Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants.

Oral Care for the Oncology Patient A Peer-Reviewed Publication Written by Kris Potts, RDH, BS, FAADH

Abstract Educational Objectives Author Profile Oral side effects are prevalent in individuals experiencing During this course the participant will: Kris Potts, RDH, BS, FAADH , a hygienist of 38 years, is a oncology treatment. Compliance with meticulous home 1. Discuss the importance of treating and member of the American Dental Hygienists’ Association and a care is essential and should be individualized based on risk preventing oral complications in the fellow with the American Academy of Dental Hygiene. She is a factors and the current state of health. Oncology therapies oncology patient. past president of the Texas Dental Hygienists’ Association and result in a host of oral side effects including tooth hyper- 2. Recognize the signs and symptoms a member of the American Academy for Oral Systemic Health. sensitivity, impaired taste, xerostomia, destruction of tooth of osteonecrosis associated with Her passion for lifelong learning has directed her to additional enamel due to vomiting, and mucositis along with discom- therapy. certifications in caries management and oncology care. She fort and pain. The goals in treating mucositis are relieving 3. List common oral side effects of has been interviewed frequently for her expertise. She is pain and preventing secondary infections through home oncology treatment. owner/CEO of Oral Health Promotion Strategies. oral hygiene and mouth rinses. Chemotherapy can 4. Describe currently available treatments to osteonecrosis of the , especially after a tooth for oral mucositis. Author Disclosure extraction or oral surgery. It is important for dental 5. Devise individualized guidelines for the Kris Potts, RDH, BS, FAADH has no commercial ties with the professionals to be familiar with these side effects and patient receiving oncology treatment to sponsors or the providers of the unrestricted educational grant discern how to counsel their patients appropriately. maintain good oral health. for this course. INSTANT EXAM CODE 15224 Go Green, Go Online to take your course

Publication date: Aug. 2017 Supplement to PennWell Publications Expiration date: July 2020

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15224 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives that may reduce oral complications during and after therapy. Table 1: Common Drugs and Their Side Effects 1. Discuss the importance of treating and preventing oral Optimally, the examination should be performed at least one COMMONLY USED USED TO TREAT ORAL AND GI SIDE EFFECTS OTHER SIGNIFICANT EFFECTS complications in the oncology patient. month before the start of treatment to permit adequate healing chemotherapeutic 2. Recognize the signs and symptoms of osteonecrosis associ- from any required invasive oral procedures. An individualized agents ated with bisphosphonate therapy. program of oral hygiene should be initiated, with emphasis Bevacizumab Breast, colorectal, lung, kidney, ovarian, Loss of appetite, heartburn, altered taste, dry Leukopenia 3. List common oral side effects of oncology treatment. on maximizing patient compliance with feasible oral health cervical, glioblastoma mouth, mucositis, coughing/gagging 4. Describe currently available treatments for oral mucositis. recommendations. In many instances, if treatment has already Lenalidomide Multiple myeloma Diarrhea, loss of appetite, altered taste, burn- Swollen glands in neck 5. Devise individualized guidelines for the patient receiving begun, referral to a dental home is too late. ing tongue oncology treatment to maintain good oral health. While no cure for cancer is currently known, incorrect state- Imatinib Myeloid leukemia, GI tract tumors Diarrhea, nausea, vomiting, altered taste, Leukopenia ment there are a number of medications that eliminate cancer mucositis, loss of appetite, dry mouth Abstract cells and can result in a cancer-free state. Unfortunately, these Pemetrexed Non-small-cell lung Nausea, vomiting, loss of appetite, diarrhea, Leukopenia, sleep disturbances Oral side effects are prevalent in individuals experiencing treatments are not without complications (Table 1).4 Dental mucositis oncology treatment. Compliance with meticulous home care is providers are the most recognized source in providing the Cetuximab Colorectal, head and neck Mucositis, dry mouth, sore throat, vomit- Confusion, and joint pain essential and should be individualized based on risk factors and patient and caregivers education about the oral implications ing, altered taste, loss of appetite, diarrhea, the current state of health. Oncology therapies result in a host of these drugs and providing appropriate tools for treatment. heartburn of oral side effects including tooth hypersensitivity, impaired Often, it may be possible for the dental professional to diminish Capecitabine Breast, colorectal Mucositis, dry mouth, vomiting, altered Leukopenia, sleep disturbances taste, loss of appetite, diarrhea, nausea taste, xerostomia, destruction of due to vomiting, these side effects through treatment recommendations in col- Erlotinib Non-small-cell lung, pancreatic Mucositis, vomiting, loss of appetite, diar- Numbness, burning, tingling of hands and feet, and mucositis along with discomfort and pain. The goals in laboration with the oncology team. rhea, nausea, heartburn anxiety, depression treating mucositis are relieving pain and preventing second- Everolimus Breast, pancreatic Dry mouth, altered taste, diarrhea Aggression and other behavioral changes, joint ary infections through home oral hygiene and mouth rinses. Oral Side Effects pain, sleep disturbances Chemotherapy can lead to osteonecrosis of the jaw, especially Chemotherapeutic/cytotoxic medications are the most com- Sunitinib Renal, GI tract tumors Mucositis, dry mouth, sore throat, vomit- Slow speech, tremors, depression, confusion, after a tooth extraction or oral surgery. It is important for dental monly used treatment of cancer therapies (Table 1). There are