Oral Health Care for Patients Undergoing Cancer Therapy
Speaker: JoAnn R. Gurenlian, RDH, PhD
Date: November 13, 2012
Outline:
Cancer stats and facts •
Cancer is the 2nd leading cause of death following heart disease
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Accounts for 23% of all deaths
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Death rate decreased 1.5% from 2007 to 2008
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Decreases in cancer deaths for lung, female breast, colorectal and prostate cancer since 1990
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Increases in last two decades of rates of kidney, thyroid, liver, esophageal adenocarcinoma, melanoma of the skin, and some throat cancers (linked to HPV infection)
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1,638,910 Americans will be diagnosed with cancer in 2012
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577,190 deaths anticipated in 2012
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Lifetime risk of developing cancer is 44.85% for all men and women born today
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Overall survival rate is 63.5%
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Tobacco use and obesity are estimated to be the two main cancer-causing factors for 2012; each factor accounting for one-third of cancer deaths
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1 in 95 individuals will be diagnosed with oral and pharyngeal cancer during their lifetime
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Overall survival rate of oral and pharyngeal cancer is 60.8%;for localized cancer, the percentage of those who survive is 82%; for distant sites, the survival rate drops to ~33%
Source: Siegel R, Nalshadham D, Jemal A. Cancer statistics, 2012. Ca Cancer J Clin 2012. Available online at http://cacancerjournal.com. Accessed 1/8/12. Treating Patients Undergoing Cancer Therapy
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Identify patients with cancer
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Post a sign asking patients to inform you they have been diagnosed with cancer o
Offer last appointment of day for initial appointment after being diagnosed
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Share common goal of education the patient
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Allows ample time for patient to ask questions
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Allows time to develop aggressive plan for reducing negative oral effects of cancer therapy
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Allows time to teach patient oral self-exam
Information Gathering •
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Identify oncology team members o
Medical oncologist, radiation oncologist, nurse practitioner, registered dietician, family practitioner, etc.
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Must be able to contact the team should oral infection or other side effects occur
Identify cancer protocol to be used o
Radiotherapy
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Chemotherapy regimens, procedures, schedule of treatment, effects (seeTables I and II)
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Helps to identify best time to schedule dental and dental hygiene appointments
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Blood studies
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Performed 24 hours before every dental/dental hygiene appointment
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Postpone oral procedures if:
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Platelet count is < 75,000/mm3
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Abnormal clotting factors are present
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Absolute neutrophil count is < 1000/mm3 (or consider prophylactic antibiotics)
If patients has a central venous catheter, antibiotic prophylaxis may be needed before any dental treatment
Phases of Care - pretreatment, cancer therapy, end of cancer/recovery Pretreatment Phase 2
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Schedule oral health care appointment prior to cancer therapy
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Educate patient about risk of oral infection, how to recognize signs of oral infection during cancer treatment, and the need for seeking immediate treatment for oral health concerns
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Perform dental treatment to restore or remove any diseased areas and to ensure meticulous oral hygiene regimen is maintained
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Assess medications for potential to produce xerostomic side effects
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Implement fluoride therapy in office and at home to reduce risk of dental caries
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Advise those with smoking and alcohol addictions to seek cessation programs
It is estimated that approximately one-third of individuals diagnosed with cancer will develop oral complications from treatment. Source: Hong CHL, Napeñas JJ, Hodgson BD, Stokman MA, et al. A systematic review of dental disease in patients undergoing cancer therapy. Support Cancer Care 2010. August;18(8): 1007-1021. Oral Care Considerations –review of products
Cancer Therapy Phase •
Maintain regular dental and dental hygiene appointments to manage periodontal health, assess for signs of infection or mucositis, and provide supportive periodontal therapy to address xerostomia, etc.
