Resources and information for parents of children with cancer . . . by parents of children with cancer.

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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:

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.

Preventing Oral Infections and Tooth Decay

Oral infections and tooth decay are primarily prevented by using an antibacterial mouthwash and brushing. Proper eating also helps.

Some definitions:

Web information on mouth care:

Anti-Bacterial Mouth Rinses

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?

So, where do we get stannous fluoride for our kids?

[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?

Doesn't fluoride cause mottling of the teeth if it is used daily?

Our oncologist advised us to have our son rinse with warm salt water. What does this do?

And what about over-the-counter rinses, like Listerine?

Anti-fungal Mouth Rinses

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.

Brushing Teeth

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?

And during times of low counts?

Tell us about toothbrushes, Dr. Mark!

Proper eating to prevent tooth decay and other problems

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)

Going to the Dentist

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:

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:

For emergency dental procedures:

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:

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

Mouth sores

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

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:

  • Oral glutamine in paediatric oncology patients: a dose finding study. E Ward et al., European Journal of Clinical Nutrition (2003) 57, 31–36. Abstract.
  • Bone Marrow Transplant 1998 Aug;22(4):339-44 Effect of low-dose oral glutamine on painful stomatitis during bone marrow transplantation. Anderson PM, Ramsay NK, Shu XO, Rydholm N, Rogosheske J, Nicklow R, Weisdorf DJ, Skubitz KM.
  • Cancer 1998 Oct 1;83(7):1433-9 Oral glutamine reduces the duration and severity of stomatitis after cytotoxic cancer chemotherapy. Anderson PM, Schroeder G, Skubitz KM. Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
  • JPEN J Parenter Enteral Nutr 1999 May-Jun;23(3):117-22 Oral and parenteral glutamine in bone marrow transplantation: a randomized, double-blind study. Schloerb PR, Skikne BS.
  • Oral glutamine to prevent chemotherapy induced stomatitis: A pilot study. Keith M. Skubitz, Peter M. Anderson, The Journal of Laboratory and Clinical Medicine, Volume 127, Issue 2, Pages 223-228 (February 1996). Abstract.
  • JPEN J Parenter Enteral Nutr 2000 Mar-Apr;24(2):61-6 Effect of oral glutamine supplementation during bone marrow transplantation. Coghlin Dickson TM, Wong RM, offrin RS, Shizuru JA, Johnston LJ, Hu WW, Blume KG, Stockerl-Goldstein KE.
  • Br J Nutr 2002 Jan;87 Suppl 1:S9-15 Glutamine supplementation in bone marrow transplantation. Ziegler TR.
  • Glutamine facilitates chemotherapy while reducing toxicity. Klimberg VS, Nwokedi E, Hutchins LF, Pappas AA, Lang NP, Broadwater JR, Read RC, Westbrook KC. J Parenter Enteral Nutr. 1992 Nov-Dec;16(6 Suppl):83S-87S.
  • Glutamine protects against doxorubicin-induced cardiotoxicity. Cao Y, Kennedy R, Klimberg VS. J Surg Res. 1999 Jul;85(1):178-82.
  • 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.

  • Baking Soda/Hydrogen Peroxide: 1/8 tsp baking soda, 1/4 tsp salt, 1/2 tsp hydrogen peroxide in 4 oz water. For 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.

    Long Term Effects on Teeth

    This topic is covered in the survivor's section:

    General Disclaimer

    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.

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