"The more we know about cancer the more lives we can save "

1. Prepared By :
FATIMA A.BADGHAISH
DENTAL MANGMENT OF PATINT
TREATED WITH CHEMOTHERAPY
AND RADIOTHERPY

2. February 4, 2019

3. World Cancer Day 2019:
" I Am and I Will ".
Cancer knows no borders.
Cancer is a disease that affects millions of families,
and the numbers are growing .
In 2018, one out of six people worldwide died from
cancer that’s more than HIV/AIDS, tuberculosis, and
malaria.
World Cancer Day on February 4, is observed to raise
awareness of cancer in order to encourage its detection,
prevention and treatment.

4. Today it is world cancer day!
CANCER FACTS
9.6 million people die from cancer every year.
That’s more than HIV/AIDS, malaria and tuberculosis combined.
By 2030, experts project cancer deaths to rise to 13 millionAt least
one third of common cancers are preventable.
Cancer is the second-leading cause of death worldwide.
70% of cancer deaths occur in low-to-middle income countries.
Up to 3.7 million lives could be saved each year by implementing
resource appropriate strategies for prevention, early detection and
treatment.
The total annual economic cost of cancer is estimated at US$1.16
trillion.

5. THE MORE WE KNOW ABOUT CANCER
THE MORE LIVES WE CAN SAVE
World Cancer Day 2019:
" I Am and I Will ".

6. Together we can continue to
transform cancer from deadly
to treatable and from treatable
to preventable.

7. DENTAL
MANGMENT

8. FATIMA ABDULLAH
BADGHAISH
DURING
CHEMOTHERPY

9. During Chemotherapy
Chemotherapy treatment can affect
patient mouth in different ways. they
may experience mouth ulcers, mouth
infections and more likely to get an
abscess .

10. During Chemotherapy
A Symptomatic Treatment only
Must be provided .
What Should We Do As A Dentist ?

11. During Chemotherapy
Most of dental treatment should be avoided during
chemotherapy , But the emergency treatment is
possible and The oncologist should be consulted in
order to know the degree of immune
suppression of the patient if immune system is strong
enough and WBC , Platelet are accepted .
One exception that may be platelet and WBC very
Low and the dental work is very important so, patient
must be hospitalized and under complete asepsis
condition ( to prevent infection ) and receive a
platelet transfusion or fresh frozen plasma prior to
dental work (to prevent bleeding ) .
VIP NOTE not everyone undergo
emergency treatment .

12. During Chemotherapy
IN CASE OF :
Oral Mucositis
Is one of the most common effect of both
chemotherapy and radiotherapy
The Severity Of Oral Mucositis
while undergoing Chemotherapy and Radiotherapy
depends on the type and dose of medication
receive, as well as how often patients receive
their treatment.

13. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
1-Dietary Management
Eat soft, moist, bland foods :
- Add sauces, gravy, salad dressings, butter/margarine, broth or another
liquid to help moisten foods
Fluid intake :
- Daily fluid intake of 8-12 cups (2-3 litres) ,to help keep oral mucosa
moist (e.g. water, sugar-free popsicles, non-acidic juices, ice cubes, sports drinks,
broth)High-energy, nutritious drinks such as milk or liquid nutritional supplements
can be taken in between or with meals.fluids should be taken through a straw as this
reduces irritation in the mouth.
Well-balanced diet :
- that is high in protein, vitamins B and C

14. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
1-Dietary Management
Avoid hot foods :
- hot food can also irritate the mouth and individuals with mucositis should
eat foods cold or at room temperature.
Use ice:
ice or ice blocks may help to numb to mouth.
Cut food into small pieces.
Avoid irritating food:
- Dry or coarse foods (e.g. toast, crackers, chips)
- Highly acidic fluids and foods (e.g. lemon glycerin swabs, vitamin C lozenges)
- Fluid or foods high in sugar (e.g. pop, some fruit juices)
- Caffeine, alcohol, tobacco
in case of sever mucositis
a PARENTERAL NUTRITION (PN)
is administrated .

15. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
If we escape this step the liability to oral infection will increase !
Patients should be encouraged to take responsibility
for their own oral care wherever possible.
This may require frequent encouragement and education.
1-Patient education

16. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
2- Brushinga- gentle brushing of teeth, gums and tongue should be
performed two to four times a day preferably after meals
and before going to bed .
b- Soft bristled toothbrush is recommended to prevent
injury to the oral mucosa .
c- Change toothbrush every 3 months or after any
infection or disinfected in chlorhexidine . in relation to
patient’s infection risk.
d- In order to protect the enamel, non-abrasive
toothpaste containing mild fluoride should be
used , Stay away from strong flavors like mint,

17. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
3- Interdental cleaning
must be ensured that patients are able and
confident on their use to prevent mucosal
injury
4- Prothesis
Edentulous patients must not wear dentures while they sleep
or when their dentures or RPD IRRITATE ulcerated mucosal tissues.

18. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
5- Mouthwash
- The goal of using mouthwashes may
include: oral hygiene, preventing/treating
infection, moistening the oral cavity or
providing pain relief

19. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
5- Mouthwash
Chlorhexidine (CHX)
used at concentrations of 0.12-0.2%, since it has been suggested to be
useful in maintaining improved oral hygiene and in reducing mucosal
inflammation
Benzydamine
Benzydamine hydrochloride is a non-steroidal anti-inflammatory
mouthwash which also poses pain relieving, antimicrobial,
antifungal and anesthetic properties
at least four times a day

20. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
5- Mouthwash
Sodium bicarbonate
- can be prepared by dissolving one teaspoon of sodium bicarbonate in a
glass of water .
- Sodium bicarbonate can improve taste and it neutralises acids and thus
prevents erosion
Normal saline
(sodium chloride 0.9% solution)

21. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
5- Mouthwash
Magic Mouthwash
- its ability to provide almost immediate pain relief while preventing or
treating the inflammation .
- They typically contain:
- antibiotic(s) to prevent or stop bacterial infection
- antifungal drug to prevent or stop a fungal infection
- a numbing drug to soothe pain (lidocaine)
- an antihistamine to bring down swelling (example, diphenhydramine)
- a steroid drug to lower inflammation — redness and swelling
- an antacid to help the mouthwash coat your mouth (aluminum
hydroxide, magnesium, or kaolin

22. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
2- Oral Hygien Care Protocol
5- Mouthwash
Dosage and Frequency
- Your doctor or pharmacist will recommend the right dose of magic mouthwash
for you. How much depends on the type of magic mouthwash and the
condition of your mucositis.
- One recommended magic mouthwash dose is 10 milliliters every three hours,
up to six times a day. This dose is typically taken for six days. Other kinds are
used every four to six hours.
- Avoid eating or drinking anything for at least 30 minutes after taking magic
mouthwash. This helps the medicine stay in the mouth long enough to work its
effects.

23. A mouth rinse containing the tricyclic antidepressant doxepin
appears to relieve mucositis pain among patients
example
amoxapine.
clomipramine (Anafranil)
desipramine (Norpramin)
During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
3- Pain Control
Anesthetics (e.g., 2% viscous lidocaine,
diphenhydramine solution)
Topical Agents:
Coating agents
Analgesics: paracetamol/metamizol.

24. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
4- Therapeutic Intervention
Growth factors
Growth factors are proteins that stimulate cell growth,
proliferation and differentiation
the growth factors most widely investigated in the prevention
and treatment of OM are palifermin (keratinocyte growth factor)
Anti inflammatory agents
Benzydamine hydrochloride is a non-steroidal anti-inflammatory
drug that inhibits pro-inflammatory cytokines including TNF-α.

25. During Chemotherapy
What Are The Dental Management Of Oral Mucositis ?
we must follow the same SEQUENCES for better effect
5- Management of bleeding
bleeding may occur from the ulcerations of oral mucositis.
Local intraoral bleeding can usually be controlled with the use
of topical hemostatic agents such as fibrin glue or gelatin sponge

26. During Chemotherapy
Management of oral infections
Infection may be bacterial, fungal or viral
Fungal infection
Management:
Treat with topical anti-fungal such as nystatin
Bacterial infection
Management:
Treat with topical anti-bacterial such as bacitracin, neomycin,
mupirocin, and polymyxin B
Viral infection
Management:
Treat with topical anti-viral such as acyclovir
Thrush is the most common mouth infection during chemo.

27. During Chemotherapy
IN CASE OF :
Xerostomia
1-Follow basic oral assessment & hygiene recommendations for oral mucositis
2- Follow dietary recommendations for oral mucositis
3- Recommendations for Moisture & Lubrication:
Water
- Adequate fluid intake (8 -12 cups/2-3 litres daily)
- Water can be used as a saliva substitute. Keep
water bottle nearby at all times
Moisturize your lips
Saliva Substitutes
- Artificial saliva products provide temporary relief to
facilitate speech, chewing, and swallowing
- Products available over the counter in spray,
lozenge, gels, swab sticks
- Milk, butter, or vegetable oil may be helpful
- Mouthwashes designed for dry mouth, especially ones with xylitol, can be effective, such as
Biotene Dry Mouth Oral Rinse or Act Dry Mouth Mouthwash, which also offer protection against
tooth decay.

