this will help you know what you should do before cancer treatments. and if you get oral mucositis during treatment.

1. Oral Care for Cancer patients By Renee Anderson, LDH.

2. Treating Cancer Patients Do you know how to treat a patient who is diagnosed with cancer? What procedures should be done prior to chemotherapy and/or radiation treatments? What treatment can be done during chemotherapy and/or radiation treatments? What to do if oral complications arise during chemotherapy and/radiation treatments?

3. Cancer Cancer is the uncontrolled growth of abnormal cells in the body.

4. Chemotherapy Chemotherapy----most chemotherapy drugs cause all dividing cells to die, and since the mucous membranes are composed of rapidly dividing cells, these tissues do not replenish during intense therapy. Mucous membranes form a barrier against infections, and without them the mouth can become inflamed, and opportunistic bacterial, yeast and fungal infections can occur.

6. Chemo can cause drops in ANC (absolute neutrophil count) which makes it harder to fight off infections.

7. Low platelet counts means that brushing and flossing can cause bleeding.

10. Pano and FMX

11. Periodontal evaluation

12. Oral exam/cancer screening

13. Identify and treat existing infections, carious and other compromised teeth, and tissue injury or trauma.

14. Stabilize or eliminate potential sites of infection.

16. Schedule oral surgery at least 7 to 10 days before myelosuppressive therapy begins.

17. Perform oral prophylaxis if indicated.

19. Chemotherapy The oral complications of chemotherapy depend upon the drugs used, the dosage, the degree of dental disease, and the use of radiation. Chemoradiation therapy carries a significant risk for mucositis.

20. Consult the oncologist before conducting any oral procedures in patients with hematologic cancers; do not conduct procedures in patients who are immunosuppressed or have thrombocytopenia.

21. Questions to Ask the Medical Oncologist What is the patient’s complete blood count, including absolute neutrophil and platelet counts? If an invasive dental procedure needs to be done, are there adequate clotting factors? Does the patient have a central venous catheter?

22. What is the scheduled sequence of treatments so that safe dental treatment can be planned? Is radiation therapy also planned?

24. Anemia (ah-NEE-mee-ah) is the scientific name for a low red blood cell count.

26. Ask the oncologist to order blood work 24 hours before oral surgery or other invasive procedures. Postpone when

27. the platelet count is less than 75,000/mm3 or abnormal clotting factors are present

29. Due to the lack of saliva, the plaque builds up faster therefore cleanings may be every 2 mos. And check for mouth sores and decay. (ANC and WBC Count permitting)

30. Emergency treatment can be done with any hematologic status to remove source of infection, work with oncologist, if count under 40,000mm consider platelet replacement.

33. Anti-bacterial mouth rinses

34. Peridex- can prevent infections (alcohol free peridex)

35. Stains teeth

36. Taste bad

37. 0.63% Stannous Fluoride-- ask oncologist if can substitute for peridex

38. Stannous part is anti-microbial

39. Does not stain teeth

40. Taste better

41. Fights cavities

43. Patients under intense chemo are at risk for fungal and yeast as well as bacterial infections

44. Nystatin to prevent fungal infections, can be used to prevent or treat.

45. Mycostatin or Nilstat rinses- “swish and swallow” because these infections can be in the throat passage as well as in the mouth.

46. Mycelex lozenges.

48. If toothpaste irritates patients mouth, use a mixture of ½ teaspoon of salt with 4 cups water. Gargle regularly with a solution made up of: 1quart of plain water ½ teaspoon table salt ½ teaspoon baking soda

50. Identify and treat potential oral problems within the proposed radiation field before radiation treatment begins.

51. Instruct patients about oral hygiene.

54. Sores or lesions can occur even in the absence of bacterial or fungal infection, but once there they should be treated with anti-bacterial agents to prevent infection.

55. Glutamine—helps and lessens mucositis.

56. Saforis- a patented, topical, oral suspension of glutamine.

57. Magic mouth wash- mixture of benadryl, maalox, nystatin, and lidocaine.

58. Baking soda and water- aids in healing and neutralizes acid.

59. Stannous fluoride.

61. Osteonecrosis of the jaw.

62. Chemo for breast cancer After breast cancer chemo patients may be placed on a estrogen reducer drug femmoren and then on IV bisphosphantates

65. Head and Neck Radiation Therapy

66. Radiation Radiation----some people who get radiation to the head/neck (and sometimes chest) areas have redness and soreness in the mouth, a dry mouth, trouble swallowing, changes in taste, or nausea. Other possible side effects include a loss of taste, earaches, and swelling, jaw stiffness and jaw bone changes.

