Smile: Protect Your Mouth

Question: I have been diagnosed with cancer and will begin therapy soon. It has been recommended that I make an appointment to see the dentist. I haven't been to an dentist in 5 years and don't think I have any problems. Why is it important that I do this?

Answer: The mouth is attached to the rest of the body and it is very important to have a dental exam prior to starting any cancer therapy if possible. It is very important that the oncology and dental teams work together to maintain optimal health before, during and following therapy. Preexisting or undetected oral disease may cause more complication in your overall health.

If circumstances allow, the pretreatment period is the optimal time to institute an oral hygiene and/or fluoride regime, restore or remove diseased teeth and eliminate potential oral sources of infection and trauma. This is not the time to have full mouth reconstruction.

Education and training on preventive oral hygiene will help reduce oralcomplications during therapy.

Question: What are my chances of having oral complications during my cancer treatment?

Answer: All head and neck radiation patients will have complications. About 75% of bone marrow transplantation patients experience complications. Chemotherapy patients have a 40% chance of having problems.

Reactions are often highly individualized. Reactions include: mucositis and ulceration, pain, infection, bleeding dry mouth and salivary gland dysfunction, taste alteration, neurotoxicity, decay.

It is very important that you advice your oncology and dental team of any problems you experience in your mouth or throat area. These areas may be sites for infections that may lead to systemic infection or sepsis and can be life threatening in the neutropenic patient.

When there is a fever is of unknown origin, consult with your dentist and oncologist to explore possible oral source for the infection.

Question: My lips have been very chapped and cracked since I stared my therapy. I am using a petroleum based lip treatment but it doesn't seem to help. I sometimes think it may be making it worse. What can I do?

Answer Lip condition can effect your eating and drinking so it is important to keep lips moist and healthy. Petroleum based lip balms may promote microbial growth. Lip moisturizers should be water or lanolin-based products. Burt's Bees lip balm is a good product. It is available at most health food stores. Lansinoh is also available over the counter. If you are allergic to lanolin, Vitamin E capsules can be broken and applied to the lips.

Another suggestion to maintain healthier lips is to use sunscreen to prevent sun blisters, and treat cold sores and dry, chapped lips. Zilactin-Lip is a good product for this.

Answer: MOST DEFINITELY. A dietitian should be involved in your care and evaluationfrom the onset. Patients should receive supportive therapy to address malnutrition and dehydration as secondary consequences of vomiting, loss or alteration of taste, nausea,pain associated with mucositis, ulceration and/or local infection.

The dietitian will work with you on what foods to eat, how often, combination offoods, liquid meal replacements, water intake, and serving suggestions. Foods to avoid (spicy, abrasive, acidic foods, foods that require excess chewing, temperature extremes,high sugar content and alcohol) should also be discussed.

Answer: Rinsing should be used in conjunction with, and not in place of an oral hygiene regimen. It helps clean and lubricate tissues, treat mucosal wounds, hydrate the tissues, soothe sore gums, remove debris and prevent accumulation of debris and bacteria.

Alcohol-based mouthwashes and peroxide solutions can cause drying and irritating effects. Hydrogen peroxide is not recommended as a daily rinse because it may disrupt the normal oral flora of the mouth. Use if for 1-2 days maximum to help in periodontal (gum) infection when anaerobic microorganismsare involved.

Chlorhexidine rinse can be used in the presence of poor oral hygiene, signs ofinflammation, or antimicrobial activity. This is a prescription. Check with your oncologist regarding use of any products. The patient should be monitored and evaluated regularly to determine the benefits of the rinse versus the risk for irritation and/or drying of tissue.

Patients who experience frequent vomiting should rinse with a neutral rinse of 1/4tsp. Salt, 1/4 tsp. baking soda, and I -quart water every 2 hours until soreness, nausea or ropy saliva contraindicates. This should not be swallowed. The patient can switch to1/2 tsp. soda and I quart water or water only if necessary.

A saline solution of 1/2tsp. salt in 8 oz. of water will also help reduce irritation while not damaging the oral mucous. This is recommended for treatment of leukemic gingivitis and head and neck radiation.

Question: If I need dental work during cancer therapy, what is the appropriate timing?

Answer: It is imperative that the dentist seek consultation with the oncologist prior to any invasive dental procedure, including a oral prophylaxis (teeth cleaning).