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Effects of cancer therapy: mucositis, herpes, fungal infections, radiation caries, xerostomia
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Treatment of mucositis o
Regular assessment of oral pain
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Topical anesthetics or other agent used for oral comfort
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Ongoing assessment of oral cavity through patient self-reports and professional exams
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Use of preventive and therapeutic oral care regimens
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Regular oral hygiene maintenance with brushing, flossing, and bland rinses/ moisturizers 3
Source: Mucositis Study Section of the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology (MASCC/ISOO) MASCC/ISOO Mucositis Recommendations •
Use of midline radiation blocks and 3 dimensional radiation treatment
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Benzydamine for prevention of radiation-induced mucositis for head and neck cancer patients
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Palifermin for those receiving high doses of chemotherapy and total body irradiation with autologous stem cell transplantation
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Cryotherapy to prevent mucositis in patients receiving high-dose melphalin and other forms of chemotherapy
MASCC/ISOO Recommendations – Resources NOT to be used for Mucositis •
Chlorhexidine
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Antimicrobial lozenges
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Sucralfate
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Acyclovir
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Pentoxifylline
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Granulocyte-macrophage-colony stimulating factor (GM-CSF) mouthwashes
Cochrane Collaboration Recommendations for Mucositis Prevention and Treatment •
Cryotherapy
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Keratinocyte growth methods (for epithelialization of mucosal tissues)
Cochrane Collaboration – Mucositis Findings Weak, unreliable evidence for use of •
Aloe vera
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Amifostine
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Glutamine (IV)
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GM-SCF
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Honey
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Laser 4
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Polymixin/tobramycin/amphotericin (PTA) lozenges/paste
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Sucralfate
No evidence supporting any benefit for using chlorhexidine for the treatment of mucositis Treatment of Herpes Prevalence is close to 50% among neutropenic cancer patients and among head and neck cancer patients with ulcerative mucositis •
Valacyclovir for HSV
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Famciclovir for VZV
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Ganciclovir for acute CMV infection
Treatment of Fungal Infections Estimated that 38% will experience oral candidiasis during chemotherapy •
Nystatin rinse
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Clotrimazole troches
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Systemic antifungal medication
Requires diligent evaluation for other fungal infections, including aspergillus, mucormycosis, and rhizopus Source: Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Cancer Care 2010;18(8):993-1006. Post-Treatment Phase •
Monitor patients frequently for post-treatment effects
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Patients who have been treated for oral cancer have up to 20X risk for developing a second cancer
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Post-treatment Effects include: o
Salivary gland dysfunction
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Xerostomia
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Rampant caries
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Trismus
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Soft tissue necrosis
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Osteoradionecrosis 5
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Bisphosphonate osteonecrosis of the jaws
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Hypersensitivity
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Taste changes
Hyposalivation and Xerostomia •
Prescriptions – pilocarpine, cevimeline
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OTC sprays, rinses, gels, toothpaste
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Daily fluoride therapy
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Avoid candy, gums, soda (unless sugar-free), spicy or acidic foods, tobacco and alcohol products
Altered Taste •
Returns within several weeks of completion of chemotherapy
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Taste receptors damaged during radiation take 6-8 weeks or more to become functional again
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Use of zinc sulfate supplements may be helpful in recovering sense of taste
