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Mouth and Teeth: Care and Problems
Note: This section has health/medical information. It was not written by a health care professional. The medical references are the web sites listed in the text below at the individual topics, a dentist who was a member of the online ALL discussion list in 1999, a booklet that Children's Hosptial sent home with us, and the book:
- Childhood Leukemia: A Guide for Families, Friends, and Caregivers, 4th ed., by Nancy Keene, 2010.
Treatment of children for cancer causes changes in the bio-environment of the mouth, making it more susceptible to oral infections and tooth decay. Most chemotherapy drugs cause all dividing cells to die, and since the mucous membranes are composed of rapidly dividing cells, these tissues do not replenish during intense therapy. Mucous membranes form a barrier against infections, and without them the mouth can become inflamed, and opportunistic bacterial, yeast, and fungal infections can occur. Chemotherapy also affects the ability to salivate, causing plaque to build up rapidly, thus increasing the incidence of gum infections and cavities. Treatment can cause drops in ANC so that the child is less able to fight off infections which do start. Low platelet counts mean that even brushing and flossing can cause bleeding. Last but not least, development of teeth is sometimes adversely affected by radiation and intensive chemotherapy protocols.
Oral infections and tooth decay during chemotherapy can usually be prevented by antibacterial mouth washes and careful, frequent teeth cleanings. That's easy for a kid to do, right? Ha! Getting healthy kids to brush twice a day requires diligent parents. Getting a prednisone-laced child to carefully wash and rinse his mouth after every meal, well, that can be very difficult.
The first sections below teach you good oral care practices for chemotherapy patients. Dr. Mark, a dentist who is the parent of a young boy with ALL, is the professional advisor. His procedures for home care are both dentist- and child- approved. Later sections discuss dental visits and long term effects of treatment.
Oral infections and tooth decay are primarily prevented by using an antibacterial mouthwash and brushing. Proper eating also helps.
- stomatitis is inflammation of the mouth
- mucositis is inflammation of the mucous membranes
- xerostomia is dry mouth
Web information on mouth care:
- Smile, Protect Your Mouth - on the Cancer Supportive Care Program site
- Oral Problems and Solutions - on the Cancer Supportive Care Program site
Most of us came home from the hospital after our child's initial diagnosis with instructions to have our children rinse their mouth after each meal and before bed with Peridex. Peridex is a prescription drug, generic name: Chlorhexidine gluconate. Peridex is a particularly bad tasting concoction.
Dr. Mark, what do use for your son to prevent mouth sores during chemotherapy for ALL?
- "David's oncologist wanted him on Peridex and I said "Not if I can help it!" I asked the doc if we could substitute 0.63% stannous fluoride rinse. He said it was okay. For the laymen here, they do the same thing, but the stannous fluoride does not stain teeth as bad or taste as bad, it prevents cavities (because of the fluoride), and the patient is more likely to comply."
- "As a dentist I knew Peridex would taste terrible and stains teeth. Peridex tastes so bad that they put a flavoring agent in it. Problem is if you rinse your mouth out after taking Peridex, you rinse out the flavoring agent and it tastes worse."
- "The stannous part of the fluoride is antimicrobial - it kills the bacteria that give you mouth sores. Also kills the bacteria that build up the plaque and tartar and destroy the gums. The reason you use Peridex or 0.63% stannous fluoride is to kill the microbes in the mouth. These two meds have substantivity, which means they stick around killing the bugs for about 8 hours. Mouthwashes in general will kill on contact, but don't stay around. I use the 0.63% stannous fluoride because of the above properties, but also because I think it is kinder to the mouth tissues. My son has not had one sore since being on chemo with the 0.63% stannous fluoride."
So, where do we get stannous fluoride for our kids?
- "It is prescription. A lot of dentists dispense this. Usually the fluoride that is dispensed from a dentist tastes better than the fluoride one picks up at the pharmacy. At the pharmacy, they are generically filling the prescription. You still get 0.63% stannous fluoride, but they fill the prescription with the cheapest one, hence it does not taste that good. Let me rephrase that. The dentist dispensed fluoride, in my experience, tastes better because we want you to keep using it."
- "I am using Stanimax, manufactured by SDI Labs Inc., out of Glenview IL 60025. It comes in mint and tropical. Used to use PerioMed, manufactured by Omni International. They have mint, and cinnamon. One mixes 1/8 oz. of concentrate with warm water, making 1 oz. (This is enough for two adult mouth rinses. You may want to cut that down.) Swish for 1 minute (time it!!!!!!!!) and spit. This needs to be used by kids who are old enough to where they won't accidentally swallow it."
