THE ORAL MANAGEMENT OF ONCOLOGY PATIENTS REQUIRING RADIOTHERAPY : CHEMOTHERAPY : BONE MARROW TRANSPLANTATION
Prior to Cancer Therapy - at Initial Diagnosis
When presented with a diagnosis of cancer a patient will be unlikely to consider the oral implications as a high priority. So counselling recommended.
Prior to Cancer Therapy - Oral/Dental Care
The use of an aqueous chlorhexidine mouthwash or dental gel will contribute to the treatment of gingival disease in combination with improved oral hygiene practices.
In children chlorhexidine is rarely used unless toothbrushing cannot be performed. There is often poor compliance because of the taste
Children should have all primary teeth within three months of exfoliation and those with any risk of pulpal involvement removed.
Permanent teeth with a doubtful prognosis should be removed. It should be borne in mind that permanent teeth with non symptomatic periapical lesions are rarely exacerbated by cancer therapy 33. Judgement needs to be made on overall prognosis
All teeth in direct association with an intra oral tumour should be removed.
Teeth should be removed with a minimum of trauma and if possible primary closure achieved.
Children undergoing orthodontic therapy should have their orthodontic appliance removed and treatment discontinued until 1 year after completion of cancer therapy.
During Cancer Therapy
The period of mucositis is extremely unpleasant. The patient should be constantly reassured during this acute phase about the limited period of this side effect of treatment.
Normal daily toothbrushing by the patient, carer or parent, should be undertaken regularly if necessary with a soft brush. If toothbrushing oes have to be discontinued it should be resumed at the earliest opportunity.
The chlorhexidine gluconate mouthwash should be continued in conjunction with and following toothbrushing. If brushing becomes too painful the chlorhexidine mouthwash should be used as an alternative. The mouthwash should be used three to four times daily The chlorhexidine helps with plaque control , although it’s value in reducing the symptoms of mucositis is less clear
The importance of preventing dental caries cannot be over-emphasised. In areas where public water supplies are not fluoridated,Children should be given fluoride tablets or drops according to the appropriate dose for their age to ensure incorporation into the developing tooth structure. Fluoride in the form of mouth rinses for children over six years of age and adults may be used daily or weekly, in addition to their fluoride dentifrice ,in order to encourage remineralisation and prevent dental caries (e.g. Fluorigard 0.05% Sodium Fluoride mouthwash - Colgate Palmolive). Younger children should receive a brush-on Stannous fluoride gel daily (e.g. Omnigel: CTS Dental Supplies, Reigate, Surrey, U.K.) There is some in vitro evidence that fluoride enhances the adsorption of chlorhexidine to tooth enamel.
Antifungals should be used following the detection of oral candida with denture hygiene implemented when relevant.The alternatives are:
i) Nystatin 100,000 units per ml sugarfree suspension, 5ml: 4 times daily.
ii) Miconazole oral gel 25mg. per ml. 5ml: 4 times daily.
iii) Fluconazole Suspension-50mg per 5mls: up to 4 times daily. Ketaconazole or Itraconazole are also helpful as a systemic medication.
iv)Nystatin pastilles or lozenges may be used in children if xerostomia is not severe. Compliance is poor because of the unpleasant taste.
v)The use of Nystatin and chlorhexidine simultaneously should be avoided, there is some evidence to suggest that both drugs inhibit each others action. It is preferable to separate administration by0 one hour53
Relief from mucositis is unpredictable .
use of a non-absorbable antibiotic lozenge reduces the most severe symptoms of mucositis. The evidence does not yet appear to be sufficiently compelling to recommend this treatment as part of standard practice
Symptomatic relief may be achieved by:
i) Difflam (benzydamine hydrochloride) is effective in alleviating mild to moderate mucositis for some patients. It should be used prior to meals 55.
ii) A 2% Lignocaine solution mouthwash will help when mucositis is more severe.
iii) Aspirin - Mucaine mouthwash (aluminium hydroxide + magnesium hydroxide + oxethazine) will help to combat dysphagia when used prior to meals. This should not be used for children under 12 years of age.
iv) Prostaglandin (P.G.E.2 tablets 0.5mgs 4 times daily), can help alleviate mucositis. However it should not be used following bone marrow transplantation since it increases the risk of herpes infections.
v) Allopurinol is particularly valuable for chemotherapy induced mucositis - particularly that induced by 5 Fluorouracil and provides some protection for methotrexate induced mucositis.
vi) Oral cooling - there is some evidence that mucositis can be reduced by using ice chips for 5 minutes prior to 5 Fluorouracil administration and for a further 25 minutes following administration.
vii) An aqueous chlorhexidine gluconate mouthwash can help to relieve the symptoms of mucositis.
viii) Steroid lozenges should not be used since they encourage the development of Candidal infections.
ix) Kamillosan.
Kamillosan rinse is prepared from the camomile plant, the combined constituents having anti-inflammatory effects in addition to promoting granulation and epithelialization.
x) Sucralfate.