Source: Silverman S Jr: Complications of treatment. In Silverman S Jr, ed.: Oral Cancer, 5th ed. Hamilton, Canada: BC Decker INc, 2003, pp.113-28. Hypersensitivity •
Associated with nausea, waterbrash, and frequent vomiting from chemotherapy causing erosion
Soft Tissue Changes •
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Anemia, neutropenia, leukopenia, and thrombocytopenia result from myelosuppression association with chemotherapy resulting in o
Spontaneous gingival bleeding
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Petechiae of lips, palate, and mucosa
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Eccyhomosis
Patients may safely perform routine oral hygiene measures and should do so to reduce biofilm accumulation and control periodontal problems
Bone Infections – ONJ, BONJ Treatment for ONJ •
Topical antibiotics 6
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Antiseptics
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Analgesics
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Local resection of bone sequestra
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Hyperbaric oxygen therapy
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Partial mandibulectomy may be warranted
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Prevention via careful evaluation of periodontium and mucosa and elimination of disease during pretreatment including restorative care and extractions
BONJ •
ADA recommendations
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CTX blood test
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Teriparatide – aides in the resolution of BONJ by augmenting effective bone remodeling under osteoanabolic conditions
Source: Subramanian G, Cohen HV & Quek SYP. A model for the pathogenesis of bisphosphonate-associated osteonecrosis of the jaw and teriparatide’s potential role in its resolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:744-753. Carotid Atheroma •
Patients who received ≥ 45 Gy of radiation are more likely to develop carotid artery atheroma than those who have not been irradiated
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Lesions may be detected by panoramic radiography
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Represents a risk factor for stroke
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Concerns warrant referral to a physician for further evaluation
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Table I: Chemotherapy Drug Types Drug
Action
Differentiating agents
Acts on cancer cells to Retinoids (Atralin®) make them mature into Bexarotene (Targretin®) normal cells Arsenic trioxide (Arsenox®) Alter the action or Anti-estrogens (tamoxifen) production of female or Aromatase inhibitors male hormones (Arimidex®) Prevents the cancer cell Progestins (Megace®) from using the hormone it Estrogens needs to grow Anti-androgens (Casodex®) Prevents the body from Gonadotropin-releasing making the hormones hormone (GnRH) Stimulates natural immune Monoclonal antibody therapy systems to more effectively (Rituxan®) recognize and attack cancer cells Directly damage DNA to Nitrogen mustards prevent the cancer cell from (mechlorethamine, Cytoxan®) reproducing Nitrosoureas (streptozocin) Can cause long-term Alkyl sulfonates (busulfan) damage to bone marrow Triasines (dacarbazine) Increases risk of leukemia Ethylenimines (thiotepa and altretamine) Interferes with DNA and 5-fluorouracil (5-FU) RNA growth methotrexate Damages cells during the S phase Interfere with enzymes Daunorubicin involved in DNA replication Doxorubicin (Adriamycin®) Works in all phases of the Actinomycin-D cell cycle Mitomycin-C Interfere with enzymes Topotecan called topoisomerases Irinotecan (CPT-11) which help separate strands Etoposide (VP-16) of DNA so they can be copied
Hormone therapy
Immunotherapy
Alkylating agents
Antimetabolites
Anti-tumor antibiotics
Topoisomerase inhibitors
Examples
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Mitotic inhibitors
Stops mitosis or inhibits Taxanes (Taxol®, Taxotere®) enzymes from making Epothilones (Ixempra®) proteins needed for cell Vinca alkaloids (vinblastine) reproduction Works during the M phase of the cell cycle; can damage cells in all phases
Source: American Cancer Society. Chemotherapy principles: an in-depth discussion. Available at: http://www.cancer.org. Accessed September 3, 2011. Table II: Examples of Chemotherapeutic Agents and Side Effects Agent
General Side Effects
Cyclophosphamide (Cytoxan®)
Myelosuppression Oral mucosal ulceration Leukopenia Increased risk of infection Moderate to severe emesis Anorexia Abdominal discomfort/pain Diarrhea Hemorrhagic colitis Jaundice Alopecia Skin or nail pigmentation Hemorrhagic cystitis Interstitial pulmonary fibrosis and pneumonitis Acute cardiac toxicity Congestive heart failure Sterility Asthenia, dizziness, depression or headache Musculoskeletal pains and rheumatic syndromes Nausea, vomiting, constipation, diarrhea Mouth or tongue sores Headache, fatigue, asthenia, fever, back pain Convulsions, hemiparesis, dizziness, amnesia, insomnia Peripheral cardiac edema Viral infection Adrenal hypercorticism Urinary tract infection Upper respiratory tract infection, pharyngitis Diffuse erythematous skin rash Anxiety, depression Weight gain Myalgia Abnormal and double vision Opportunistic infections Leukemia, glioblastoma multiforme