- "The salesman for the PerioMed had a daughter with leukemia on the 0.63% Fluoride Rinse and said she never did have a mouth sore!"
- "Your oncologist could probably prescribe stannous fluoride. However, Stanimax and PerioMed are only sold to dentists -- NOT pharmacies. I am sure that the pharmacists carry or can get someone's brand of 0.63% stannous fluoride, I just can't guarantee the taste if it's not Stanimax or PerioMed. Best bet would be to contact your dentist, but alas, not all of these guys dispense this stuff either."
- "I offer this as an alternative to Peridex. If your child tolerates the Peridex, stick with it. If your child's onc insists on Peridex, stay with it. My child's onc said it was ok to use the 0.63% stannous fluoride instead of Peridex. I knew my child is picky about bad tasting medicines, and I wanted to smooth out his roller coaster. It is something I could do."
- "My son has no problem taking this. He is 6 yrs. old. He is only taking it before he goes to bed. If and when he starts developing mouth sores, he will take it AM and PM."
[Note added Jan 2010: A company contact the author of these pages with a suggestion that I list their product. I have no personal knowledge of this product, but it sounds like it might be an alternative to stannous fluoride or Peridex. Their web site is www.medactive.com. From the company: "The use of Stannous Fluoride rinses as an effective cleanser of oral bacteria is well established in clinical studies and in the FDA's monograph. The problem issue, as we at MedActive see it, is COMPLIANCE. . . . We provide the rinse in non-prescriptive, unit dose dispensers which are mixed at time of use and include flavoring that patients find pleasant. We believe that our product can be of significant benefit to relieve the discomfort of oncology oral complications."]
Wait Dr. Mark, I thought you said that Peridex and stannous fluoride are preventatives. Now you are saying you would use it if mouth sores developed, too?
- "If the mouth ulcers are chemo induced, I personally don't think the Peridex or fluoride will help. But they will keep ulcers down from bacteria and reduce opportunistic secondary infections due to low counts. So what I am saying here is use the Peridex or 0.63% Stannous fluoride daily, as a preventative and as a therapeutic agent."
Doesn't fluoride cause mottling of the teeth if it is used daily?
- "You only swish with the 0.63% stannous fluoride and then spit it out, so mottling of the teeth from too much fluoride should not be a problem. This concentration of fluoride used in this home rinse is different than the fluoride you get after a cleaning in the dental office. So if your kid has ever puked after taking fluoride at the dentist's, the Stanimax or PerioMed is not as bad."
- "Stannous fluoride is used in dentistry all the time as a therapeutic agent in the treatment of periodontal disease, sensitivity, and controlling bleeding after cleanings. This fluoride is more powerful than one would find in an over the counter toothpaste or mouthwash."
Our oncologist advised us to have our son rinse with warm salt water. What does this do?
- "Salt water rinses are good because they alkalinize the mouth (opposite of acidify, which is what the bacteria create.) Use one-half teaspoon each of baking soda and salt in a cup of warm water. The alkalinity helps decrease the bacteria count because they like an acid environment. As far as hot or cold, I'm not sure it matters. The rise in pH (alkalinity) is temporary. That is why the docs are promoting the Peridex, because they last longer."
And what about over-the-counter rinses, like Listerine?
- They kill bacteria, they just do not work as long as Peridex and stannous fluoride.
Patients under intense chemo are at risk for fungal and yeast as well as bacterial infections. Some oncologists prescribe Nystatin to prevent fungal infections; other oncologists only prescribe Nystatin after infections occur. These infections are evidenced by white patches in the mouth. Other names for the medicine are Mycostatin or Nilstat rinses, or Mycelex lozenges. The rinses are known as "swish and swallow", since the kids do not spit them out because this type of infection can occur down the throat passage as well as in the mouth. After "swish and swallow", the child should not eat, drink, or rinse their mouth for 30 minutes so that the medicine can have time to act.
Different brands of this medicine taste differently, as reported by child-patients. Ask your pharmacist to order a different brand if your child cannot tolerate this medicine.
Your child should brush after every meal and before bed time. During periods of low ANC and platelets, or when your child's gums are tender, swollen, and bleed easily, avoid dental floss and toothbrushes.
Dr. Mark: how should our kids brush their teeth?
- "Get them on a soft toothbrush and monitor how hard they are brushing. Have them use two fingers worth of pressure, not the whole hand "death grip"! And have them brush in small circles and slow down. They should be able to clean their teeth in under a minute or two if done correctly.
- "Also ask you dentist about the modified bass technique of toothbrushing. The toothbrush is held at a 45 degree angle and pressed into the gums until they blanch, then gently brushed in a circular or back and forth method, cleaning about two teeth at a time, not the whole side of the mouth. This technique not only cleans the teeth above the gums, but gets into the sulcus (space between the tooth and gum) of the tooth and cleans at the gum line, which is a problem with people who have gum disease or have a problem with tartar building up at the gum."
