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ORAL CARE GUIDELINES
FOR PATIENTS RECEIVING
CANCER AND/OR
RADIATION THERAPY
Chris Rowland
Chief of Dentistry
St. Jude Children’s Research Hospital
[email protected]
introduction
• The aim of the guidelines presented
here is to recommend a regimen of
treatment for clinically assessed stages
of mucositis.
• Oral complications are common side
effects of chemotherapy and radiation.
• Children experience 3x more oral
complications than adults do.
Intro cont’d
Opening questions
• What country are you from and do
you have a dental service for your
patients?
• Tissue sensitivity to radiation in children has
also been estimated to be 30% greater than
in adults.
• Most common oral complications are
mucositis , ulceration, and infection.
• Enter your country name , and Yes or
No in the message area below this
slide.
Intro cont’d
Opening questions
• Is oral care included in your training?
• Enter Yes or No in message area
below this slide.
• Oral mucositis and ulceration cannot be
totally predicted nor presented, but proper
management can help to minimize the
duration, discomfort, and potential for
infection.
• Pre-chemotherapy oral care can significantly
reduce both the severity and duration of
mucositis.
• Main objectives are palliative treatment and
prevention of infection.
Therapeutic agents
Normal oral cavity
• A variety of palliative rinses, topical
anesthetics, and antibiotic
mouthwashes are available to manage
the oral complications of cancer
therapy.
• Signs of poor oral hygiene puts patients
at greater risk for developing severe
mucositis.
evaluation
Racial pigmentation
• An evaluation should be done prior to
therapy beginning.
• Ideally, this is done by Dental Clinic, but
this is not always possible.
• Therefore, either the attending physician
or nurses must do the assessment.
Assessment
Normal Mucosa and Gingiva
(Grade 0: no mucositis)
• Oral mucosa is pink & moist; no lesions,
crusts, or debris.
• Patients with healthy oral cavity should
still be counseled and encouraged to
keep up their hygiene regimen as
therapy begins.
Beginning of inflamation
Orthodontics is a problem
Medication
• To lessen incidence & severity of mucositis,
which may accompany chemotherapy, a twicedaily regimen of rinsing with Peridex
(chlorhexidine gluconate) is indicated:
– Swish with 5-10 ml for 30 sec after brushing 2x
daily
– It has been effective in delaying the onset of
mucositis and decreasing its severity and
duration
– Contraindications: medicinal taste, after taste,
and potential of producing tooth staining, which
is easily removed by dental prophylaxis
Disclosing and Toothbrushing
question
• What are the medications and
treatments that you us to prevent
mucositis ?
PERIDEX
Mucositis (Gingivitis)
(Grade 1: early, mild form)
• Mucositis is an inflammation of the oral mucosa
secondary to local or systemic factors, which may
affect a portion or all of the mouth.
• Oral mucosa and/or gingiva are red, shiny, with
possible white patches:
– Gingiva may appear swollen
– “Painless” ulcers may be present
– Patient may complain of a burning sensation or
general discomfort in the mouth
– Tongue appears coated, red, dry, or swollen
– Patient should be on a bland diet. Avoid acidic,
spicy, fried, hard, and extreme temperature foods
Picture grade 1
question
• Why would you use sodium
bicarbonate for treatment?
Picture grade1
answer
• The saline approximates normal body
fluids and the addition of the sodium
bicarbonate buffers the usually lowered
pH of the saliva secondary to
chemotherapy and/or radiation therapy.
The solution is bland, palliative, and
promotes healing.
Treatment for grade 1
• Treatment at this stage is essentially
palliative.
• Have patient rinse with alkaline-saline
solution q 2-4 h or PRN while awake.
• This is a 2% sodium bicarbonate solution in
normal saline.
Sodium bicarbonate
Cleaning for grade 1
• Debride teeth and gingiva using the Ultra
Suave (soft bristle nylon) toothbrush dipped
in Peroxyl (form of hydrogen peroxide)
diluted 1:1, followed by rinsing with water or
alkaline/saline.
Ultra sauve toothbrush
question
• What is the major source of halitosis
(bad breath)?
answer
peroxyl
tongue
• Since the tongue is the primary source
of bad breath (halitosis), it needs to be
brushed and scraped twice daily to aid
in removal of coating. Scraping may be
done with a tongue blade or special
“scraper”.
Grade 2
Tongue scraper
Mucositis with ulceration
(Grade 2: moderate form)
• Mucositis and gingivitis as previously
described.
• Painful ulcers may be present.
• Patient can still eat, but may be hesitant
because of pain.
antiseptic
Picture grade 2
• For milder forms of mucositis, ST-36 is
recommended.
• It is a soothing antiseptic and mild topical
anesthetic that usually does not sting or burn
and is more acceptable to children.
• Have patient swish and hold 5-10 ml of 30
seconds before spitting out. Use as needed.
antiseptic
Picture grade 2
Instructions for grade 2
kanka
• Debride teeth and gingiva using ultra suave
toothbrush dipped in peroxyl diluted 1:1, followed
by copious rinsing with alkaline/saline solution.
• If the tissues are too sensitive to allow for tooth
brushing then Peroxyl rinse may be indicated.
• Peroxyl is a hydrogen peroxide solution. Although
peroxide has some antibacterial effect, its primary
benefit is the non -mechanical cleansing action
produced by the nascent oxygen.
• It is especially helpful in cleansing the interdental
areas and softening and removing hardened
deposits and crusts on the mucosa.
