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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