And during times of low counts?
- "You could use the pink Toothettes sponge tip brush, a facecloth, or 2x2 gauze and wipe/massage the teeth and gums. This only needs to be done when counts are down, like below ANC of 500."
- Editor's note: the AAPD advises the following:
- Daily tooth brushing and flossing when the ANC is greater than 500 and platelet count is greater than 20,000.
- Dental hygiene with a moist gauze or Toothettes only when ANC is less than 500 and/or platelet count is less than 20,000.
- "The teeth have to be cleaned at least once a day very thoroughly, but it is better to clean them after every meal."
Tell us about toothbrushes, Dr. Mark!
"Change at least every 3 months. And only use soft! If you are brushing correctly, anything harder will damage your gums. We used to keep our kids toothbrushes by the sink in the bathroom, on top of the counter. My wife read somewhere that flushing the toilet caused an aerosol mist that floated over and contaminated the toothbrushes. So now we keep their toothbrushes in the drawer."
"Yes, I have to watch to see that my kids brush."
"One word on toothpastes. We use them, but they are not necessary. Brushing is the key. The reason I say this is when the counts are low, the toothpaste may cause or aggravate the mouth sores. If you are brushing/massaging with whatever you are using to clean the teeth and there is a film or slime coming out, then the toothpaste is too strong. You essentially are burning the initial layers of mucosa off in their mouths, and this is what you are seeing."
Sodas and Fruits. Both have an acid in them, Both have sugar in them. Bacteria break down sugar into acids. The acids give your teeth the cavities. Sodas and fruits are harmful because the speed up the cavity process by having the acid already in the product. We need the fruits, so you have to brush right after eating them or rinse your mouth out. A recent study showed it is better not to brush if you are doing fruits if you can't immediately brush because you will brush the decalcified part of the tooth away. It takes 15 minutes to neutralize acids we ingest. Kool-Aid and other candy drinks are bad, but not as bad because of the lack of acid. They will still do damage, though.
Remember, It is better to eat a whole box of candy at one sitting (for your teeth) than to eat one piece every day. Less damage to the teeth. It is better to drink a soda at mealtime than to nurse it over several hours. No sooner does the saliva neutralize the acid than you dump more acid on it. You are slowly dissolving your teeth. Look in your kids mouths. If you see a chalkiness down by the gums or between teeth, these are potential cavities. (Dr. Mark)
During treatment for cancer, continue to take your child to his or her regularly scheduled visits to the dentist, ANC and platelet counts permitting. During treatment for cancer, the patient is immunosuppressed and at greater risk for oral infections of all kinds. You may need to take your child more often than before diagnosis, especially if excessive plaque builds up because of decreased saliva production. Your oncologist may advise you to give your child prophylactic antibiotics. (These topics are discussed below.)
Your dentist should look for and fix cavities as well as check for and treat periodontal disease and mouth lesions, working in conjunction with the oncology team to halt infections and maintain oral health. Sealing of the teeth to prevent cavities should also be done.
X-rays may be taken as needed; children undergoing chemotherapy are not at any greater risk than anyone else for harmful effects of X-rays. (A dental X-ray gives about the same radiation dose as a day in the sun, which is about half that of a chest X-ray. The dental x-ray machines have to be fairly new, with-in the last twenty years. "If it looks like a museum piece, it probably is, and I wouldn't use it." (Dr. Mark)
It's best if your dentist consults your child's oncologist for the latest practices for pediatric oncology dental patients and for specific therapy related dental problems. Your child's dentist can also refer to Pediatric Dentistry Reference Manual, an annual reference book which delineates the proper treatment methods for pediatric patients who are undergoing chemotherapy and for therapy related problems. I found a version of this reference manual on-line, giving parents ready access to this information:
- "Guidelines for the Management of Pediatric Dental Patients Receiving Chemotherapy, Bone Marrow Transplantation, and/or Radiation - Prevention of Bacterial Endocarditis), by the American Academy of Pediatric Dentistry (AAPD), 1997-1998 version, revised 2001. (This is still online 2011; I have a copy of this.)
How high must the ANC and platelet counts be to safely take a child undergoing chemotherapy to the dentist?
Most parents have been told by their child's oncologist that the ANC must be greater than 1000 for dental visits. This agrees with the The AAPD on-line manual gives the following general hematologic guidelines, while cautioning the dentist that specific guidelines should be established between the pediatric dentist and oncologist.
