Oral health care for the cancer patient

The goal of this paper is to present oral mucositis management approaches that are currently available in Canada.
Basic oral care is the foundation of management of oral complications in cancer therapy and is strongly recommended by the Mucositis Study Group prior to, during and after cancer treatments. Prior to cancer treatment, a complete oral dental examination (dental radiographs, periodontal probing) and dental intervention, if indicated, should be carried out in coordination with the oncology care plan. Basic oral care should be reinforced throughout cancer therapy and following treatment and when patients become symptomatic oral care should be intensified.7 Basic oral care also includes nutritional guidance.
Cryotherapy (ice chips):Sucking on ice chips (cryotherapy) for oral cooling has been shown effective in reducing oral mucositis that may be caused by intravenous cytotoxic chemotherapy that has a short half-life in the blood (such as 5-fluoruracil, high dose melphalan in SCT). Anti-Inflammatory Agents.Because the inflammatory response to cancer therapy is thought to play an important role in the pathogenesis of oral mucositis, several anti-inflammatory agents have been evaluated. Antimicrobial AgentsSeveral antimicrobials agent have been studied for oral mucositis based on the rationale that secondary colonization of oral mucositis ulcerations may aggravate mucosal damage. Coating AgentsSeveral topical coating agents are marketed for oral mucositis, with the rationale that covering the ulcerated area will protect the nerve endings and reduce pain. Low level Laser therapyTreatment of the oral mucosa with low-level laser therapy (LLLT) has been demonstrated to have an anti-inflammatory effect (Fig. AnalgesicsPain is the most prominent symptom or oral mucositis, and for those reasons plays a central role in the management or oral mucositis.
Management of pain commonly includes systemic analgesics with escalation of medication (from OTC to opioid) if pain increases. ConclusionOral mucositis is a significant toxicity of systemic chemotherapy and radiotherapy to the head and neck. Practical Oral Care for People With Developmental Disabilities – This booklet presents an overview of physical, mental, and behavioral challenges common in patients with developmental disabilities and offers strategies for providing oral care.
Oral cancer accounts for roughly two percent of all cancers diagnosed annually in the United States. With early detection and timely treatment, deaths from oral cancer could be dramatically reduced. The 5-year survival rate for those with localized disease at diagnosis is 83 percent compared with only 32 percent for those whose cancer has spread to other parts of the body.
Two lesions that could be precursors to cancer are leukoplakia (white lesions) and erythroplakia (red lesions). Possible signs and symptoms of oral cancer that your patients may report include: a lump or thickening in the oral soft tissues, soreness or a feeling that something is caught in the throat, difficulty chewing or swallowing, ear pain, difficulty moving the jaw or tongue, hoarseness, numbness of the tongue or other areas of the mouth, or swelling of the jaw that causes dentures to fit poorly or become uncomfortable. If these problems persist for more than 2 weeks, a thorough clinical examination and laboratory tests, as necessary, should be performed to obtain a definitive diagnosis. Most cases of oral cancer are linked to cigarette smoking, heavy alcohol use, or the use of both tobacco and alcohol together. Infection with the sexually transmitted human papillomavirus (specifically the HPV 16 type) has been linked to a subset of oral cancers. A thorough head and neck examination should be a routine part of each patient's dental visit and general medical examination. Follow-up to make sure a definitive diagnosis is obtained on any possible signs or symptoms of oral cancer. This exam is abstracted from the standardized oral examination method recommended by the World Health Organization. LIPS: (Figure 2) Begin examination by observing the lips with the patient's mouth both closed and open. LABIAL MUCOSA: (Figures 3 and 4) With the patient's mouth partially open, visually examine the labial mucosa and sulcus of the maxillary vestibule and frenum and the mandibular vestibule.
GINGIVA: (Figure 7) First, examine the buccal and labial aspects of the gingiva and alveolar ridges (processes) by starting with the right maxillary posterior gingiva and alveolar ridge and then move around the arch to the left posterior area.
Second, examine the palatal and lingual aspects as had been done on the facial side, from right to left on the palatal (maxilla) and left to right on the lingual (mandible). TONGUE: (Figure 8) With the patient's tongue at rest, and mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration, coating, or variation in size, color, or texture.
FLOOR: (Figure 12) With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings, or other surface abnormalities.
PALATE: (Figures 13 and 14) With the mouth wide open and the patient's head tilted back, gently depress the base of the tongue with a mouth mirror. This external link provides additional information that is consistent with the intended purpose of this site.
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Although advances in cancer therapy have improved survival rates for many tumor types, these treatments may cause side effects, including some in the oral cavity.