28. During Chemotherapy
IN CASE OF :
Xerostomia
- Chewing may help stimulate residual salivary flow
- Eat foods that require vigorous chewing (e.g.
apples, carrots, celery)
- Chew sugar free gum or suck on hard candy
- Pilocarpine recommended for use in patients
receiving radiation therapy to the head and neck
4- Fluoride treatments may be prescribed for patients
with xerostomia to prevent or minimize dental caries or
secondary tooth demineralizat
Saliva Stimulants

29. During Chemotherapy
IN CASE OF :
Taste Changes
Radiation therapy to the head, neck and mouth area may damage
the salivary glands and taste buds on the tongue
Chemotherapy drugs can change the taste receptor cells in the mouth.
They can also cause an increased sense of smell and sensitivity
to certain smells, which can change the way food tastes.

30. During Chemotherapy
Try to schedule dental work a few
days prior to chemo treatment.
This is the time when the patient
feels best. After treatment they
are weak.

31. FATIMA ABDULLAH
BADGHAISH
DURING
HEAD AND NECK
RADIOTHERPY

32. Patients During Radiation Therapy
Monitor the patient’s oral hygiene.
Excellent oral hygiene must be maintained
A mouth block should be placed during head and neck radiotherapy

33. Patients During Radiation Therapy
Taste disturbance (Loss of taste )
most common side effect during radiation to the tongue and palate
during 1–2 weeks after radiotherapy which gradually returns back
to normal after the course is completed. The most common
contributing factors are damaged taste buds disrupted innervations
and decreased salivary flow

34. Patients During Radiation Therapy
Trismus
When the muscles of mastication are in the direct field of radiation,
instruct the patient to exercise the muscles three times daily by
opening and closing the mouth 20 times as far as possible without
causing pain. Opening against gentle pressure generated by
placing the hand against the midline mandible may also be helpful.
This exercise may lessen the degree of trismus experienced by the
patient.

35. Patients During Radiation Therapy
Xerostomia and salivary hypofunction
as in chemotherapy
Radiation applied in the area of the salivary glands (below and in front of the ears and under the chin) can
affect the amount and quality of saliva. This can be a permanent side effect of radiotherapy.
Sometimes saliva becomes thick and ropey, making swallowing difficult. This usually improves after
radiotherapy is completed.
Whether the mouth is dry or has thick saliva, you need to take special care to protect teeth from losing
enamel. Sipping water or using gels and lubricants can help moisten your mouth.

36. Patients During Radiation Therapy
Mouth ulceration (mucositis)
as in chemotherapy
Ulceration and inflammation of the lining of the mouth occurs in
areas that are directly affected by radiation. Tissues become red,
swollen and painful ulcers may develop. Wearing dentures may be
uncomfortable
Ulcers usually heal after treatment has finished. Mouthwashes and
gels may help to reduce your discomfort.

37. Patients During Radiation Therapy
Radiation caries
is defined as tooth decay that results from radiation-induced dry mouth (xerostomia)
.
Prevention and management of dental caries :
A strict daily oral hygiene regimen that includes fluoride and plaque removal has been shown to
prevent the development of caries. Chlorhexidine gel has also been
shown to clinically reduce caries risk by lowering mutans
streptococci and lactobacilli counts in patients undergoing RT
The daily use of 4 percent stannous fluoride also is effective.

38. Patients During Radiation Therapy
The periodontium
RT effects on periodontal health include direct effects on the
periodontium so , the liability to get periodontal disease will
increase .
periodontal surgery could be performed in selected
patients following RT
If adequate oral hygiene is not established, periodontal
destruction will likely occur.

39. Patients During Radiation Therapy
Extraction
Extractions in irradiated bone may increase risk for ORN .
See if RCT can be done or no !
If the answer is no , we must do the following :
the patient must be 1- hospitalized
2- under complete coverage of antibiotic
3- atraumatic as possible
4- under asepsis condition

40. Reference sources
 Cancer care Connect ---booklet Mouth Pain and Discomfort.
All you need to know about oral mucositis
 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.
 Sonis ST, oral mucositis in cancer therapy.
The Journal of Supportive Oncology 2(6 suppl3) 3- 8, Nove 2004