ing, altered taste, loss of appetite, diarrhea, decreased alertness professionals to be familiar with these side effects and discern many types of chemotherapeutic drugs, so it is always prudent heartburn, nausea, burning tongue, bleeding how to counsel their patients appropriately. to look up the specific medication that the patient is taking in , loosening of teeth, difficulty swal- order to be familiar with any unique side effects. Oral side ef- lowing Introduction fects occur often, in up to 40% of oncology patients, and include Sorafenib Renal, liver Mucositis, dry mouth, vomiting, loss of ap- Jaundice, seizures, confusion, sudden severe Cancer is an ever present fact in society today and the second generalized hypersensitivity due to discomfort and pain, ulcer- petite, diarrhea, nausea headache, shortness of breath leading cause of death in the United States, surpassed only by ated gingival tissues, and impaired taste.3 Additionally, chemo- Goserelin Breast, prostate Dry mouth, vomiting, nausea, fruity breath Difficulty breathing or swallowing, sleep distur- heart disease.1 According to the American Cancer Society, as therapy can cause vomiting leading to tooth enamel erosion, bances, uncontrolled emotions of June 1, 2016, it was estimated that there were 15.5 million which in turn to tooth sensitivity. Patients should be ad- Methotrexate Breast, head and neck, lung, , Swollen gums, vomiting Sudden fever, severe headache, stiff neck, seizures, people in the United States who were living with some type of vised to not brush immediately after vomiting due to removal of osteosarcoma, leukemia (ALL) confusion, difficulty breathing or swallowing invasive cancer.2 With so many people living with cancer, the outer layers of enamel, which have been softened by the acidic Cyclophosphamide Leukemia (ALL, AML, CLL, CML, NHL), Mucositis, vomiting, loss of appetite, diar- Leukopenia, difficulty breathing or swallowing, breast, ovarian, retinoblastoma, lym- rhea, nausea, slow healing jaundice dental community should be knowledgeable of the many drugs discharge. An alternative is the use of buffering agents, includ- phoma, myeloma, neuroblastoma used to treat cancer and the side effects affecting oral health. ing rinsing the mouth with lukewarm water mixed with either Doxorubicin Leukemia (AML), breast, gastric, Mucositis, vomiting, loss of appetite, diar- Difficulty breathing or swallowing, seizures, cardio Of the 67% who were diagnosed more than five years ago, 61% baking soda or salt, and brushing afterwards. Lastly, cytotoxic , neuroblastoma, ovarian, rhea, nausea toxicity are age 65 or older, with increased . In 2017, 1.6 medications can cause xerostomia, which leads to caries, and it non-small-cell lung, thyroid, soft tissue million new cases are expected, and by 2026, the number of is important to be mindful of the increasing use of cannabinoids and bone sarcomas survivors is expected to reach 20.3 million with 89% over the for neuropathic pain.36 Anastrozole Breast Dry mouth, vomiting, loss of appetite, diar- Leukopenia, joint pain, mood changes, depression, age of 50.3 The oncology team should be able to educate patients on rhea, heartburn, nausea sleep disturbances, interactions with other meds Unfortunately, many oncology patients have suboptimal salivary substitutes, stimulants, and remineralization products Letrozole Breast Dry mouth, vomiting, loss of appetite, diar- May worsen , leukopenia, joint pain, oral health prior to the diagnosis and, therefore, are at increased as well as recommending the patient have a dental consultation rhea, heartburn, nausea fatigue, sleep disturbances risk for potentially life-threatening odontogenic infections for evaluation and instruction on preventive measures.13,14 Trastuzumab HER2+ breast, Diarrhea, heartburn, loss of appetite Depression, sleep disturbances, leukopenia during cytotoxic therapy. The knowledge and expertise of dental professionals regarding the prevention and treatment Mucositis and Xerostomia of complications in these patients are vital. Integration of oral One of the most common and painful oral side effects of oncol- It may become so severe that the patient can no longer tolerate palliative. They now include general oral care protocols, pain care with the oncology team requires effective communication ogy treatment is mucositis, the ulceration of the mucosal lining cytotoxic or radiation therapy. In these cases, treatment will be control, oral rinses, interventions to reduce the mucositis, and between the two, ideally beginning at diagnosis and prior to anywhere along the digestive tract, including the oral cavity. interrupted, potentially limiting its effectiveness. Patients with the palliation of dry mouth.23,44 Since the primary symptom of beginning treatment. This condition can affect up to 40% of individuals undergoing inflamed mucosa and reduced immunity due to their therapy mucositis is pain, it can adversely affect nutritional intake, oral The pretreatment dental assessment is critical, and in some treatment.45 Oral and gastrointestinal mucositis may occur in regimen are at high risk of developing opportunistic infections health care, and quality of life. Although they do not provide cases, the only opportunity to identify preexisting dental con- up to 100% of patients undergoing high-dose chemotherapy that may be potentially fatal. Hospital stays may need to be long-term relief, saline mouth rinses, ice chips, and topical ditions that may lead to significant and difficult-to-manage with transplantation (HSCT).17 extended for patients with severe mucositis and can adversely alcohol-free mouth rinses with an anesthetic can provide short- complications that occur during cancer treatment. This assess- Patients feel it is the most debilitating side effect of HSCT.24 affect the patient’s gums and teeth.24 term relief.18,19,20 Quite often, 2% viscous lidocaine is used in ment allows the dentist to determine the status of the oral cavity Oral mucositis symptoms vary greatly and range from pain and Many options are available to treat this condition. Until re- a compounded rinse called Magic Mouthwash. There are before treatment begins and to initiate necessary interventions discomfort to the complete inability to tolerate food or drink. cently, the primary methods of treating mucositis were strictly several recipes for this rinse that combine equal parts of lido-