Sucralfate is composed of a non-absorbable aluminium salt of sucrose octasulphate, which adheres to the ulcer base to create a surface barrier. It has an additional cytoprotective effect, probably mediated by prostaglandin release68 . Children have difficulty coping with this treatment.
Parotid function can be partially maintained by radiotherapy delivery that spares the contralateral gland69. The symptoms of Xerostomia can be helped by:
i) Frequent sips of cold water/milk or other sugarfree non acidic cool drinks70.
ii) Saliva substitutes :
*Oral Balance saliva replacement gel (Lactoperoxidase)
*Oral Balance mouthwash
Glandosane mouthwash) - for edentate patients Salivix Pastilles only. These are acidic and consequently will rapidly erode natural teeth and cause tooth sensitivity.
*For these materials to be effective Oral Balance dentifrice must be substituted for conventional toothpaste. The sodium lauryl succinate in toothpaste destroys the bulking agent within the Oral Balance saliva replacement gel.
Alternatively a hospital pharmacy can formulate a saliva substitute using methyl cellulose.
iii) Flavourless salad oil or dietary fat at night time lubricates the lips and tongue. 73
iv) Sugarfree chewing gum stimulates saliva production (e.g Orbit). 74
v) Salivary stimulants can cause unwanted side effects that are often more distressing than the xerostomia. The following have been used: Pilocarpine - ophthalmic drops - 5 -10 mgs. 3 times daily. 75-77
Anetholetrithione (Sialor - sulfarlem, latema) 1-2 tablets 3 times daily.
Pilocarpine and Anetholetrithione can be combined.
vi) Ripe bananas are a good lubricant; however, they should be avoided for dentate patients because of their high refined sugar content.
If dentures are left out during the period of mucositis they should be brushed with an unperfumed soap or toothpaste, soaked in a solution of sodium hypochlorite (Milton Solution : Dentural : Steradent for Metal Dentures) for 30 minutes and stored dry overnight. 80 If Candidal infection has been diagnosed, a Miconazole oral gel or varnish, should be applied to the fit surface prior to re-insertion. Miconazole must be avoided if the patient is on Warfarin medication.
Obturators should not be discontinued. If painful , a clinical examination and adjustment is indicated.
When the mouth is too painful for cleaning and a mouthwash cannot be used the oral tissues should be swabbed with Polygon oral swabs (Rochaille Medical Limited, Cambridge, U.K) or a gauze soaked in chlorhexidine 3 to 4 times daily16. Polygon swabs are softer than cotton buds and cause less bleeding and pain when applied to the already inflamed mucosa. 82
Avoidance of certain food, drinks and mouthwashes can can help to prevent discomfort. The following should be avoided:
i) Hard food.
ii) Spicy food.
iii) Strongly flavoured toothpaste.
iv) Alcohol (spirits).
v) Tobacco.
vi) Fizzy drinks.
vii) Sweets.
viii) Acid drinks and fruit.
ix) Hot (temperature) drinks.
x) Many non prescription oral preparations are acidic , causing erosion and tooth sensitivity, or damaging to the mucosa - Listerine: Hydrogen Peroxide: Plax: Sodium Bicarbonate: Glycerin and Lemon swabs : Lemon/Raspberry Mousselage.83-86
xi) Glandosane mouthwash is very acidic (pH 5.1), and should not be used for dentate patients. 71
xii) Pineapple chunks and fruit flavoured ice cubes are also acidic and can contribute to tooth sensitivity in the dentate patient and can traumatise the mucosa.
Dental treatment should be avoided during the period of cancer therapy. If the patient has been inadequately prepared dental extractions may become unavoidable. Timing of extractions should be agreed with the Haematologists or the Oncology team. Pulp treatment of primary teeth during the course of chemotherapy is contra-indicated.
Following Cancer Therapy - Prevention and Monitoring
The risk of uncontrolled dental disease following cancer treatment can continue for at least 12 months following radiotherapy or total body irradiation prior to bone marrow transplantation. Susceptibility to dental disease can be lifelong.
In children general growth and development including facial growth and dental development should be closely monitored. Damage to developing teeth is a frequent complication following radiotherapy88 or total body irradiation. Chemotherapy on the other hand appears to have little permanent effect on oral health. There is some evidence to suggest that chemotherapy alone may result in an increased incidence of dental developmental disturbances.
Following treatment, and as taste returns,there is an unpleasant period of altered taste. Many patients will seek comfort in sweet food and drink. Diet counselling needs to be rigorously reinforced at regular intervals particularly with regard to sugar and acid consumption. Plaque and gingival scores need to be carefully monitored by the dental hygienist.
Bone marrow transplant patients on Cyclosporin may need more frequent hygienist support to help maintain health in the presence of gingival hyperplasia.
Regular oral healthcare monitoring should be undertaken by a designated member of dental staff in close liaison with the dental hygienist. Where continuing care is provided within the Community Dental Service or General Dental Service there should be liaison with the dentist responsible for that care.
The role of fluoride in the continuing prevention of dental caries is essential to the maintenance of oral health. Fluoride supplements should be used for children with developing teeth, topical application should continue and a fluoride dentifrice should be used
Chlorhexidine gel should continue to be applied every three months using an applicator. The gel should be placed in the applicator and seated in the mouth for five minutes each night over a two week period.