67. Patients receiving radiation therapy to the head and neck are at risk for developing oral complications. Because of the risk of osteonecrosis in irradiated fields, oral surgery should be performed before radiation treatment begins.

69. Pano and FMX

70. Periodontal evaluation

71. Oral exam/cancer screening

72. Identify and treat existing infections, carious and other compromised teeth, and tissue injury or trauma.

73. Stabilize or eliminate potential sites of infection.

74. Extract teeth in the radiation field that are non-restorable or may pose a future problem to prevent later extraction-induced osteonecrosis.

75. Conduct a prosthodontic evaluation if indicated. If a removable prosthesis is worn, make sure that it is clean and well adapted to the tissue. Instruct the patient not to wear the prosthesis during treatment, if possible; or at the least, not to wear it at night.

77. Be sure that the trays cover all tooth structures without irritating the gingival or mucosal tissues. Instruct the patient in home application of fluoride gel. Several days before radiation therapy begins, the patient should start a daily 10-minute application. Have patients brush with a flouride gel if using trays is difficult.

78. Allow at least 14 days of healing for any oral surgical procedures. Conduct prosthetic surgery before treatment, since elective surgical procedures are contraindicated on irradiated bone.

79. Questions to Ask the Radiation Oncologist What parts of the mandible/maxilla and salivary glands are in the field of radiation? What is the total dose of radiation the patient will receive, and what will be the impact on these areas? Has the vascularity of the mandible been previously compromised by surgery?

80. How quickly does the patient need to start radiation treatment? Will there be induction chemotherapy with the radiation treatment?

81. During Radiation Therapy Monitor the patient’s oral hygiene. Watch for mucositis and infections. Advise against wearing removable appliances during treatment.

82. After Radiation Therapy Recall the patient for prophylaxis and home care evaluation every 4 to 8 weeks or as needed for the first 6 months after cancer treatment. Reinforce the importance of optimal oral hygiene

85. Amifostine (ethyol)—protects salivary tissues against radiation damage. Approved for reducing dry mouth. May also reduce mouth sores: research is ongoing. N-acetylcysteine (RK-0202) - prevents inflammation due to radiation therapy.

86. What are the common side effects of radiation Reduced resistance to bacterial, viral or fungal infections which allows them to become opportunistic Dry mouth/ altered taste sensations-including a burning sensation Sore/stiff jaw Damage to tooth enamel Swallowing difficulties

88. Trismus/tissue fibrosis: Instruct the patient on stretching exercises for the jaw to prevent or reduce the severity of fibrosis.

90. Follow instructions for fluoride gel applications. Avoid mouthwashes containing alcohol. Rinse the mouth several times a day with a baking soda and salt solution, followed by a plain water rinse. Use ¼ teaspoon each of baking soda and salt in 1 quart of warm water.

91. Try the following if dry mouth is a problem: Sip water frequently. Suck ice chips or use sugar-free gum or candy. Use saliva substitute spray or gel or a prescribed saliva stimulant if appropriate. Avoid glycerin swabs.

92. Exercise the jaw muscles three times a day to prevent and treat jaw stiffness from radiation treatment. Avoid candy, gum, and soda unless they are sugar-free. Avoid spicy or acidic foods, toothpicks, tobacco products, and alcohol.

93. Taste changes: Refer to a dietitian. Etched enamel: Advise the patient to rinse the mouth with water and baking soda solution after vomiting to protect enamel.

94. Special Care for Children Children receiving chemotherapy and/or radiation therapy are at risk for the same oral complications as adults. Other actions to consider in managing pediatric patients include the following:

96. Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.

99. Consult the oncologist about scheduling dental treatment.

100. Schedule oral surgery at least 7 to 10 days before myelosuppressive therapy begins.

101. Prevent tooth demineralization and radiation caries:

102. Instruct the patient in home application of fluoride gel (not fluoride rinses).

104. Monitor the patient’s oral health for plaque control, tooth demineralization, dental caries, and infection.

106. What is mucositis? Mucositis refers to the breakdown of mouth tissues. It can range in severity from a red sore mouth and gums to open sores in the mouth. Chemotherapy and radiation therapy kill not only cancer cells, but other rapidly dividing cells including the lining of the mouth and throat.

107. Oral mucositis leads to several problems: Pain Nutritional problems/inability to eat Increased risk of infection due to open sores in the mucosa

109. Blood in the mouth

110. Sores in the mouth or on the gums or tongue

111. Soreness or pain in the mouth or throat

112. Difficulty swallowing or talking

113. Feeling of dryness, mild burning or pain when eating food

114. Soft, whitish patches or pus in the mouth or on the tongue

116. Course of a mouth sore Not everyone undergoing treatment for cancer develops mouth sores. 1st day of treatment ---no noticeable change, but injury is beginning to accumulate. 3-5 days after treatment---damage to genetic material in mouth cells, soft tissue starts to feel warm. 7-10 days after treatment---Inflammation and sores appear.