2 www.DentalAcademyOfCE.com www.DentalAcademyOfCE.com 3 caine, diphenhydramine, and a soothing agent such as Maalox Patients can also rinse with a solution of baking soda and salt in Patients should check with an oral surgeon and oncology This increase in aciduric results in an increased risk or Kaopectate.16 Oral morphine gargles were found to be more a cup of warm water several times a day to alleviate symptoms. team to see if it is possible to discontinue IV for caries.26 This imbalance can result in secondary infections, effective than this compound in reducing pain, intensity, and Rinsing with this solution will also clean and lubricate the oral prior to oral surgery. Newer drugs are available that potentially including but not limited to candidiasis, angular , her- duration.18,19 Another study found patients undergoing radia- tissue, elevate oral pH, and provide a protective barrier for the allow a “drug holiday” from bisphosphonate therapy allowing petic infections, dentialveolar abscesses, and aspiration pneu- tion therapy had better outcomes with supersaturated calcium . The chewing of tart, sugarless gum (preferably for emergency treatment, then resuming the IV bisphospho- monia.32 Nutritional considerations such as avoidance of sweets phosphate rinses than with Magic Mouthwash.46 Patients re- 100% xylitol sweetened 47,48,49) to stimulate salivary flow and nates once the surgical site is completely healed. This might and high carbohydrate foods should be communicated. Certain port that Magic Mouthwash can effectively numb the mouth saliva substitutes can be utilized as necessary.24 give the patient the best chance to avoid developing ONJ. Con- medications will cause cravings for these foods, and nutritional and cause taste alterations. Formulations containing alcohol, as clusive evidence that discontinuation of bisphosphonate ther- supplements that are routinely given contain an elevated su- most compounded rinses do, can cause further irritation and Bisphosphonates and ONJ apy has an impact on healing ONJ is controversial.11 Another crose level detrimental to tooth structure. These foods can also pain.19 Other topical agents have been studied that include Bisphosphonates are frequently used in patients undergoing treatment being investigated is hyperbaric oxygen therapy. change the bacterial makeup of plaque and increase gingival sucralfate and benzydamine topical rinse.17 chemotherapy to increase and reduce the risk for Although it has not been clearly defined, it has demonstrated .55 Caries prevention and effective oral hygiene Updated guidelines for treating mucositis do not recommend developing fractures. Their benefit has been well established in accelerated healing by stimulating osteoclastic activity.35 As an- practices should be shared with the patient. Those who expe- their use because effectiveness has not been established.51,52 the treatment of hypercalcemia from malignancy and prevent- other precautionary measure, many oral surgeons recommend rience increased biofilm formation should be scheduled more Chlorhexidine (CHX) alone as a treatment for mucositis is ing skeletal complications from bone metastasis.5,6,7 The wide- a course of antibiotics prior to surgery to fight off any possible frequently.15 In patients with implants, particular care should ineffective and not recommended17 (Table 2). The current lit- spread use of bisphosphonates began in 1970 and reports of the infections.12 These antibiotics are normally continued postsur- be taken to assess for peri-implant mucositis. erature on nonopioid pain control includes the use of additional association with osteonecrosis first appeared in 2003.8 When gery for 10 days. Research has shown that penicillin generally treatments including nonsteroidal anti-inflammatory drugs given intravenously (IV), their use can lead to osteonecrosis is most effective at fighting off infections in these patients. Spe- Oral Care Guidelines for the Patient and gabapentin.17 Cryotherapy or sucking on ice chips appear of the jaw (ONJ), an area of exposed bone in either the max- cific antibiotic therapy should be adapted to an antibiogram to There are numerous oral care guidelines that dental provid- to be equally effective in treating pain.17 illa or persisting longer than eight weeks in patients ensure efficacy.12 Always check with the oncology team before ers can introduce to oncology patients, emphasizing the need For those undergoing HSCT, current guidelines recom- without prior craniofacial radiation to the jaw. Older drugs are performing any dental treatment or stopping any medications. for the patient to maintain meticulous oral hygiene (Table mend patient-controlled analgesia (PCA) with morphine.17 more likely to cause this even when used for a short duration.9 Current findings further reinforce the recommendation for a 3). Patients should be encouraged to gently brush their teeth There is increasing concern regarding the current level of opi- Osteonecrosis can remain asymptomatic for weeks or months pre-bisphosphonate dental evaluation as a strategy for preven- two times a day. When brushing, the patient should use an oid use in general and caution should be used. IV palifermin and is usually identified by its unique clinical presentation of tion of ONJ.11 ultrasoft, postsurgical type toothbrush and rinse it under warm has been shown to accelerate growth of epithelial cells, reduc- exposed bone in the oral cavity, occurring in 1-10% of oncology water before use to soften the bristles and avoid damaging any ing the severity and duration of mucositis, but due to its high patients.10 Systemic risk factors that can contribute to ONJ are Guidelines for the Dental Professional tissues.24,26 The toothbrush should be changed often, typically cost, it is not used as frequently as