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Oral care for cancer patients power point
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.
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6. Chemo can cause drops in ANC (absolute neutrophil count) which makes it harder to fight off infections.
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?
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
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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.
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
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50. Identify and treat potential oral problems within the proposed radiation field before radiation treatment begins.
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.
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.
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.
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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
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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
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:
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96. Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.
102. Instruct the patient in home application of fluoride gel (not fluoride rinses).
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104. Monitor the patient’s oral health for plaque control, tooth demineralization, dental caries, and infection.
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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
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.
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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.
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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.
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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.
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126. Opiates (ex. morphine)—are an important tool for controlling pain and not something to be shunned or feared.
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
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.
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167. Dentists should closely monitor children who have received radiation to craniofacial and dental structures for abnormal growth and development.
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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.
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172. Dental extractions, root plane and scales, should be done 10days to 2 wks prior to chemotherapy or radiation treatments.
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
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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.
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Notas do Editor
Over 1,500,000 new cases of cancer were diagnosed in 2010!!!! Chances are pretty good you will provide care to someone with cancer. So hopefully you will remember some of what we talk about today.Some pt’s will not be able to have dental tx during cancer tx. Most will, but it is up to the oncologist.The patient benefits if their dental team is knowledgeable about cancer treatments since many times the mouth is affected.
This is why people going through chemo loss their hair (rapidly dividing cells), fingernails are very britel, and vomit a lot. GI tract (rapidly dividing cells)
With low ANC if pt get an oral infection or even just a sore without infection it can lead to bacteria getting into the blood stream and the body cannot fight off infection, and they may have to stop their chemo tx. Until infection is gone and then restart the chemo process
If pt. is going to have a bisphosphanate drug, then you would not want to do an extraction that could cause osteonecrosis.If denture or partial is rubbing and causing sores it should not be worn due to a sore could cause an infection that the body cannot fight.
Myelosuppressive therapy is any form of tx that is aimed at slowing down the rate of blood cell production.
These are questions to ask if a pt comes in and needs tx. During chemo. Remember you may need to clean teeth every 2-3 mos. Also you may need to do emergency tx. If tooth becomes infected during chemo, you have to get rid of the infection due to ANC. Work with oncologist.
The oncologist will do blood work 24 hrs. prior to dental work and will work with dentist.
This is for routine prophy’s.
Stannous fluoride comes in flavors. Mint , cinnamon, tropical. May aggravate some tissue. Some pt. cannot toerate the taste of chlorhexidine and may not use it as recommended. Ask oncologist if pt. can use stannous fluoride instead if it does not irritate the tissue.
Some oncologist will give nystatin as a preventive measure , some will only give after infection has started.
Salt helps with healing of mouth sores while the baking soda nuetralizes the acids.
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Saforis or L-glutamine reduces inflammation. May reduce severity of mouth sores and amount of pain medication needed.Magic mouth wash has soothing, anti-fungal and numbing agents and anti acid to reduce acids.
Aredia and zometa are just 2 IV bisphosphonates related to ONJ ONJ can also be caused by long term steroid use, diabetes, old age, idiopathic, Is exposed bone that has to last more than 8 weeks. 1 in 100,000 can get it from oral bisphosphonates. IV is 10 times greater than oral.
So, regular dental visits, check complete blood count, ask about bisphosphonates.
This is also important for the dental team to know that if your patient comes in for a dental emergency that these are common side affects and most will go away after radiation treatment is over.
Xerostomia will make it difficult to wear C/C and may cause rubbing.If denture or partial is rubbing and causing sores it should not be worn due to a sore could cause an infection that the body cannot fight.
The vascularity is what causes ONJ. If the isn’t blood flow to the bone it dies.
Cleocin is a good antibiotic for bone infections.
These are drugs on the horizon. Still in clinical trials.
For stiff jaw. Pt. can do jaw exercises such as opening and closing 20 times 2-3 times a day to help loosen up.
The most rapid dividing cells are in the bone marrow,(why body can not fight off infection as easy) hair folicals (loss of hair), and GI tract, (causing diarrhea and mucositis).
Some patients will have to be hospitalized and put on IV’s for nutrition.
Myelosuppressive chemo effects bone marrow and thus the body cannot fight off infection.
Hospitals have their own protocol for checking patients mouths during treatments. If a patient has a fever then it is likely that they have an infection. Contact the oncologist.
You can relieve mouth pain by sucking ice chips when the chemotherapy drug is most concentrated in the body. This technique, called cryotherapy, works by decreasing blood flow to the cells in the mouth, reducing exposure to the drug and decreasing the risk of developing mouth sores.
Stage 1
Opiates—some people think they will become addicted and will not take as needed. This are usually given for Stage 2 oral mucositis.
Opiates—some people think they will become addicted and will not take as needed. This are usually given for Stage 2 oral mucositis.
Smoking and tobacco cause mouth sores to worsen and affect healing.
Soothing foods. Vs acidic, and foods that cause trauma to the tissue
Now some study’s show hyperbaric oxygen may not help
All dentist and dental hygienist should be doing oral cancer screenings. Use of Vizilite?