Instructions cont’d
• Daily long-term use of peroxide may
cause the filiform papillae of the dorsum
of the tongue to elongate producing a
heavily coated surface.
Numerous ulcers
• For more extensive and numerous ulcers, the
patient should swish and hold 5-10 ml of UlcerEase solution (anesthetic for ulcers) in the mouth
for 30 seconds or longer than spit out. BID or 1 2
h.
• Orakote: powdered mouthrinse mix for relief of
mucositis.
• Mix per bottle directions.
• Swish or gargle 10 ml for 1 minute or longer 3x
daily.
• It may be swallowed.
• No food or drink for 1 h.
Ulcer ease
Isolated ulcers
• Severity and extent of the ulceration
dictates the regimen of choice. For
isolated small ulcers (less than 1 cm),
apply Kanka solution (or some form of
mouth sore topical medication) with
provided applicator or Q-tip directly to
the ulcer, which has been dried. A very
slight burning sensation is felt at first.
This provides a protective coating for
the ulcer.
orakote
Picture grade 3
Picture grade 3
Mucositis with severe ulceration
(Grade 3: severe form)
• Severe erythema, ulceration, or white
patches present.
• Patient complains of severe pain and
can not eat.
Picture grade 3
Instructions for grade 3
• Before brushing: rinse with Ulcer-Ease
for 30 sec to anesthetize mucosa.
– Debride teeth and gingiva using UltraSuave toothbrush dipped in
alkaline/saline solution. Follow with
copious rinsing with alkaline/saline.
Instructions cont’d
dyclone
• Palliative treatment:
• Ulcer Ease solution
• Dyclone 1% solution diluted 1:1 ratio with
water
– Effective anesthesia usually occurs in 2-10
minutes after application and persists much
longer than other topical agents.
– It will cause numbness of tongue and buccal
mucosa, which increase the danger of biting
trauma. The patient should be warned of this
potential.
– This use of this agent should be strictly
controlled and limited to reduce systemic
toxicity.
Sponge sticks
What is the differential
diagnosis?
Swab sticks
candidiasis
• If white patches are present,
Candidiasis should be considered and
cultures done. Nystatin may be added
to the oral care regimen.
• Other possibilities are: 1.
Leukoplakia, 2. Debris, 3. Linea
alba
Nystatin oral suspension
Picture grade 4
Grade 4
Picture grade 4
Mucositis
(Grade 4: severe form)
• Patient requires parenteral or enteral
support
Picture grade 4
xerostomia
Xerostomia
(Mouth dryness)
• It is due to direct effects of drugs and/or
radiation on the salivary glands.
• Other factors contributing are dehydration,
mouth breathing, and fever.
• Characterized by apparently thick, ropy
saliva (early signs), and/or obviously dry
mouth.
Glands affected
Lip care
• Lips are dry, chapped, rough, but free of
crusts and debris.
• Lips cracked, ulcerated, or crusted.
Ropey saliva
What is the fissuring and cracking at the corner of
the lips?
Instructions for xerostomia
• Mucositis mouth care as described
previously.
• Ad-lib alkaline-saline mouth rinse.
• Swab mouth several time daily with Moi-Stir
oral swabsticks .
• Use of Biotene products: toothpaste, alcoholfree mouthrinse, and/or gel.
• Lip care as needed.
• High moisture foods such as Jello, etc.
answer
• angular chelitis
Treating dry lips
Treating
• How would you treat angular chelitis?
• Moisten lips with “Nature’s Second Skin” every 2-4
hours for dry, chapped, and rough lips.
• Clean every 2-4 hours with gauze saturated with
saline. Pat dry and apply “Nature’s Second Skin”
for cracked, ulcerated, or crusted lips.
• Nature’s Second Skin is a purified form of natural
lanolin with no additives and it retains moisture
better than petroleum based agents.
Mycolog 4x daily with Q-tip
Nature’s second skin
Dry lips
Care of the teeth
Included in the routine oral care regimen
should be the meticulous debridement of
the teeth.
• This can be an overwhelming problem in the
presence of severe mucositis, neutropenia,
and thrombocytopenia.
• If the debris is not removed, then the
degradation products will further irritate the
gingiva, thus increasing discomfort,
ulceration, and the potential of septicemia.
Radiation caries
For Discussion
• What are your challenges in providing oral
care?
• Enter your comments in the text area below
this slide
Platelet counts
• Platelet count >20,000 and no/or
minimal pain on brushing, then gently
brush with a soft bristly brush, being
careful to debride the gingiva also.
• Platelet count <20,000. Patient unable
to tolerate brushing due to pain or there
is spontaneous bleeding from the
gingiva.
• No flossing <40,000.
Further Contact
Use the Dentistry Discussion Board on Cure4Kids
http://www.cure4kids.org
Chris Rowland
Chief of Dentistry
St. Jude Children’s Research Hospital
Email: [email protected]
Telephone: (901) 495-3622
Low platelets
• Then you want to rinse mouth with alkaline/saline
solution.
• Use the Ultra-Suave toothbrush dipped in very
diluted peroxyl, or alkaline/saline solution can be
used to debride the teeth and gingiva.
• This should be followed with a copious rinsing of
either water or alkaline/saline.
• A moistened gauze wrapped over a finger can also
be used to debride the teeth.
• Non-mechanical cleansing rinses can also be used,
ex., Peroxyl