other options.21 Low-level the use of or antiangiogenic agents.9 Patient education regarding potential oral side effects as well as every three months or after any type of infection. laser therapy (LLLT) as a treatment for mucositis is another The lesions become symptomatic when the site is second- necessary prophylactic information are integral parts of the oral Use of a mild flavored toothpaste is recommended, as strong area of current research activity. arily infected or trauma occurs to adjacent healthy tissue due and systemic care for oncology patients. As dental providers, flavors can be irritating to many oncology patients. Toothpastes Table 2: Common Mucositis Treatment Comparisons to irregular surfaces of exposed bone. However, lesions can there are things to be mindful of in treating oncology patients. designed for whitening can be drying to the oral mucosa and occur spontaneously in about 21% of those affected.9 The signs Treatment regimens are incredibly tiring for the patient, and a number of individuals are sensitive to common ingredients Chlorhexidine Fewer bacterial and fungal infections reported, but no and symptoms of osteonecrosis include localized pain, soft tis- the best time to administer dental care is just prior to their next such as sodium lauryl sulfate (SLS). All these components can more effective on mucositis than sterile water. Tooth sue swelling and inflammation, loosening of previously stable scheduled oncology treatment. When dental care is adminis- increase the incidence of mucosal irritation and ulceration.35 discoloration, bitter taste, unpleasant to use.38,39 teeth, exudate, and visibly exposed bone. Commonly, these tered at that time, patient fatigue most likely won’t interfere The patient can swab their teeth and gums with a gentle Nystatin No effect on mucositis40 symptoms occur at sites of previous tooth extractions or other with the dental treatment planned, and the white blood cells cloth if they cannot tolerate even a soft toothbrush.26 The 41 Magic Mouthwash No difference in severity, time of onset, or duration invasive procedures. It should be noted that some patients may will be at their highest levels. Before any dental care is carried use of 100% xylitol gel, spray, gums, or mints can reduce the Iodine Significantly less severe mucositis, shorter duration, present with atypical sensory neuropathy reporting as “numb- out, both the patient and the dental provider should consult the bacterial load in the oral cavity if brushing is not possible. 42 further study needed ness,” or the feeling of a “heavy jaw.”9 oncology team for blood count information.3 Platelet counts These are found over the counter and can be administered by NaCl 0.9% Less expensive, readily available, just as effective43 Any patient who has previously received or is currently need to be greater than 75,000 mm³ so that the blood can clot a caregiver.50 The dental provider should also encourage the receiving IV bisphosphonates should have their oral cavity ex- properly, and the neutrophil count should be greater than 1,000 patient to clean interdentally at least once daily. Patients skilled amined thoroughly for ONJ at every visit. They should be en- mm³. Treatment should be given whenever the patient has the at flossing without traumatizing gingival tissues may continue Unfortunately, there is currently no definitive cure for couraged to practice meticulous oral hygiene and keep frequent, highest possible level of formed blood elements outside of what flossing throughout immunosuppressive therapy adminis- mucositis, so symptomatic and preventive treatments are the scheduled preventive visits in order to help reduce risk for is referred to as “nadir” or lowest point.28,29 When the white tration. Flossing allows for interproximal removal of dental options available to oncology patients. Preventive treatments developing ONJ. The frequency of scheduled preventive visits blood cell count is in nadir, there is an increased risk for infec- bacterial plaque, promoting overall gingival health. 24,25 Those include maintaining a very clean oral cavity through regular, in this instance may be every three to four months depending tion, so dental treatment should be provided when the blood lacking flossing skills can use extra-soft interdental brushes or a gentle brushing, interdental cleaning, and avoiding strong on the individual’s risk factors and overall oral health. Remov- counts are as high as possible. Antibiotic prophylaxis may be water flosser on the lowest setting, enabling the removal of food stimuli, such as spices, foods that are too hot, and smoking.24 able dentures should also be examined for cleanliness and the indicated.27 debris and biofilm in deeper pockets. Patients should also keep their well moisturized.22 The ab- potential to cause tissue injury and adjusted accordingly.9 During an appointment, the dental provider can have the Topical fluoride is often used to prevent caries that are sence of saliva (hyposalivation) or the reduced flow associated Certain types of bisphosphonate therapy are more likely patient prerinse with chlorhexidine to help avoid infections; caused by reduced salivary flow. For certain individuals, the with oncology therapy can exacerbate existing mucositis, put- to cause ONJ than others, due to the cumulative effect of the however, long-term or daily use of CHX is not recommended.29 use of fluoride gels in custom trays can aggravate sensitivity, ting the patient at risk for infection and making chewing diffi- drugs over the length of treatment. It is more likely to occur in When performing the intraoral exam, the dental provider and frequent application of a fluoride varnish in office may cult. Patients are frequently advised to sip water as necessary to patients with breast cancer related to hormone receptor status. should check for any lesions that could potentially be cultured be preferred. The provider should advise the patient to avoid alleviate dry mouth. The use of salivary stimulants is preferable This is believed to be due to an estrogen positive status be- and tested for infection. Since oncology therapies inhibit sali- mouthwash that contains alcohol.31 This can cause a strong for those patients with reduced flow as saliva contains necessary ing equivalent to a longer survival rate and longer duration of vary flow, creating an imbalance in the oral microbiota due to burning sensation. Baking soda rinses can be palliative and mucins needed for optimal oral health where water does not.37 therapy.11 immunosuppression, some patients will have more biofilm. soothing to the oral mucosa.31 Ill-fitting dentures greatly in-