The most commonly used scales are the World Health Organization (WHO) scale and the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE).
Symptomatic dental disease should be managed along the continuum of cancer treatment, and a preventive dental program completed. Benzydamine (Pharixia®) is a unique non-ulcerogenic NSAID with local analgesic and anti-inflammatory properties when applied to mucosal surfaces (Fig. Health Canada has approved Benzydamine for acute sore throat, and symptomatic relief or oropharyngeal mucositis caused by radiation therapy. Products are commonly mixed as an equal percentage of the mix for each ingredient, thereby diluting each component of the rinse, and resulting in a lower concentration of each medication in the rinse. Pain management all too often becomes the only focus of management of oral mucositis, with the important topics of oral decontamination, oral moisturization and wound healing not addressed at all.
The morbidity or oral mucositis, includes pain, nutritional compromise, decreased quality of life, alteration in cancer therapy, risk of infection and economic costs.
Epstein, Division of Otolaryngology and Head and Neck Surgery, City of Hope, Duarte, CA; Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center Los Angeles CA, and private practice Vancouver, BC. Saunders, Department of Dental Oncology, North East Cancer Center, Health Sciences North and Northern Ontario School and Medicine, Sudbury, Ontario. Bellm LA, Cunningham G, Durnell L, Eilers J, Epstein JB, Fleming T, FuchsHJ, Haskins MN, Horowitz MM, Martin PJ, McGuire DB, Mullane K, Oster G. Epstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, Popplewell L, Maghami E. McGuire DB, Fulton JS, Park J, Brown CG, Elvira M, Correa P, Eilers J, Elad S, Gibson F, Oberle-Edwards LK, Bowen J, Lalla RV, et al.
Epstein JB, Silverman S Jr, Paggiarino DA, Crocket S, Schubert MM, Senzer NN, Lockhart PB, Gallagher MJ, Peterson De, Leveque FG. A systematic review with meta-analysis of the effect of low-level laser therapy (LLLT) in cancer therapy-induced oral mucositis. Migliorati C, Hewson I, Lalla RV, Antunes H-SEstilo CL, Hodgson B, Fontana Lopes NN Schubert MM, Bowen J, Elad S, et al. Sonis ST, Oster G, Fuchs H, Bellm L, Bradford WZ, Edelsberg J, Hayden V, Eilers J, Epstein JB, LeVeque FG, Miller C, Peterson DE, Schubert MM, Spijkervet FK, Horowitz M. Approximately 36,500 people will be diagnosed with oral cancer each year and about 7,900 will die from the disease. Tissue changes in the mouth that might signal the beginnings of cancer often can be seen and felt easily. Although less common than leukoplakia, erythroplakia and lesions with erythroplakic components have a much greater potential for becoming cancerous. Clinicians should be particularly vigilant in checking those who use tobacco or excessive amounts of alcohol. The method is consistent with those followed by the Centers for Disease Control and Prevention and the National Institutes of Health.
The Extraoral ExaminationFACE: (Figure 1) The extraoral assessment includes inspection of the face, head, and neck.
Note the color, texture and any surface abnormalities of the upper and lower vermilion borders. Observe the color, texture, and any swelling or other abnormalities of the vestibular mucosa and gingiva. Examine first the right then the left buccal mucosa extending from the labial commissure and back to the anterior tonsillar pillar. Drop to the left mandibular posterior gingiva and alveolar ridge and move around the arch to the right posterior area. Also note any change in the pattern of the papillae covering the surface of the tongue and examine the tip of the tongue. Both of which will support, guide, and inspire you toward the best possible health outcomes for you and your family. Healthy reproductive organs are central to a female's womanhood beginning with her first period at puberty, through pregnancy and childbirth, and ending with menopause. Hysterectomies were standard treatments for everything from anxiety (known back then as hysteria) to abnormal bleeding. It not only closes the door to childbirth, it has other potential repercussions, beyond the risks posed by any surgery - bleeding, infection, reactions to anesthesia and injury to nearby organs, nerves and tissue.
But most hysterectomies are performed for non-cancerous conditions - such as fibroids, endometriosis, and uterine prolapse.
Patients receiving radiation therapy to the head and neck will experience symptoms of oral mucositis within two to three weeks of radiation therapy, increasing to the end of care and resolving one to two, or more months following treatment over. Non petroleum-based lip applications, caries prevention, diet instruction (atraumatic diet), hydration and avoiding local irritants (tobacco, alcohol).