Temosolomide (Temodar®)
Oral Side Effects
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Carboplatin
Cisplatin
5-fluorouracil (5-FU)
Methotrexate
Bone marrow suppression Mucositis Thrombocytopenia Stomatitis Vomiting, abdominal pain Peripheral neuropathies Abnormal liver function tests Ototoxicity Dehydration Nephrotoxicity No significant effects Emesis, nausea, diarrhea reported Sensory polyneuropathy Ototoxicity, headache, strokes Tinnitus, hearing loss Myelosuppression Anemia Optic neuritis, cortical blindness, blurred vision Myocardial infarction, CVA, cerebral arteritis Anaphylactic-like reactions Transient elevated liver enzymes Soft tissue toxicity Rash, alopecia, digital necrosis Esophagopharyngitis, anorexia, nausea, Stomatitis vomiting, diarrhea, Leukopenia (principally granulocytopenia), thrombocytopenia, anemia, Alopecia, dermatitis (principally pruritic maculopapular rash Myelosuppression Speech impairment Anemia, aplastic anemia, thrombocytopenia Ulcerative stomatitis Nausea, vomiting, diarrhea Gingivitis Anorexia, GI bleeding Pharyngitis Acute hepatitis, chronic fibrosis and cirrhosis Opportunistic infections Headache, dizziness, drowsiness, blurred vision, moodiness, tinnitus Pulmonary toxicity Interstitial pneumonitis Renal insufficiency Malaise, fatigue, chills TEN, Stevens-Johnson syndrome, erythema multiforme Alopecia Pericarditis, pericardial effusion, myocardial ischemia, hypotension Conjunctivitis
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Doxorubicin (Adriamycin®)
Mitoxantrone
Irinotecan (CPT-11)
Paclitaxel (Taxol®)
Heart failure, late cardiomyopathy, congestive heart failure Myelosuppresion resulting in suprainfection and/or hemorrhage Alopecia Hyperpigmentation of nailbeds Oncholysis Nausea,vomiting, bleeding, local infection, colonic ulceration Renal insufficiency Secondary leukemia Myelosuppression Secondary leukemia Nausea, vomiting, diarrhea Left ventricular systolic function and congestive heart failure Blue streaking in or around the vein and of skin Renal insufficiency Drug rash with eosinophilia and systemic signs (DRESS) Green urine Amenorrhea “Early” diarrhea, diaphoresis, stomach cramping Late diarrhea can be life threatening Ulcerative and ischemic coliltis Nausea, vomiting Leukopenia, anemia, neutropenia Asthenia, fever, pain, headache, chills, minor infections, edema abdominal enlargement Minor upper respiratory infections Weight loss Dehydration Alopecia, sweating, rash, parasthesias Dyspnea, increased coughing, rhinitis Insomnia, dizziness Myocardial ischemia Renal insufficiency Muscular contractions and cramps Bone marrow suppression Fever Bleeding episodes Sinus bradycardia, tachycardia, and premature beats Neurotoxicity Nausea, vomiting, diarrhea Hepatic toxicity Edema Transient skin changes Alopecia (usually irreversible) Myalgia and/or arthralgia Cellulitis 11
Stomatitis Mucositis Tongue hyperpigmentation
Mucositis Stomatitis Mouth pain
Increased salivation Mucositis Stomatitis
Mucositis Stomatitis Sores of the lips
Vinblastine (Velban®) Leukopenia and septicemia Leukemia Alopecia Nausea, vomiting, anorexia, Pharyngitis, diarrhea, rectal bleeding Myocardial infarction, CVA, Raynaud’s phenomenon Shortness of breath, severe bronchospasm, progressive dyspnea Malaise, bone pain, weakness, dizziness, myalgia, ototoxicity Estramustine Gynecomastia, impotence, breast tenderness (Emcyt®) and enlargement Exacerbation of pre-existing heart disease Nausea, diarrhea, GI upset Dyspnea Leukopenia Lethargy, insomnia Easy bruising, pruritis, dry skin Dexamethasone Bradycardia, cardiac arrest, cardiac (Decadron®) arrhythmias, cardiac enlargement, congestive heart failure Muscle weakness, steroid myopathy, osteoporosis, compression fractures, aseptic necrosis of femoral and humeral heads, pathologic bone fractures, tendon rupture Peptic ulcer, bowel perforation, abdominal distention, nausea, increased appetite, esophagitis Cushingoid state Convulsions, increased intracranial pressure, vertigo, malaise, headache, psychic disturbances Weight gain, hirsutism, Cataracts, glaucoma, increased intraocular pressure, exophthalmos Impaired wound healing, petechiae, ecchymosis, dry skin, thinning scalp hair, increased sweating, rash, urticaria Euphoria, insomnia, mood swings, personality changes, severe depression, psychosis Reversible hepatomegaly
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Stomatitis Metallic taste Jaw pain Vesiculation of the mouth
Hoarseness Sore throat
Angioedema
Bortezomib (Velcade®)
Imatinib (Gleevec®)
Tretinoin (ATRA or Atralin®)
Asthenia, pyrexia, headache, insomnia, Abnormal taste dizziness, dehydration Stomatitis Nausea, diarrhea, constipation, decreased Angioedema and appetite, vomiting, pain Laryngeal edema Thrombocytopenia, neutropenia Oral candiasis Peripheral neuropathy, neuralgia, hemorrhagic stroke, motor dysfunction Arthralgia, pain in limb, back pain, bone pain Hypotension (orthostatic) Edema, hypertension, aggravated atrial fibrillation and atrial flutter Dyspnea, cough, upper and lower respiratory tract infections Rash, herpes zoster, pruritis Dysgeusia, impaired hearing, bacteremia, herpes viral infections,, septic shock Blurred vision Hepatitis Anorexia, agitation, confusion, psychotic disorder, mental status change, suicidal ideation Nausea, vomiting, edema, tumor necrosis, Mouth ulceration muscle cramps Taste Disturbance Neutropenia, thrombocytopenia, anemia Angioedema Cardiac edema Headache, CNS hemorrhage Skin rash, pruritis, petechiae, alopecia Nasopharyngitis, cough, upper respiratory tract infection weight increase renal failure depression, anxiety, memory impairment breast enlargement periorbital edema, conjunctivitis, blurred vision Peeling, dry skin, burning, stinging, erythema, Xerostomia pruritis Stinging of the eye Isolated vaginal bleeding