4 www.DentalAcademyOfCE.com www.DentalAcademyOfCE.com 5 10. Ruggiero S, Gralow J, Marx R, et al. Practical guidelines for the https://www.cancer.gov/about-cancer/treatment/side-effects/ crease the risk of developing osteonecrosis of the jaw.31 Any 1. Cancer Treatment & Survivorship Facts & Figures 2016-2017. www. prevention, diagnosis, and treatment of osteonecrosis of the jaw in mouth-throat/oral-complications-hp-pdq prosthesis should be removed and cleaned every night, and the cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed May 21, 2017. patients with cancer. American Society of Clinical Oncology. 2006. 26. Anderson R. Oral Care for Cancer Patients. 2011. Available at: patient should avoid wearing them while sleeping.34 Encourage 2. www.cancer.org/content/dam/cancer-org/research/cancer- 2: 7-14. http://jop.ascopubs.org/content/2/1/7.full. Accessed May www.slideshare.net/lreneeanderson87/oral-care-for-cancer- patients to report any redness, tenderness, or sores on their lips facts-and-statistics/cancer-treatment-and-survivorship-facts- 21, 2017. patients-power-point. Accessed June 3, 2017. or mouth and to seek prompt treatment for oral mucositis or and-figures/cancer-treatment-and-survivorship-facts-and- 11. King AE, Umland EM. Osteonecrosis of the jaw in patients 27. Brennan MT, Woo S-B, Lockhart PB. Dental treatment planning infection. Educate patients regarding possible later effects of figures-2016-2017.pdf. Accessed May 21, 2017. receiving intravenous or oral bisphosphonates. Pharmacotherapy: and management in the patient who has cancer. Dental Clinics of therapy.33 3. 2016 National Comprehensive Cancer Network. Silver tsunami of The Journal of Human Pharmacology and Drug Therapy. 2008. 28: North America. 52.1. 2008. 19-37. Conclusion cancer survivors to slam US. Medscape Jul 25 2016. 667–677. doi:10.1592/phco.28.5.667. 28. www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ 4. www.cancer.gov/about-cancer/treatment/drugs 2016. Accessed 12. Hoefert S. Medication-related osteonecrosis of the . OralComplicationsCancerOral.htm. When individuals discover that they will require oncology Microbiology and Antibiotics in the Context of Medication-Related 29. www.bccancer.bc.ca/health professionals/professional-resources/ Table 3: Oral Care Guidelines for Patients Osteonecrosis of the Jaw. September 2014. pp 121-129 24. cancer-management-guidelines/head-neck/oral-dental-care 13. Brennan MT, Woo S-B, Lockhart PB. Dental treatment planning Published: May 2003. Accessed May 21, 2017. Brushing Mouth rinses Interdental cleaning Other and management in the patient who has cancer. Dental Clinics of 30. www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ Use an ultrasoft, postsurgical Rinsing with a solution of bak- Interdental cleaning at least Do not wear ill-fitting dentures. These can increase the North America. 2008. 52.1: 19-37. OralComplicationsCancerOral.htm Accessed May 21, 2017. toothbrush, and rinse it with warm ing soda and saline can help once daily risk of a disease process called osteonecrosis of the jaw. 14. www.cancer.gov/about-cancer/treatment/side-effects/mouth- 31. www.oncolink.org/healthcare-professionals/nci/pqid- water before brushing to avoid tender tissues to heal. throat/oral-complications-hp-pdq Accessed May 21, 2017. CDR0000062871. Post Date: Dec 16, 2016. damaging any tissues. 15. Oral complications of chemotherapy and head/neck radiation. 32. Silva AP, Caruso P, Jaguar GC, et al. Support Care Cancer. 2014. 22: Replace your toothbrush either every 3 Avoid using mouthwash that If the gums are bleeding Be aware of the side effects of any medications you http://www.cancer.gov/cancertopics/pdq/supportivecare/ 2645. doi:10.1007/s00520-014-2233-0. months or after any infection. contains alcohol. It can burn heavily, do not floss those are taking. Knowing what to expect can help you to oralcomplications/HealthProfessional. www.cdeworld.com/ 33. Elad S, Raber-Durlacher JE, Brennan MT, et al. Support Care the tissues. areas. Wait for the tissues maintain healthy teeth and gums. courses/20015-dental-oncology-the-hygienist-s-role-in-a-cancer- Cancer. 2015. 23: 223. doi:10.1007/s00520-014-2378-x. to heal. care-team#sthash.VDs7zhN8.dpuf Accessed May 21, 2017. 34. Walsh L. Clinical assessment and management of the oral 16. Elting LS, Cooksley C, Chambers M, et al. The burdens of cancer environment in the oncology patient. Australian Dental Journal. Use mild toothpaste without sodium lauryl Many chemotherapeutic Please consult your dental professionals with any therapy. Cancer. 2003. 98: 1531–1539. doi:10.1002/cncr.11671. 2010. 55: 66–77. doi:10.1111/j.1834-7819.2010.01201. x. sulfate (SLS). Avoid using strong flavors or agents cause dry mouth, which specific questions and concerns. 17. Rubenstein EB, Peterson DE, Schubert M, et al. Clinical practice 35. Andrews N, Griffiths C. Dental complications of head and neck whitening agents. may lead to cavities. Topical guidelines for the prevention and treatment of cancer therapy- radiotherapy: part 2. Australian Dental Journal. 2001. 46: 174–182. fluoride, remineralization, and induced oral and gastrointestinal mucositis. Cancer. 2004. 100: doi:10.1111/j.1834-7819. 2001.tb00278. x. pH buffers can help to prevent 2026–2046. doi:10.1002/cncr.20163. 