ORAL CARE OF THE CANCER PATIENT BC CANCER ORAL ONCOLOGY – DENTISTRY MARCH 2018 Oral Care of the Cancer Patient ORAL CARE OF THE CANCER PATIENT 1. INTRODUCTION…………………………………………………………………………PAGE # 3 2. PRACTICE GUIDELINES SALIVARY GLAND DYSFUNCTION / XEROSTOMIA………………..……………… 4 ORAL MUCOSITIS / ORAL PAIN…………………………………………………….. 7 DYSGEUSIA (ALTERED TASTE)……………………………………………………..… 11 TRISMUS…………………………..………………………………………………….… 12 ORAL FUNGAL INFECTIONS………………………………..………………………… 14 ORAL VIRAL INFECTIONS…………………………………………………………….. 16 ACUTE & CHRONIC ORAL GRAFT VS. HOST DISEASE (GVHD)……………… 19 OSTEORADIONECROSIS (ORN)…………………………………………………….. 22 MEDICATION-INDUCED OSTEONECROSIS OF THE JAW (MRONJ)…………… 25 3. MANAGEMENT OF THE CANCER PATIENT………………………………………………..... 28 4. MEDICATION LIST GUIDE………………………………………………………………………. 35 5. REFERENCES………………………………………………………………………………………. 39 6. ACKNOWLEDGEMENTS/DISCLAIMER…….………………………………………………….. 41 BC Cancer - Vancouver BC Cancer - Surrey BC Cancer - Kelowna BC Cancer – Prince George 600 West 10th Avenue 19750 96th Avenue 399 Royal Avenue 1215 Lethbridge Street Vancouver, B.C. V5Z 4E6 Surrey, B.C. V3V 1Z2 Kelowna, B.C. V1Y 5L3 Prince George, B.C. V2M 7E9 Page 2 of 41 (604) 877-6136 (604) 930-4020 (250) 712-3900 (250) 645-7300 Oral Care of the Cancer Patient INTRODUCTION The purpose of this manual is to provide user-friendly, evidence-based guidelines for the management of oral side-effects of cancer therapy. This will allow community-based practitioners to more effectively manage patients in their practices. It is well known that the maintenance of good oral health is important in cancer patients, including patients with hematologic malignancies. Oral pain and/or infections can cause delays, reductions or discontinuation of life-saving cancer treatment. Poor oral health can also lead to negative impacts on a patient’s quality of life including psychological distress, social isolation and inadequate nutrition. By providing these guidelines, we hope to achieve better patient outcomes. The information contained within this manual has been collected from many resources but, most significantly, from the work of the Oral Care Section of the Multinational Association for Supportive Care in Cancer (MASCC) and the International Society of Oral Oncology (ISOO). MASCC/ISOO has continually updated and published systematic reviews of the literature on the common oral complications of cancer therapy. As new evidence emerges, these guidelines will be periodically updated. The oral side-effects that are reviewed and presented in this manual include the following: 1. Salivary Gland Dysfunction / Xerostomia 2. Oral Mucositis / Oral Pain 3. Dysgeusia (Altered Taste) 4. Trismus 5. Oral Fungal Infections 6. Oral Viral Infections 7. Acute and Chronic Oral Graft Versus Host Disease (GVHD) 8. Osteoradionecrosis (ORN) 9. Medication-Induced Osteonecrosis of the Jaw (MRONJ) In addition, general Principles in the Management of the Cancer Patient in community-based dental practice and a Medication List Guide have been included. This will help the community-based clinician offer the best possible care to their patient. Finally, it must be stated that guidelines are just that; in some topic areas, research quality is poor leading to a paucity of evidence-based guidelines. It is clinical judgment, experience and the individual patient response that ultimately determines recommended therapy. BC Cancer - Vancouver BC Cancer - Surrey BC Cancer - Kelowna BC Cancer – Prince George 600 West 10th Avenue 19750 96th Avenue 399 Royal Avenue 1215 Lethbridge Street Vancouver, B.C. V5Z 4E6 Surrey, B.C. V3V 1Z2 Kelowna, B.C. V1Y 5L3 Prince George, B.C. V2M 7E9 Page 3 of 41 (604) 877-6136 (604) 930-4020 (250) 712-3900 (250) 645-7300 Oral Care of the Cancer Patient SALIVARY GLAND DYSFUNCTION & XEROSTOMIA Salivary gland hypofunction (the objective finding of reduced salivary flow) and xerostomia (the subjective sensation of dry mouth) are often seen following high dose H&N radiotherapy and are frequently reported by patients receiving various forms of chemotherapy or resection surgeries affecting salivary glands. Dry mouth can have a very significant effect on both oral health and general quality of life. Because of decreased saliva, patients are at increased risk of dental caries, periodontal disease, oral infection, halitosis, taste disorders, oral pain, difficulties with swallowing and speech, and more at risk of premature death from aspiration pneumonia. Diminished salivary flow can also affect denture retention and cause oral tissues to be more easily traumatized. At BC Cancer, we routinely measure resting and stimulated salivary flow before the initiation of high dose H&N radiotherapy, as well as 3 months and 12 months post radiation. Similarly, we