Oral and Dental Management After Cancer Therapy
Routine systematic oral hygiene is important for reducing incidence and severity of oral sequelae of cancer therapy. The patient must be informed of the rationale for the oral hygiene program as well as the potential side effects of cancer chemotherapy and radiation therapy. Effective oral hygiene is important throughout cancer treatment, with emphasis on oral hygiene beginning before treatment starts.
Management of patients undergoing either high-dose chemotherapy or upper-mantle radiation share selected common principles. These principles are based on baseline oral care (refer to the list of suggestions for Routine Oral Hygiene Care below) and reduction of physical trauma to oral mucosa (refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy below).
Routine Oral Hygiene Care
- Toothbrushing. [Note: Electric and ultrasonic toothbrushes are acceptable if the patient is capable of using them without causing trauma.]
- Soft nylon-bristled brush (two to three rows).
- Brush 2 to 3 times daily with Bass sulcular scrub method.
- Rinse frequently.
- Foam toothbrushes:
- Use only when use of a regular toothbrush is not feasible.
- Use with antimicrobial rinses when routine brushing and flossing are not possible.
- Brush teeth 2 to 3 times a day.
- Rinse frequently.
- Patient preference, as tolerated.
- (Note: Non–mint-flavored products are typically better tolerated than mint-flavored products when oral mucositis or oral graft-versus-host disease [GVHD] is present).
- Fluoride recommended.
- Use 0.9% saline or water if toothpaste causes irritation.
- Patient preference, as tolerated.
- Once daily.
- Atraumatic technique with modifications as needed.
- Bland rinses:
- 0.9% saline.
- Sodium bicarbonate solution.
- 0.9% saline plus sodium bicarbonate solution.
- Use 8 to 12 oz of rinse, hold a mouthful, and expectorate until total volume is used; repeat every 2 to 4 hours or as needed to ameliorate discomfort.
- 1.1% neutral sodium fluoride gel.
- 0.4% stannous fluoride gel.
- Brush on gel for 2 to 3 minutes.
- Expectorate and rinse mouth gently.
- Apply once a day.
- Topical antimicrobial rinses:
- 0.12% to 0.2% chlorhexidine oral rinse for management of acute gingival lesions.
- Povidone iodine oral rinse.
- Rinse, hold 1 to 2 minutes, and expectorate.
- Repeat 2 to 4 times a day, depending on severity of periodontal disease.
Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy 
- Minimize denture use during first 3 weeks posttransplant.
- Wear dentures only when eating.
- Discontinue use at all other times.
- Clean twice a day with a soft brush and rinse well.
- Soak in antimicrobial solutions when not being worn.
- Perform routine oral mucosal care procedures 3 to 4 times a day with the oral appliances out of the mouth.
- Leave appliances out of mouth when sleeping and during periods of significant mouth soreness.
- Dentures may be used to hold medications needed for oral care (e.g., antifungals).
- Discontinue use of removable appliances until oral mucositis has healed.
- Remove orthodontic appliances (e.g., brackets, wires, retainers) before conditioning.
Considerable variation exists across institutions relative to specific nonmedicated approaches to baseline oral care, given limited published evidence. Most nonmedicated oral care protocols use topical, frequent (every 4–6 hours) rinsing with 0.9% saline. Additional interventions include dental brushing with toothpaste, dental flossing, ice chips, and sodium bicarbonate rinses. Patient compliance with these agents can be maximized by comprehensive overseeing by the health care professional.
Patients using removable dental prostheses or orthodontic appliances have risk of mucosal injury or infection. This risk can be eliminated or substantially reduced prior to high-dose cancer therapy. (Refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-dose Cancer Therapy.)
Dental brushing and flossing represent simple, cost-effective approaches to bacterial dental plaque control. This strategy is designed to reduce risk of oral soft tissue infection during myeloablation. Oncology teams at some centers promote their use, while teams at other centers have patients discontinue brushing and flossing when peripheral blood components decrease below defined thresholds (e.g., platelets <30,000/mm3). There is no comprehensive evidence base regarding the optimal approach. Many centers adopt the strategy that the benefits of properly performed dental brushing and flossing in reducing risk of gingival infection outweigh the risks.
Periodontal infection (gingivitis and periodontitis) increases risk for oral bleeding; healthy tissues should not bleed. Discontinuing dental brushing and flossing can increase risk for gingival bleeding, oral infection, and bacteremia. Risk for gingival bleeding and infection, therefore, is reduced by eliminating gingival infection before therapy and promoting oral health daily by removing bacterial plaque with gentle debridement with a soft or ultra-soft toothbrush during therapy. Mechanical plaque control not only promotes gingival health, but it also may decrease risk of exacerbation of oral mucositis secondary to microbial colonization of damaged mucosal surfaces.
Dental brushing and flossing should be performed daily under the supervision of professional staff:
- A soft nylon-bristled toothbrush should be used 2 to 3 times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus, keeping them free of bacterial plaque.
- Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma.
- Oral rinsing with water or saline 3 to 4 times while brushing will further aid in removal of dental plaque dislodged by brushing.
- Rinses containing alcohol should be avoided.
- A toothpaste with a relatively neutral taste should be considered because the flavoring agents in toothpaste can irritate oral soft tissues.
- Brushes should be air-dried between uses.
- While disinfectants have been suggested, their routine use to clean brushes has not been proven of value.
- Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use.
Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. Flossing allows for interproximal removal of dental bacterial plaque and thus promotes gingival health. As with dental brushing, this intervention should be performed under the supervision of professional staff to ensure its safe administration.
The oral cavity should be cleaned after meals:
- If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary.
- Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals.
- Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary.
- Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy.
- Toothettes have limited ability to cleanse the dentition; however, they may be useful for cleaning maxillary/mandibular alveolar ridges of edentulous areas, palate, and tongue.
Preventing dryness of the lips to reduce risk for tissue injury is important. Mouth breathing and/or xerostomia secondary to anticholinergic medications used for nausea management can induce the condition. GVHD of the lips can also contribute to dry lips in allogeneic transplant patients. Lip care products containing petroleum-based oils and waxes can be useful. Lanolin-based creams and ointments may be more effective in moisturizing/lubricating the lips and thus protecting against trauma.References
- Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.