36. Lynch ME, et al. A double-blind, placebo-controlled, crossover this. 18. Haritha CM, Shankar V. Oral morphine gargles: A cost effective pilot trial with extension using an oral mucosal cannabinoid extract Use an antibacterial mouth rinse to help pre- approach for pain relief in patients with chemoradiation induced for treatment of chemotherapy-induced neuropathic pain. Journal vent infections. Ask your dental professional acute oral mucositis in head and neck cancers. Journal of Clinical of Pain and Symptom Management, Volume 47, Issue 1, 166–173. for more information. Many alternatives and Oncology, 2009 ASCO Annual Meeting Proceedings (Post-Meeting 37. Frenkel ES, Ribbeck K. Salivary mucins protect surfaces from new products are now available. Edition). 2009. 27 (15S; May 20 Suppl.), e20504. www.meeting. colonization by cariogenic bacteria. Appl. Environ. Microbiol. ascopubs.org/cgi/content/abstract/27/15S/e20504. Published ahead of print 24 October 2014. doi:10.1128/ 19. Cerchietti LC, Navigante AH, Bonomi MR, Zaderajko AEM.02573-14. MA, Menéndez PR, Pogany CE, Roth B. Effect of topical 38. Dodd MJ, Larson PJ, Dibble SL, et al. Randomized clinical trial treatment, they are less likely to consider the side effects in their May 21, 2017. morphine for mucositis-associated pain following concomitant of chlorhexidine versus placebo for prevention or oral mucositis mouths, with their first thoughts being of more commonplace 5. Rosen LS, Gordon D, Kaminski M, et al. Long-term efficacy and chemoradiotherapy for head and neck carcinoma. Cancer. 2002. 95, in patients receiving chemotherapy. Oncology Nursing Forum 23, effects such as hair loss or vomiting. The oral ramifications can safety of compared with pamidronate disodium in 2230-2236. doi:10.1002/cncr.10938. 1996. 921-927. affect the quality of life as much or more than the familiar side the treatment of skeletal complications in patients with advanced 20. Dodd MJ, Dibble SL, Miaskowski C, et al. Randomized clinical 39. Pitten F, Kiefer T, Buth C, Doelken GH, Kramer A. Do cancer effects. The dental community has a responsibility to supply multiple myeloma or breast carcinoma: A randomized, double- trial of the effectiveness of 3 commonly used mouthwashes to treat patients with chemotherapy-induced leukopenia benefit from an these patients with the appropriate knowledge and tools to blind, multicenter, comparative trial. Cancer. 2003. 98:1735-1744. chemotherapy-induced mucositis. Oral Surgery, Oral Medicine, antiseptic chlorhexidine based oral rinse? A double-blind, block 6. Saad F, Gleason DM, Murray R, et al. Long-term efficacy of Oral , Oral Radiology and Endodontics. 2000. 90, 39–47. randomized, controlled study. Journal of Hospital Infection. 2003. conquer these adverse effects, resulting in the best possible doi:10.1067/moe.2000.105713. 53, 283-291. care for patients undergoing oncology treatment. A multidis- zoledronic acid for the prevention of skeletal complications in patients with metastatic hormone refractory prostate cancer. J Natl 21. Rosen LS, et al. Palifermin reduces the incidence of oral mucositis 40. Epstien JB, Vickars L, Spinelli J, Reece D. Efficacy of chlorhexidine ciplinary approach is required, but to date no gold-standard Cancer Inst. 2004. 96:879-882. in patients with metastatic colorectal cancer treated with and nystatin rinses in prevention of oral complications in leukemia 53 protocol exists that is prominently better than others. The 7. Rosen LS, Gordon D, Tchekmedyian NS, et al. Long-term efficacy fluorouracil-based chemotherapy. Journal of Clinical Oncology. and transplantation. Oral Surgery, Oral Medicine, dental provider can develop a personalized home-care routine and safety of zoledronic acid in the treatment of skeletal metastases 2006. 24.33 5194-5200. Oral Pathology. 1992. 73, 682-689. for the patient and their specific condition.30 The knowledge in patients with nonsmall cell lung carcinoma and other solid 22. Epstein JB, Saunders DP. Managing Oral Mucositis Cancer 41. Dodd MJ, Dibble SL, Miaskowski C, et al. Randomized clinical and expertise of the dental community regarding prevention tumors: A randomized, phase III, double-blind, placebo-controlled Therapy. 2015. trial of the effectiveness of 3 commonly used mouthwashes to treat 23. Lalla RV, Bowen J, Barasch A, Elting L, et al, and the Mucositis chemotherapy-induced mucositis. Oral Surgery Oral Medicine Oral and treatment of oral complications makes them a core part of trial. Cancer. 2004. 100:2613-2621. Guidelines Leadership Group of the Multinational Association Pathology Oral Radiology and Endodontics. 2000. 90, 39-47. an oncology team. These capable clinicians may be identified 8. Hoff AO, Toth BB, Altundag K, et al. Frequency and risk factors associated with osteonecrosis of the jaw in cancer patients treated of Supportive Care in Cancer and International Society of Oral 42. Adamietz LA, Rahn R, Bottcher HD, Schafer V, Reimer K, Fleischer at cancer centers, hospital dental programs, and in the commu- with intravenous bisphosphonates. J Bone Miner Res. 2008. 23: Oncology (MASCC/ISOO). MASCC/ISOO clinical practice W. Prophylaxis with povidone-iodine against induction of oral nity. With a proactive approach, the dental team can take care 826–836. doi:10.1359/jbmr.080205. guidelines for the management of mucositis secondary to cancer mucositis by radiochemotherapy. Supportive Care in Cancer. 1998. of any existing dental problems presented by an individual and 9. Saad F, Brown JE, Van Poznak C, et al. Incidence, risk factors, and therapy. Cancer. 2014. 120: 1453–1461. doi:10.1002/cncr.28592. 6, 373-377. provide advice as treatment progresses, reducing the chances of outcomes of osteonecrosis of the jaw: integrated analysis from three 24. www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ 43. Potting CM, Uitterhoeve R, Op Reimer WS, Van Achterberg serious complications. blinded active-controlled phase III trials in cancer patients with ChemotherapyYourMouth.htm NIH Publication No. 13-4361. T. The effectiveness of commonly used mouthwashes for the bone metastases. Ann Oncol. 2012. 23 (5): 1341-1347. doi: 10.1093/ August 2013. Accessed May 21, 2017. prevention of chemotherapy-induced oral mucositis: a systematic References annonc/mdr435. 25. Oral Complications of Chemotherapy and Head/Neck Radiation review. European Journal of Cancer Care. 2006. 15:431–439.