For elective dental procedures, the following must be satisfied:
- Absolute Neutrophil Count (ANC) greater than 1000
- Platelet count greater than 40,000
For emergency dental procedures:
- These may be performed with any hematologic status (any ANC or platelets value) to remove sources of infection if done in coordination with the oncology service. Consider platelet replacement if the platelet count is less than 40,000.
What are prophylactic antibiotics and why are they prescribed?
Prophylactic antibiotics are given before and after dental treatments to prevent an infection of the heart called endocarditis. This occurs in susceptible individuals when bacteria enter the bloodstream during dental work, such as routine cleanings. Patients who are immunosuppressed are susceptible to endocarditis, as well as patients who have an implanted device, for instance, a central venous catheter. The bacteria cling to the catheter - a foreign object - and grow, causing infection.
According to the AAPD on-line manual, 1997-1998 version: Prophylactic antibiotic coverage (to prevent endocarditis) should be provided according to the current American Heart Association (AHA) recommendations under the following circumstances:
- Patient has an ANC less than 500 and/or WBC less than 2000/mm
- Patient has a central venous catheter
- Patient is taking long-term immunosuppressive drugs, i.e. cyclosporine, prednisone, etc.
In discussions on-line of many parents of kids with cancer, we have found that different oncologists have different views on prophylactic antibiotics. While most doctors believe that they are necessary, there are some findings which show that kids under chemo do not get endocarditis more than the general population. Best advice: ask your child's oncologist.
Recommendations for antibiotic prophylaxis for dental procedures: www.qualitydentistry.com/dental/information/abiotic.html
Sores in the mouth occur because the cells of the mucous linings are not replaced as quickly as needed due to the chemotherapy. These sores, or lesions, can occur even in the absence of bacterial or fungal infection. Once they do occur, anti-bacterial agents should be used to prevent infection.
Remedies for Mouth Sores
General: Putting Evidence Into Practice: Evidence-Based Interventions for the Management of Oral Mucositis
- Feb. 2008 article on the Oncology Nursing Society web site
Glutamine: The son of an online list member was treated with glutamine throughout his relapse treatment to help or lessen mucositis (mouth sores, G-I tract problems) -- and it seemed to work, in that he had fewer mouth sores and never had any stomach/GI ulcers once he began glutamine. Here are some references:
Gelclair® (Cannot find the generic name for this drug, it is listed on Wikipedia without the reg mark.) This drug has been used successfully in the UK (2006). It might be available in the US (by prescription), try the Gelclair web site.
Palifermin A new drug (2004) discussed on Wikipedia. The study was published in the New England Journal of Medicine (Vol. 351, No. 25: 2590-2598).
Magic Mouth Wash: a prescription medication which is a mixture of Benadryl, Maalox, Nystatin, and lidocaine. The child swishes it around their mouth without swallowing it. It numbs the mouth for about a half hour. Some doctors prescribe it right after an intense methotrexate treatment to prevent mouth sores.
Baking Soda and Water: Swish with baking soda and water several times a day can aid in healing mouth sores.
Stannous Fluoride: With the meds our kids are taking, if we can reduce the bacteria in their mouth, the sores will be lessened if not eliminated. (Dr. Mark)
Hot Stuff helps decrease pain from mouth sores.
- Cayenne Candies - used to be available to order on the web, try a Google search
- Here are two candy recipes using cayenne pepper, which is said to help keep mouth saliva flowing and lessen the pain from mouth sores. (From a mailing from the Child Cancer Fund, Florida.)
- Cayenne Taffy
- 1 cup sugar, 3/4 cup light corn syrup, 1 tablespoon cornstarch, 2 tablespoons butter, 1 teaspoon salt, 2 teaspoons vanilla, 1/2 teaspoon cayenne pepper
- Cook all except the vanilla and pepper over medium heat into a hard ball stage (265 degrees). Stir constantly. Remove from heat and stir in vanilla and pepper. When cool enough to handle, butter hands and pull until satiny and stiff. Pull into long strips, cut into 1-inch pieces and wrap with wax paper.
- Cayenne Hard Candy
- 2 cups brown sugar, 1/4 cup molasses, 1/2 cup butter, 2 tablespoons water, 2 tablespoons vinegar, 1/2 teaspoon ground cayenne pepper.
- Stir all except pepper together over low heat until sugar is dissolved. Boil gently, stirring frequently, until candy is at hard crack stage (300 degrees). Add pepper. Drop mixture from teaspoon onto buttered slab or foil to form patties, working quickly as the mixture hardens rapidly.
This topic is covered in the survivor's section:
These pages are intended for informational purposes only and are not intended to render medical advice. The information provided on Ped Onc Resource Center should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you suspect your child has a health problem, you should consult your health care provider.