routinely measure salivary volumes at the Day 100 examination for allogeneic stem cell transplant patients as dry mouth is a consistent finding in patients with chronic oral GVHD due to T-cell mediated damage to salivary glands. Frustratingly, there are very limited strategies in prevention of salivary gland hypofunction. Management strategies have focused on meticulous oral hygiene, topical fluoride and remineralizing rinses and pastes, oral lubricant gels and sprays and the use of sialagogue medications. Maintaining the patient’s dentition after high dose radiotherapy is of paramount importance due to the risk of jaw necrosis should teeth need to be removed after radiotherapy. As importantly, healthy teeth and tissues add greatly to the patient’s quality of life and ability to maintain adequate nutrition. PREVENTION STRATEGIES As mentioned, nothing has ever been shown to predictably prevent radiotherapy-induced salivary gland hypofunction. However, newer 3-dimensional radiotherapy delivery techniques (such as IMRT, VMAT and stereotactic radiotherapy) have shown great potential in preventing severe post-treatment oral dryness. BC Cancer - Vancouver BC Cancer - Surrey BC Cancer - Kelowna BC Cancer – Prince George 600 West 10th Avenue 19750 96th Avenue 399 Royal Avenue 1215 Lethbridge Street Vancouver, B.C. V5Z 4E6 Surrey, B.C. V3V 1Z2 Kelowna, B.C. V1Y 5L3 Prince George, B.C. V2M 7E9 Page 4 of 41 (604) 877-6136 (604) 930-4020 (250) 712-3900 (250) 645-7300 Oral Care of the Cancer Patient MANAGEMENT STRATEGIES Conservative management: o Frequent sips of water o Following general nutritional strategies discussed below o The use of various oral wetting agents such as moisturizing gels, mouthwashes and sprays. These products are available over the counter at most pharmacies. o Biotene and Oral Science are two companies that make a wide range of dry mouth relief products. o Sugar free mints and chewing gums: Some patients report transient relief from dry mouth by using xylitol-based products which can be ingested as a dissolvable mint, lozenge or chewing gum. Xylitol is a natural sugar that can not be metabolized by cariogenic bacteria to produce acidic by-products. Its presence alters oral bacteria environment while decreasing caries risk. Pharmaceutical management: Sialagogue medications have been used widely for patients with chronic and symptomatic oral dryness: o Pilocarpine (Salagen) – 5 mg t.i.d o Cevimeline (Evoxac) – 30 mg t.i.d o Anetholtithion (Sailor) – 25 mg t.i.d o Bethanacol – 25 mg t.i.d Side-effects of these medications are not uncommon and may include headache, sweating, nausea, runny nose, increased urination and blurring of vision. Therefore, it is recommended that the dose be increased slowly over time to allow the patient to adjust to any side-effects. It should be noted that since drug costs are high and that benefits are not long-term and decline after cessation of therapy. These drugs therefore tend to be ineffective and/or impractical long-term management strategies for patients with dry mouth. GENERAL NUTRITIONAL MANAGEMENT STRATEGIES o Add extra moisture to foods by adding sauces, gravies, butter, dressings, broth or other liquids BC Cancer - Vancouver BC Cancer - Surrey BC Cancer - Kelowna BC Cancer – Prince George 600 West 10th Avenue 19750 96th Avenue 399 Royal Avenue 1215 Lethbridge Street Vancouver, B.C. V5Z 4E6 Surrey, B.C. V3V 1Z2 Kelowna, B.C. V1Y 5L3 Prince George, B.C. V2M 7E9 Page 5 of 41 (604) 877-6136 (604) 930-4020 (250) 712-3900 (250) 645-7300 Oral Care of the Cancer Patient o Soft, mild-tasting food is often better tolerated in the dry mouth environment o Frequent sips of cold water or dissolving ice chips in the mouth may provide significant oral comfort o Avoid highly acidic foods, foods high in sugar, caffeine and alcohol Objective salivary gland hypofunction and subjective xerostomia are common long-term side-effects of high dose H&N radiotherapy and are less frequently seen with certain chemotherapy protocols. Dry mouth puts the patient at risk of serious dental and periodontal disease and may be a permanent condition. Therefore, effective management is important and patients must be reminded of the need to adhere to their proper hygiene protocols. Fortunately, newer radiotherapy delivery techniques are resulting in less severe chronic oral dryness. Nonetheless, it remains a common and troubling side-effect of cancer therapy. The entire dental team has a role to play in effectively managing the dry mouth cancer patient. BC Cancer - Vancouver BC Cancer - Surrey BC Cancer - Kelowna BC Cancer – Prince George 600 West 10th Avenue 19750 96th Avenue 399 Royal Avenue 1215 Lethbridge Street Vancouver, B.C. V5Z 4E6 Surrey, B.C. V3V 1Z2 Kelowna, B.C. V1Y 5L3 Prince George, B.C.