6 www.DentalAcademyOfCE.com www.DentalAcademyOfCE.com 7 Online Completion INSTANT EXAM CODE 15224 Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete doi:10.1111/j.1365-2354.2006. 00684.x. the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. Notes An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed 44. Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in anytime in the future by returning to the site, sign in and return to your Archives Page. patients with cancer. Dent Clin North Am. 2008. 52:61–viii. 45. Harris DJ. Cancer treatment-induced mucositis pain: strategies for assessment and management. Therapeutics and Clinical Risk Questions Management. 2006. 2:251–258. 46. Miyamoto C, Wobb J, Micaily B, Li S, Achary M. A retrospective 1. According to the American Cancer Soci- A. hypersensitivity 22. OHI and education of oncology ety, the number of individuals estimated B. altered taste patients should include: match controlled study of the supersaturated calcium phosphate to be living through invasive cancer is: C. mouth sores A. meticulous oral hygiene oral rinse (Scpor) vs supportive care for radiation induced oral A. 15.5 million D. all of the above B. frequent tooth brushing mucositis. Journal of Cancer Therapy. 2012. 3:630-636. doi: B. 17.7 million C. 6.6 million 12. When vomiting occurs, patients should: C. interdental cleaning 10.4236/jct.2012.35081. A. rinse with warm water and baking soda 47. Marsh PD. Dental plaque as a biofilm: the significance of pH D. 25 million B. brush immediately D. all of the above in health and caries. Compendium of Continuing Education in 2. Pretreatment dental care for an oncology C. use antiseptic mouth rinse with alcohol 23. Patients with existing prostheses should patient can help to: Dentistry. March 2009. Vol. 30, no. 2. D. eat more be evaluated for: A. lessen chances of oral complications A. fit 48. Burt BA. The use of sorbitol- and xylitol-sweetened chewing gum B. integrate care with the oncology team 13. ONJ occurs most often in patients with: in caries control. Journal of the American Dental Association. 2006. C. customize home-care recommendations A. breast cancer B. shade B. multiple myeloma Vol. 137, no. 2, 190–196. D. all of the above C. cleanliness C. liver metastases D. both A and C 49. Masalin K. Caries-risk reducing effects of xylitol-containing 3. Risk factors for medically related osteone- D. both A and B chewing gum and tablets in confectionery workers in Finland. crosis of the jaw (ONJ) do not include: 24. This infection is not usually related to A. corticosteroids 14. After a cancer diagnosis, a dental oncology patients. Community Dental Health. March 1992. Vol. 9, no. 1, 3–10. consultation should occur: B. ill-fitting dentures A. candidiasis 50. Badet C, Furiga A, Thébaud N. Effect of xylitol on an in vitro C. alcohol use A. one month prior to start of oncology treatment B. midway through treatment B. herpetic lesions model of oral biofilm. Oral Health & Preventive Dentistry. 2008. D. dental surgical procedures Vol. 6, no. 4, 337–341. C. after treatment has been completed C. dentoalveolar abscesses 4. All of these conditions are common in D. only if there is a problem D. measles 51. Kuk JS, Parpia S, Sagar SM, et al. A randomized phase III oncology patients except: trial of magic mouthwash and sucralfate versus benzydamine A. xerostomia 15. A major oral side effect of IV bisphos- 25. Dental examinations prior to or early phonate use is: B. excess biofilm on in oncology treatment allows the dental hydrochloride for prophylaxis of radiation-induced oral mucositis A. gingival hyperplasia C. ulcers professional to do all of the following except: in . Journal of Clinical Oncology. 2011. B. migratory ASCO Annual Meeting Abstracts Part 1, 29(15S; May 20 Suppl.), D. C. ONJ A. establish baseline status B. initiate interventions 5521. http://meeting.ascopubs.org/cgi/content/abstract/29/15_ 5. Oral care guidelines for patients undergo- D. mucositis ing oncology treatment include all except: C. maximize patient compliance suppl/5521. Accessed May 21, 2017. A. mild toothpaste 16. Symptomatic treatment for mucositis includes all but: D. maximize production 52. McGuire DB, Fulton JS, Park J, et al. Systematic review of basic B. interdental cleaning daily A. avoiding caffeine, alcohol, and tobacco oral care for the management of oral mucositis in cancer patients. C. soft postsurgical toothbrush 26. The pretreatment dental assessment B. avoiding spicy foods Supportive Care in Cancer 2013. 21, 3165-3177. doi:10.1007/ D. alcohol based mouth rinses allows the dentist to: C. palliative rinses A. determine the status of the oral cavity before s00520-013-1942-0. 6. Research shows insufficient evidence of D. using firm, intense toothbrush strokes treatment begins 53. Mirabile A, et al. Pain management in head and neck cancer finding short-term relief for mucositis using: 17. Prior to initiating dental care, blood B. initiate necessary interventions patients undergoing chemo-radiotherapy: clinical practical A. ice chips platelet counts should be: B. saline rinses C. reduce oral complications during and after recommendations. Critical reviews in oncology/hematology 99. A. above 75,000 mm3 C. sucralfate CHX compound 3 therapy 2016. 