Blood work needs to be done 24 hours prior to dental appointment to check on platelet count and neutrophil count. Work must be postponed if the platelet count is less than 50,000/3 or abnormal clotting factors are present or the neutrophil count is less than I,OOOmm/3.

If chemotherapy is being delivered through a vascular access device (central venous catheter, osteoport), the patient should receive the American Heart Association endocarditis prophylactic antibiotic regime prior to invasive dental procedures. Check with the oncologist to see if this is required before any dental appointment.

Answer: This is a very common side effect of oncology therapy. Saliva loss is very harmful because as the levels of harmful bacteria increase while levels of natural salivary protective elements decrease severe complications may result. Mouth pain, mouth infections, tooth decay, weight loss, bleeding gums, dryness in your throat, dry, cracked tongue and cracks at the comers of your mouth and badly fitting dentures or partial dentures can result from a dry mouth.

We all need saliva to help lubricate our mouth and throats, for protections from bacterial,viral, and fungal growth, which cause mouth infections and tooth decay and to help break down food so we can taste it.

When there is a lack of saliva, it is very important to hydrate the tissue. Frequent sips of water, sucking on ice chips or using sugar free candies or gum will provide some relief. There are over the counter products that will provide symptomatic relief from oral dryness for several hours. Blotene products, Salivart, OraLube, Glandodane are some brand names that are available.

Water alone remains the most frequently used mouth-wetting agent. Adding a small amount of glycerine(1/4 tsp) to 8 oz. of water can offer longer lasting relief from dryness. A humidifier in the room, especially at night and in dry environments may also be a benefit.

For head and neck radiation patients, Salagen may be prescribed when there has been damage to the salivary glands. It can take up to 3 months before your doctor can determine if Salagen works for you. This is not a medication for everyone.

Question: I am 50 years old. Why do I need to have fluoride trays done and do fluoride treatment everyday?

Answer: Radiation caries is a lifelong risk of head and neck radiation patients. It may begin within three months of completing radiation. To prevent demineralization of tooth structure, the minerals normally provided by saliva must be replaced on a daily basis for the rest of the patient's life. The presence of fluoride ions enhances the teeth's ability to uptake calcium and phosphate ions. Custom gel-applicator trays are the best way to do this.

If, possible, start the daily five-minute application of fluoride several days beforethe initiation of radiation therapy. A 1. 1% neutral pH sodium fluoride or a 0.4%stannous fluoride (unflavored) are acceptable. If you have porcelain crowns or are sensitive to the acidity of other fluoride preparations, use the neutral pH fluoride.

Make sure the trays cover all of the tooth structure. The trays must not irritate the gums or the tissues in the mouth. Follow the instructions given to you by your dentist and dental hygienist.

Answer: Try putting a little Oral Balance Gel by Biotene on the pill before you swallow. This helps it slide down the throat.

Question: I drink a lot of sugar free soda. My hygienist has recommended that I cut downon my intake. If I need to have a lot of liquids daily, what is wrong with these drinks?

Answer: Carbonation in soda, diet or regular, along with the acid in the drink, can cause the breakdown of the tooth structure. This can occur around the root surface or around tooth structure that has had gold or porcelain crowns. It also can breakdown weak areas of tooth structure especially along the gumline areas.

Question: I wear a denture and am having problems due to my dry mouth. I need help. How do I take care of my removable applicance?

Answer: The best thing to do is to make sure your removable prostheses are kept very clean. Removable dental appliances need to be cleaned daily, kept in water or commercial cleanser overnight when not being worn. Avoid using denture adhesives that can harbor bacteria. Always keep appliance in solution when not in the mouth, soaking overnight in commercial cleanser or water. If you develop a fungal infection, use one of the following antifungal therapies. Always check with your dentist.

If possible, try not to wear removable appliances during treatment. Edentulous patientsshould cleanse their tongue and oral tissue daily with gauze or a soft toothbrush.

Biotene Oral Balance Gel can be placed on the removable appliance to help moisten the tissue under the appliance and act as an antimicrobial agent

Question: Are there any resources I can order regarding information on taking care of my mouth?

The National Oral Health Information Clearinghouse
ATTN: OCCT
I NOHIC WAY
Bethesda, NM 20892-3500
1-8787-216-1019
www.aerie. com/nohicweb

Supportive Cancer Care: by Ernest H. Rosenbaum, MD & Isadora R. Rosenbaum, MA
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