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Tamoxifen
Hot flashes, nausea, vomiting No significant effects or Endometrial abnormalities – adenocarcinoma, complications reported uterine sarcoma, hyperplasia, endometrial polyps Endometriosis, vaginal bleeding, discharge, altered menses Bone pain, severe hypercalcemia Jaundice, hepatitis Ocular toxicity CVA, edema, phlebitis, thromboembolism Pulmonary embolism Depression, delusional syndromes Anorexia, Hair loss Visual memory, word fluency, processing speed tasks problems Leuprolide (Lupron®) Hot flashes, gynecomastia, breast Gingival hemorrhage enlargement and tenderness Gingivitis Depression, emotional lability Dry mucous membranes Headache, dizziness, blurred vision Dysphagia Vaginal dryness, urinary frequency, hematuria, testicular and breast soreness/pain, testicular atrophy, erectile dysfunction Peripheral edema, hypertension, hypotension, murmur, phlebitis, deep vein thrombosis, stroke, sudden cardiac death, myocardial infarction Constipation, anorexia, nausea, vomiting Skin rash, hair loss, ecchymosis Bone pain Anemia, leukopenia, hemoptysis Dyspnea, sinus congestion, cough, pulmonary fibrosis Granulomas Fibromyalgia, hearing disorder, hard nodule in throat, weight gain, increased uric acid Difficulty with/painful urination, bladder spasm Hyperglycemia Rituximab (Rituxan®) Fever, chills, asthenia, headache, abdominal Throat irritation pain Angioedema Hepatitis Myocardial infarction, ventricular fibrillation, cardiogenic shock Rhinitis, bronchospasm, pneumonitis Nausea, vomiting Leukopenia, thrombocytopenia, neutropenia Myalgia, dizziness, pruritis, rash, urticarial Renal insufficiency Disease progression of Kaposi’s sarcoma Bilateral conjunctivitis Pyelonephritis
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Interleukin-2 (IL-2)
Hypotension Generalized body edema Ascites Pulmonary edema Chills, fever Headache, malaise Nausea, vomiting Loss of appetite, diarrhea Renal failure if severe hypotension occurs
Stomatitis Mucositis
Sources: Winn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry, 15th ed. 2009. Hudson, Oh: Lexicomp; Drugs.com. Drug information online. Available at:www.drugs.com. Accessed 9/3/11.
Additional References 1. Howlander N, Noone Am, Krapcho M, Neyman N, etal. (eds.) SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, http:// seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER web site, 2011. 2. National Institute of Dental & Craniofacial Research. National Institutes of Health. Oral complications of cancer treatment: what the dental team can do. Date last modified March 25, 2011. Available at: www.nidcr.nih.gov/OralHealth/Topics/ CancerTreatment/OralComplicationsCancerOral.htm. Accessed September 4, 2011. 3. Campaign targets oral complications of cancer treatment. January 1999. U.S> Department of Health and Human Services, National Institutes of Health, 15
National Institute of Dental and Craniofacial Research Website. Available at http://www.nidcr.nih.gov/NewsAnd Reports/NewsReleases/News Release0111271999.htm. Accessed July 20,2011. 4. Hong, CHL, Napeñas JJ, Hodgson BD, Stokman MA, et al. A systematic review of dental disease in patients undergoing cancer therapy. Support Cancer Care 2010, August;18(8):1007-1021. 5. McClure D, Essary D, Gurenlian JR: A collaborative team approach for symptom management for head and neck cancer patients. Grand Rounds 2007;2(7):43-51. 6. The Oral Cancer Foundation web site. Oral Cancer Facts. Available at: http:// oralcancerfoundation.org/facts/index/htm. Accessed June 28, 2011. 7. American Cancer Society. Chemotherapy principles: an in-depth discussion. Available at http://www.cancer.org. Accessed September 3, 2011. 8. The Cleveland Foundation. Cleveland Clinic Cancer Center. Chemotherapy drugs-drug names. Available at: www.chemocare.com. Accessed September 2, 2011. 9. Winn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry, 15th ed. 2009. Hudson, Oh: Lexicomp. 10. Drugs.com. Drug information online. Available at:www.drugs.com. Accessed 9/3/11. 11. The Cleveland Foundation. Cleveland Clinic Cancer Center. Managing chemotherapy side effect. Available at www.chemocare.com. Accessed September 2, 2011. 12. Keefe DM, Schubert MM, Elting LS, Sonis ST, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 2007;109:820-831. 13. McGettigan S, Tompkins C. Managing mucositis in head and neck cancer patients undergoing radiation therapy. Community Oncology 2006;3:653-656. 14. Washington HV, Clarkson JE, Bryan G, Furness S, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment (Review). 2011, Issue 4. The Cochrane Collaboration. John Wiley & Sons. Available at http://www.thecochranelibrary.com. Accessed September 4, 2011.