100-106. B. under 75,000 mm D. PCA with morphine C. undetectable D. all of the above 54. Swartzentruber L, Haveles EB. Oral health care during 7. The percentage of patients undergoing D. above 100,000 mm3 27. Rinsing with a solution of baking soda chemotherapy. April 1, 2013, www.rdhmag.com/content/dam/ HSCT who experience mucositis is: 18. Oral health maintenance visits for and salt: rdh/printarticles/Volume%2033/Issue%204/1304RDH067-075. A. 100% an oncology patient should be recom- A. will alleviate symptoms pdf. Accessed May 21, 2017. B. 40% mended: B. will elevate oral pH 55. Baumgartner S, Imfeld T, Schicht O, Rath C, Persson R, Persson G. C. 21% A. every 6 months C. is not considered effective The impact of Stone Age diet on gingival conditions in the absence D. 5% B. every week C. every 3-4 months D. A and B of oral hygiene. J Periodontology. 2009. May;80(5):759-68. 8. Patients with xerostomia are at higher risk of decay and should be using all on a D. not at all 28. Proper interdental cleaning: regular basis except: Author Profile 19. The number of new cancer cases A. is important to reduce bacterial load in the mouth A. home Fl2 expected to be diagnosed in 2017 is: B. buffering agents B. should only occur under supervision Kris Potts, RDH, BS, FAADH a hygienist of 38 years, is a A. 1.6 million C. can only be accomplished with string floss member of the American Dental Hygienists’ Association and a C. metronidazole B. 5 million D. 100% xylitol D. reduces the need for adjunctive Fl2 fellow with the American Academy of Dental Hygiene. She is a C. 250,000 9. When scheduling treatment for a patient D. 2.5 million 29. Clinicians who take a proactive approach past president of the Texas Dental Hygienists’ Association and undergoing chemotherapy, this should not 20. This product is not used to treat in advising the oncology team can be found: a member of the American Academy for Oral Systemic Health. be considered. xerostomia. A. at dental schools associated with local hospitals Her passion for lifelong learning has directed her to additional A. antibiotic prophylaxis A. saliva substitute B. at local cancer treatment centers B. cycle of NADIR B. saliva stimulant certifications in caries management and oncology care. She has C. postponement of elective procedures C. in your own community C. anticholinergic drugs D. all of the above been interviewed frequently for her expertise. She is owner/CEO D. cost D. 100% xylitol of Oral Health Promotion Strategies. 10. Presentations of ONJ may include all except: 30. During a dental appointment, the 21. During the dental appointment, all provider should: A. numbness should be considered except: Author Disclaimer B. heavy feeling in jaw A. prerinsing with CHX A. not bother with bacterial testing C. pain The author of this course has no commercial ties with the B. assessing biofilm and OH B. stay away from nutritional counseling D. compound fracture C. awareness of cannabinoid use C. avoid eye contact sponsors or the providers of the unrestricted educational grant 11. Oral side effects of chemotherapy include: D. what the patient had for dinner D. have the patient prerinse with CHX for this course.

8 www.DentalAcademyOfCE.com www.DentalAcademyOfCE.com 9 INSTANT EXAM CODE 15224 ANSWER SHEET Oral Care for the Oncology Patient

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681 If not taking online, mail completed answer sheet to Educational Objectives PennWell Corp. Attn: Dental Division, 1. Discuss the importance of treating and preventing oral complications in the oncology patient. 1421 S. Sheridan Rd., Tulsa, OK, 74112 2. Recognize the signs and symptoms of osteonecrosis associated with bisphosphonate therapy. or fax to: 918-831-9804 3. List common oral side effects of oncology treatment. For IMMEDIATE results, 4. Describe currently available treatments for oral mucositis. go to www.DentalAcademyOfCE.com to take tests online. 5. Devise individualized guidelines for the patient receiving oncology treatment to maintain good oral health. INSTANT EXAM CODE 15224 Answer sheets can be faxed with credit card payment to Course Evaluation 918-831-9804. 1. Were the individual course objectives met?  Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No If paying by credit card, please complete the Objective #4: Yes No Objective #5: Yes No following: MC Visa AmEx Discover Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Acct. Number: ______2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 1. 16. 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 2. 17. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 3. 18. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 4. 19. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 5. 20. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 6. 21. 10. Do you feel that the references were adequate? Yes No 7. 22. 11. Would you participate in a similar program on a different topic? Yes No 8. 23. 12. If any of the continuing education questions were unclear or ambiguous, please list them. 9. 24. ______10. 25. 13. Was there any subject matter you found confusing? Please describe. 11. 26. ______12. 27. 14. How long did it take you to complete this course? 13. 28. ______14. 29. 15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 754 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from IMAGE AUTHENTICITY their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2015) to (10/31/2019) Provider ID# 320452 The images provided and included in this course have not been altered. California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. © 2017 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell ORCA1709DIG

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