117. During treatment period---sores can become painful and infected. Eating and swallowing can become difficult. 2-9 weeks after treatment---sores heal and disappear.

119. (2) Painful ulceration with pseudomembrane formation and, in the case of myelosuppressive treatment, potentially life-threatening sepsis, requiring antimicrobial therapy. Pain is often of such intensity as to require treatment with parenteral opiate analgesics.

122. Patients receiving chemotherapy or radiation to the chest/head/neck area should have their mouths checked daily for redness, sores, or signs of infection.

124. Pain Control --Ibuprofen (such as motrin) or acetaminophen(tylenol) for mild pain. --over-the –counter anesthetics, such as xylocaine, anbesol, or orajel. --Difflam- benzydamine mouthwash is a local anesthetic ---Gelclair- an oral gel designed to coat and soothe mouth sores by forming a protective barrier in the mouth. Gelclair contains 3 key ingredients: one to coat raw tissue with protective film, a second to moisten and lubricate the tissues and licorice root extract for flavoring. RX only.

126. Opiates (ex. morphine)—are an important tool for controlling pain and not something to be shunned or feared.

127. Pills

128. Liquids

129. Patches

131. Opiates (ex. morphine)—are an important tool for controlling pain and not something to be shunned or feared.

132. Pills

133. Liquids

134. Patches

136. Oral Care Do’s Use an ultra-soft bristle toothbrush after meals and a bedtime. Use gauze or washcloth if patient has difficulty swallowing or ANC or WBC counts are low.

137. Oral Care Don’ts No mouthwashes with alcohol No dental floss if counts below 40,000 No lemon or glycerine swabs No hard or medium toothbrushes No petroleum based products for lip care because they can promote infection Do not use water pik during treatment

138. Oral Care Don’ts No mouthwashes with alcohol No dental floss if counts below 40,000 No lemon or glycerine swabs No hard or medium toothbrushes No petroleum based products for lip care because they can promote infection Do not use water pik during treatment

140. Include foods high in protein in the diet

141. Avoid hot, spicy or acidic foods, alcohol, hard or coarse foods (crusty bread, chips, crackers), soda.

142. Do not smoke cigarettes, cigars or pipes.

143. Do not use smokeless tobacco (chewing tobacco or snuff)

144. Let food cool to room temperature

146. Milkshakes

147. Baby food

148. Bananas and applesauce

149. Mashed potatoes

150. Cooked cereal

151. Cottage cheese

152. Pudding/gelatin

153. Cooked meats pureed in blender, with gravy or broth added

154. Tomatoes

155. Citrus fruits or juice

156. Salty or spicy foods

157. Raw vegetables

158. Raw fruits (unless soft)

159. Drinks with caffeine or alcohol

160. Pickles

161. Vinegar

162. Chocolate

165. Because of the risk of osteonecrosis, principally in the mandible, patients should avoid invasive surgical procedures, including extractions that involve irradiated bone. If an invasive procedure is required, use of antibiotics and hyperbaric oxygen therapy before and after surgery should be considered.

167. Dentists should closely monitor children who have received radiation to craniofacial and dental structures for abnormal growth and development.

169. Mouth sores can be extremely painful, cause malnutrition, delay cancer treatments and can cause serious infections.

170. The oral cavity usually goes back to normal after chemotherapy, but has life long complications after head and neck radiation treatments.

172. Dental extractions, root plane and scales, should be done 10days to 2 wks prior to chemotherapy or radiation treatments.

173. Pain management is very important to patient recovery.

175. The patient Do not lecture the patient on oral care. This patient already has a lot on their mind. New instructions to follow every day and may not physically be able to get up and brush properly!! Encourage good oral hygiene. Have a written instruction sheet Give booklet from cancer care.

176. Web sites http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/OralComplicationsCancerOral.htm American Oncology Nursing Association Customer.service@ons.org OncoLink Abranson Centre Cancer Centre University of Pensylvania http://www.oncolink.com National Cancer institute website, www.cancer.gov http://www.nursing.upenn.edu http://www.cancer.org/docroot/MBC/content... http://www.cancerbackup.org.uk/resourcessupport/symptomssideeffects/mouthcare/chemotherapy http://ONJ.net.org /fosamax

178. Eilers J. nursing intrventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment, Oncology nursing forum online 31(4suppl):13-23 2004 July.