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.[1] Effective oral hygiene is important throughout cancer treatment, with emphasis on oral hygiene beginning prior to initiation of that treatment.[2-4]

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 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 possible.
    • Brush teeth and mucosal surfaces 2 to 3 times a day.
    • Rinse frequently.



• Dentifrice:
  • Patient preference as tolerated.
  • Fluoride recommended.
  • Use 0.9% saline or water if toothpaste causes irritation.



• Flossing:
  • Once daily.
  • Atraumatic technique with modifications as needed.



• Bland Rinses:
  • Varieties:
    • 0.9% saline.
    • Sodium bicarbonate solution.
    • 0.9% saline plus sodium bicarbonate solution.
  • Use 8 to 12 oz of rinse, hold and expectorate; repeat every 2 to 4 hours or as needed for pain.



• Fluoride:
  • 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.
  • Povidone iodine oral rinse.
  • Rinse, hold 1 to 2 minutes, 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 [4]

• Minimize denture use during first 3 to 4 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) prior to conditioning.

Considerable variation exists across institutions relative to specific nonmedicated approaches to baseline oral care, given limited published evidence. Most nonmedicated oral care protocols utilize 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 healthcare professional.

Patients utilizing 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 (see the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-Dose Cancer Therapy above).

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).

Periodontal infection (gingivitis and periodontitis) causes 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 prior to 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 supervision of the professional staff. Patients should use a soft nylon-bristled toothbrush 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. Since the flavoring agents in toothpaste can irritate oral soft tissues, a toothpaste with relatively neutral taste should be considered. 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 the chemotherapy admission. Flossing allows for interproximal removal of dental bacterial plaque and thus promotes gingival health. As with dental brushing, this intervention should be performed in the context of daily monitoring by staff to assure 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 relative to use of the variety of mechanical hygiene aids that are available; for example, dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy. Toothettes have limited ability to cleanse the dentition. They may, however, 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. Lip care products containing petroleum-based oils and waxes can be useful. Lanolin-based creams and ointments may be more effective in protecting against trauma.

References

1. Sonis S, Kunz A: Impact of improved dental services on the frequency of oral complications of cancer therapy for patients with non-head-and-neck malignancies. Oral Surg Oral Med Oral Pathol 65 (1): 19-22, 1988.  [PUBMED Abstract]
   
   
2. Ezzone S, Jolly D, Replogle K, et al.: Survey of oral hygiene regimens among bone marrow transplant centers. Oncol Nurs Forum 20 (9): 1375-81, 1993.  [PUBMED Abstract]
   
   
3. Armstrong TS: Stomatitis in the bone marrow transplant patient. An overview and proposed oral care protocol. Cancer Nurs 17 (5): 403-10, 1994.  [PUBMED Abstract]
   
   
4. Schubert MM, Peterson DE, Lloid ME: Oral complications. In: Thomas ED, Blume KG, Forman SJ, eds.: Hematopoietic Cell Transplantation. 2nd ed. Malden, Mass: Blackwell Science Inc, 1999, pp 751-63. 
   
   

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