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15. National Cancer Institute: PDQ® Oral Complications of Chemotherapy and Head/ Neck Radiation. Bethesda, MD: National Cancer Institute. Date last modified March 24, 2011. Available at: http://cancer.gov/cancertopics/pdq/supportivecare/ oralcomplications/HealthProfessional. Accessed July 20, 2011. 16. Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Cancer Care 2010; 18(8): 985-992. 17. Ellis ME, Clink H, Ernst P, et al.: Controlled study of fluconazole in the prevention of fungal infections in neutropenic patients with haematological malignancies and bone marrow transplant recipients. Eur J Clin Microbiol Infect Dis 1994;13(1): 3-11. 18. Elad S, Zadik Y, Hewson I, et al: A systematic review of viral infection associated with oral involvement in cancer patient: a spotlight on Herpesviridea. Support Care Cancer 2010;18(8):993-1006. 19. Nicolatou-Galitis O, Athanassiadow P, Kouloulias V, et al. Herpes simplex virus-1 (HSV-1) infection in radiation induced oral mucositis. Support Care Cancer 2006;14:753-762. 20. Leflore S, Anderson PL, Fletcher CV: A risk-benefit evaluation of acyclovir for the treatment and prophylaxis of herpes simplex infections. Drug Saf 2000;23(2): 131-142. 21. Reusser P: Management of viral infections in immunocompromised cancer patients. Swiss Med Wkly 2002;132(27-28):374-378. 22. Naesens L, De Clercq E: Recent developments in herpesvirus therapy. Herpes 2001;8(1):12-16. 23. Jublet B: Valacyclovir and famciclovir therapy in herpes zoster. Curr Neurol Neurosci Rep 2002;2(6):477-478. 24. Burns LJ, Miller W, Kandaswamy C, et al: Randomized clinical trial of ganciclovir vs acyclovir for prevention of cytomegalovirus antigenemia after allogenic transplantation. Bone Marrow Transplant 2002;30(12):945-951. 25. Zaia JA: Prevention of cytomegalovirus disease in hematopoietic stem cell transplantation. Clin Infect Dis 2002;35(8):999-1004.
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26. Peterson DE, Doerr W, Hovan A, et al.: Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 2010;18(8):1089-98. 27. Silverman S Jr: Complications of treatment. In Silverman S Jr, ed.: Oral Cancer. 5th ed. Hamilton, Canada: BC Decker Inc, 2003, pp.113-28. 28. Ripamonti C, Zecca E, Bruncelli C, et al.: A randomized controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer 1998;82(10):1938-1945. 29. Oral Cancer Self-Examination. Available at: http://www.floss.com/ oral_cancer_self-test.htm. Accessed 9/4/11. 30. National Institute of Dental & Craniofacial Research, National Insitutes of Health. Detecting oral cancer: a guide for health care professionals. Bethesda, MD. Available at: www.nidcr.nih.gov. Accessed September 5, 2011. 31. Pacak DK. Developing a documentation protocol. Dimensions Dent Hyg. 2011. April;38-43.
Other Resources: “Detecting Oral Cancer: A Guide for Health Care Professionals and can be downloaded through www.nidcr.nih.gov. “Maintaining Oral Health During Cancer Treatment” available through Young Dental through www.richmondinstitute.com.
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*The information contained within this handout is the intellectual property of JoAnn R. Gurenlian, RDH, PhD. This information may not be reproduced in any manner nor distributed without written permission from the author.
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