinoma
b. Squamous cell carcinoma
c.Sarcoma
d.Lymphoma
8.Head and neck squamous cell carcinomas include
cancers of the:
a. Oral cavity
b.Oropharynx
c.Larynx
d. All of the above
9.Myelosuppression is a condition:
a. In which bone marrow activity is decreased
b. Which results in fewer red blood cells, white blood cells and platelets
c. Which is an indirect cytotoxic effect of chemotherapy
d. All of the above
12www.ineedce.com
Questions (Continued)
10. Which of the following has a 100% chance of causing
oral complications?
a. Primary chemotherapy
b. Adjunctive chemotherapy
c. Head and neck radiation therapy
d. None of the above
11. Oral complications of radiation therapy are related to
which of the following?
a. The site irradiated
b. The total radiation dose
c. Integration with other therapies, such as chemotherapy
d. All of the above
12. Which of the following conditions is NOT a radiation
induced side effect of oral cancer treatment?
a.Mucositis
b.erostomia
c. Dental anxiety
d.Pain
13. Symptoms of radiation induced mucositis include all of
the following except:
a. Intense pain
b. Difficulty swallowing
c. Generalized swelling
d. Difficulty speaking
14. Which of the following is true regarding the toxicity of
a combination of radiation and chemotherapy?
a. The same as with radiation alone
b. The same but develop more rapidly
c. The same but more severe when maximum dosages are reached
d. All of the above
15. Chemotherapy is toxic to which of the following rapidly
growing cells?
a. Bone marrow
b.Hair
c. Mucosa of the gastrointestinal tract
d. All of the above
16. What is the total radiation dose given to most head and
neck cancer patients?
a. 74 – 96 Gy
b. 64 – 70 Gy
c. 49 – 68 Gy
d. 32 – 56 Gy
17. Signs of radiation induced mucositis include which of
the following?
a.Erythema
b.Ulceration
c.Necrosis
d. All of the above
18. Which of the following is the most common negative
side effect of head and neck radiation?
a. Oral ulcers
b.Xerostomia
c.Nausea
d.Inflammation
19. Which of the following is the most common negative
side effect of chemotherapy?
a.Gingivitis
b.Trismus
c.Mucositis
d.Dysgeusia
20. Oral mucositis occurs in what percentage of head and
neck cancer patients?
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a.30%
b.50%
c.60%
d.10%
21. The primary reason a head and neck cancer patient
may need to stop chemotherapy is:
a.Pain
b.Mucositis
c.Infection
d. All of the above
22. Chemotherapy induced neutropenia refers to:
a. Reduced white blood cell count
b. Reduced red blood cell count
c. Reduced platelet count
d. None of the above
23. Treatment of oral mucositis should include all of the
following except:
a. Commercially available mouthrinses
b. Mucosal coating agents
c.Emollients
d.Lubricants
24. Which fluoride formulation is recommended to prevent
dental caries during cancer treatment?
a. 2.0% neutral sodium fluoride
b. 4.0% acidulated fluoride
c. 0.4% stannous fluoride
d. None of the above
25. Which oral rinse may delay wound healing?
a. Neutral rinse
b. Magic mouthwash
c. Hydrogen peroxide
d. Saline rinse
26. Which of the following is not an ingredient in a neutral
mouthrinse?
a.Salt
b.Water
c. Baking powder
d. Baking soda
27. The percentage of cancer patients estimated to have
inadequate pain control is:
a. 45% - 80%
b. 35% - 75%
c. 25% - 50%
d. 50% - 100%
28. Which of the following products are recommended for
optimal pain control for head and neck cancer patients?
a.Antidepressants
b. Topical analgesics
c. Extended released opioids
d. Nonsteroidal anti-inflammatories
29. Which of the following can also be beneficial in reducing oral pain?
a. Cold/heat application
b. Ice chips
c.Hypnosis
d. All of the above
30. The impact of mucositis pain is profound because:
a. It can delay treatment and result in dose reduction
b. It can interfere with oral function
c. It can diminish quality of life
d. All of the above
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Notes
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ANSWER SHEET
Oral Health Maintenance in Head and Neck Cancer Patients
Name:
Title:
Specialty:
Address:E-mail:
City:
State:ZIP:Country:
Telephone: Home (
)
Office (
Lic. Renewal Date:
) AGD Member ID:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681
Educational Objectives
If not taking online, mail completed answer sheet to
1. Recognize common oral complications resulting from radiation therapy, chemotherapy, and other cancer treatments,
2. Identify when it is considered safe to treat a patient undergoing cancer treatment and when it is not safe
3.Develop an individual plan for treatment of various oral complications to assist in the supportive care of the patient
undergoing cancer therapy.
For IMMEDIATE results,
go to www.ineedce.com to take tests online.
Answer sheets can be faxed with credit card payment to
918-831-9804.
Course Evaluation
1. Were the individual course objectives met?Objective #1: Yes No
Objective #2: Yes No
PennWell Corp.
Attn: Dental Division,
1421 S. Sheridan Rd., Tulsa, OK, 74112
or fax to: 918-831-9804
Objective #3: Yes No
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
2. To what extent were the course objectives accomplished overall?
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3. Please rate your personal mastery of the course objectives.
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5. How do you rate the author’s grasp of the topic?
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6. Please rate the instructor’s effectiveness.
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7. Was the overall administration of the course effective?
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8. Please rate the usefulness and clinical applicability of this course. 5
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9. Please rate the usefulness of the supplemental webliography.
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10. Do you feel that the references were adequate?
Yes
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11. Would you participate in a similar program on a different topic?
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Charges on your statement will show up as PennWell
12. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
13. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
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14. How long did it take you to complete this course?
___________________________________________________________________
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15. What additional continuing dental education topics would you like to see?
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AGD Code 741, 735
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included
with the course. Please e-mail all questions to: [email protected].
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done manually. Participants will
receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be
mailed within two weeks after taking an examination.
COURSE CREDITS/COST
All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE
credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/
Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact
their state dental boards for continuing education requirements. PennWell is a California Provider. The
California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.
PROVIDER INFORMATION
PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association
to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours
by boards of dentistry.
Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada.
org/cotocerp/.
The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General
Dentistry. The formal continuing dental education programs of this program provider are accepted by the
AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from
(11/1/2015) to (10/31/2019) Provider ID# 320452
RECORD KEEPING
PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
contact our offices for a copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business days of receipt.
Completing a single continuing education course does not provide enough information to give the
participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
many educational courses and clinical experience that allows the participant to develop skills and expertise.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
IMAGE AUTHENTICITY
The images provided and included in this course have not been altered.
© 2014 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
H&NCP414IMP
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Customer Service 800-633-1681
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