The anti-inflammatory and analgesic effects may have a role to play in management of traumatic lesions and other inflammatory conditions. In some cases, some constituents may interfere with the action of one of the other ingredients. Guidelines and effective symptom management tools exist in the selection of effective management strategies. Defining clinically meaningful outcomes in the evaluation of new treatments for oral mucositis.

Systematic review of basic oral care for the management of oral mucositis in cancer patients.
Benzydamine HCl for prophylaxis of radiation-induced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial. Bowen J, Di Palma M, Kouloulias VE, Niscola P, Riesenbeck D, Stokman M, Wim Tissing & Eric Yeoh E, Elad S, Lalla RV, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Systematic review of laser and other light therapy for the management of oral mucositis in cancer patients. Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation. The economic burden of toxicities associated with cancer treatment: review of the literature and analysis of nausea and vomiting, diarrhoea, oral mucositis and fatigue. Any white or red lesion that does not resolve itself in 2 weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis. A 2-3 week course of anti-fungal treatment may turn this type of lesion into a homogenous leukoplakia.
Note any change in pigmentation, color, texture, mobility, and other abnormalities of the mucosa, making sure that the commissures are examined carefully and are not covered by the retractors during the retraction of the cheek.
But there are newer treatments with fewer side effects and long-term consequences that are forcing doctors to consider the role of a woman's uterus.
Yet, it is the second most common surgery performed on reproductive-aged women after delivery by cesarean section. Much will depend on why a hysterectomy is being considered, the type of hysterectomy offered, a woman's goal for treatment and her willingness to tolerate side effects or symptoms. Mucositis affects between 20 percent and 40 percent of patients receiving conventional chemotherapy regimens for solid tumors, depending on the dose and cytotoxicity of the drug. In SCT patients, symptoms arise one to two weeks after chemotherapy, and may persist for weeks. The basis of activity appears to be via the prostaglandin pathway and activity against tumor necrosis factor that is an important effector of mucosal damage. The local anesthetic component may cause oral burning upon application to ulcerated surfaces, may obtund taste sensation and affect the gag reflex.
Patient-reported measurements of oral mucositis in head and neck cancer patients treated with radiotherapy with or without chemotherapy: demonstration of increased frequency, severity, resistance to palliation and impact on quality of life.
Systematic review of anti- inflammatory agents for the management of oral mucositis in cancer patients. More than a half a million of these surgeries are performed in the US every year, which begs the question - how could they all be necessary?
Fibroids can prevent a pregnancy from taking hold, and cause enough bleeding to cause severe blood loss and anemia. It may also depend on where you live, as doctors practicing in certain geographical regions are more hysterectomy-centric.
In patients receiving high dose chemotherapy before a hematopoietic SCT, oral mucositis may be seen in up to 80 percent. The impact is significant due to associated pain, risk of infection, duration of the condition and the effect on oral and pharyngeal function. Furthermore, even when effective, the duration of relief is typically reported as five to 20 minutes. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes.
While most are less then a few centimeters in diameter, they can also grow to a size of a grapefruit that can elbow organs in the abdomen to cause urinary frequency and changes in bowel habits. Almost all patients receiving therapeutic radiation for head and neck cancer develop oral mucositis.4,5 Clinical examples of erythematous and ulcerative mucositis commonly seen in head and neck cancer therapy and in bone marrow transplant are shown in Figures 1,2, and 3. Solid tumor patients with epithelial cancers (such as breast, colon, lung) may also experience mucositis due to damage to mucosal surfaces by chemotherapy active against epithelial cells of the cancer with increased risk in later cycles of chemotherapy.
The study had few patients also receiving concomitant chemotherapy and therefore, there is not sufficient data to recommend for use in these settings.
As a result, these may be used before meals, but paradoxically may reduce taste sensation and mouth feel, resulting in less oral intake of food.
A recommended order of examination includes the preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical regions.
In addition, new therapies (such as targeted chemotherapy) have other unique mechanisms of toxicity that may affect skin and mucosal surfaces. In addition to prevention of mucositis, the analgesic effects iseffects are an important additional consideration in painful mucositis.
Common to all therapies, patients experience oropharyngeal pain and dysfunction affecting all aspects of oral function limiting oral care, use of oral prostheses, and in turn, impacting nutrition and speech. The impact of oral mucositis may lead to disruption or discontinuation of cancer therapy due to this toxicity which ultimately impacts quality of life, cost of care, and cure rates.
Also, oral toxicities are linked in symptom complexes that may include fatigue, mood and cognitive change.
The management of oral mucositis is aimed to prevent or reduce the severity of the toxicity and to manage the associated symptoms, which will in turn allow continuity of cancer therapy without interruption.4,5 Management is limited by available products leading to ongoing research.

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