Despite better focused radiation dose and improved screening, progressive jaw stiffness and limitation of opening remains a common complication. In the event of limitation a strict regimen of mouth exercises is advisable to minimise the problem. A simple wedge made by stacking and taping together tongue spatulas can be used by the patient both as a guide to improved opening and as a target for exercises at least 3-4 times daily. Patients receiving treatment for a tumour of the masticatory muscles or temporo-mandibular joint should use exercises routinely post-treatment Increasing trismus should be investigated for potential local recurrence.
Following Cancer Therapy - Restorative Care
Uncontrolled periodontal disease can predispose to osteoradionecrosis. It is essential therefore that any evidence of periodontal disease should be treated rigorously. In the few instances of Cyclosporin induced gingival hyperplasia, gingival surgery may be required.
Restorations should be kept simple ensuring the maintenance of acceptable aesthetics and function. Where appropriate, a restorative material with fluoride release should be used.
In children , routine restorative treatment must be delayed until the patient is in remission, when a careful study of the medical history should be made. Some children may have developed other medical complications as the result of treatment (e.g. cardiomyopathy) with implications for restorative care. If the patient is on maintenance chemotherapy it is still important to have a full blood count performed within the 24 hour period prior to any proposed dental treatment that might result in a bacteraemia . If platelet or neutrophil counts are low, the elective procedure should be delayed until the patients haematological status has improved. A full blood count is prudent if an invasive procedure is planned. If a patient is thrombocytopenic or neutropenic, their management should be discussed with the haematologist prior to dental treatment.
Dental extractions following radiotherapy put the patient at risk of osteoradionecrosis and should be avoided if possible. If unavoidable they should be undertaken in a hospital environment with an appropriate antibiotic prophylaxis.
0.2% chlorhexidine gluconate mouthwash should be used prior to surgery.
The extractions should be performed carefully with minimal trauma where possible ensuring soft tissue primary closure.
Systemic antibiotics should be used until healing has taken place.
Where multiple extractions are required hyperbaric oxygen therapy is recommended both before and after tooth removal. 99 However the significant number of “ dives “ involved can lead to poor compliance.
Patients are at particular risk of osteoradionecrosis when:
i) The total radiation dose exceeded 60Gy.
ii) The dose fraction was large with a high number of fractions.
iii) There is local trauma as the result of a tooth extraction, uncontrolled periodontal disease or an ill-fitting prosthesis.
iv) The person is immuno deficient.
v) The person is malnourished.
Dentures should be avoided wherever possible. Appliances will contribute to plaque retention and disease particularly when there is xerostomia. When dentures are essential to ensure good function following treatment, construction will aid ability to chew solid food , social adaptation and weight gain
Oseointegrated implants are a useful adjunct to fixed or removable prosthesis provision. Hyperbaric oxygen may be required to facilitate
placement. The provision of implants should take into consideration both the patient’s prognosis and the published national guideline on their use
Following Cancer Therapy - Requirements for Denture Wearers
Appliances removed at night should be subject to the cleansing regimen indicated previously. Obturators should not be left out at night for the six months following treatment.
In the event of oral candidal infection, antifungals should be prescribed for at least two consecutive weeks:
i) Miconazole varnish or gel. This should be avoided if the patient is taking Warfarin, the anticoagulant effect is enhanced by Miconazole
ii) Nystatin powder - 800,000 units per application of Viscogel can be incorporated into a denture soft lining material. The Nystatin powder is added when the powder and liquid of the liner are mixed. It can be effective for up to seven weeks
iii)Amphotericin B should be avoided since it is inactivated by Viscogel.
iv) Fluconazole may be indicated for resistant infections.
The Management of Osteoradionecrosis
Strenuous efforts should be made to avoid osteoradionecrosis by careful oral health monitoring and ensuring prevention compliance, timely dental treatment and dealing promptly with oral trauma. It is a painful and debilitating condition for the patient and can be very difficult to treat.
Oral trauma can be reduced by implementation of a soft diet and adjustment or removal of any denture that could be contributing to trauma.
Hyperbaric oxygen therapy at 2-2.5 atmospheres pressure for 1.5 - 2 hours per day. Up to 80 sessions have been recommended to treat severe cases of osteoradionecrosis.
There have been promising results with ultra sound at frequencies of 3mhz pulsed 1 in 4 at an intensity of 1w/cms sq. applied to the mandible for 10 minutes daily for 50 days106.
Excision of necrosed bone with primary closure and appropriate hyperbaric oxygen therapy is recommended. Closure of orocutaneous fistulae will be required. Hemi-mandibulectomy may be necessary in severe cases and reconstruction appropriate.
Platelets
>80 x 109/litre Routine Management
1.5 x 109/litre Routine Management
8 x 109/litre Routine Management
< 8 x 109/litre Special Care for General Anaesthesia
Note: For a short pathway for care see:
http://www.rxbds.com/postp870.html#870
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Copyright 2004 Onwards by Akilesh Ramasamy |
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