Chemotherapy: considerations for dental hygienists.

ABSTRACT

The incidence and mortality of cancer are on the rise in Canada. Chemotherapy is a highly aggressive, systemic cancer treatment that is used solely, or in conjunction with other modalities such as surgery or radiation. Its purpose is to cure a cancer, provide symptomatic relief or palliative comfort, and improve quality of life. Consequently, clinically practising dental hygienists can reasonably expect that they will provide care, at some time, to clients who have had cancer or are undergoing treatment for the disease. As primary oral healthcare providers, dental hygienists are responsible for providing comprehensive, safe, and effective care for a variety of healthy and medically compromised people. Oral and medical side effects, as well as psychosocial issues affecting clients undergoing chemotherapy will have an impact on the assessment, diagnosis, planning, and implementation of dental hygiene care. Information provided by an intraoral assessment, review of the medical history, consultation with physicians, oncologists and dentists, and listening to the client, will enable dental hygienists recognize some of the oral complications of chemotherapy and provide helpful home care advice.

RESUME

L'incidence et la mortalite dues au cancer augmentent au Canada. La chimiotherapie est un traitement tres agressif du cancer generalise, qui est administre seul ou conjointement avec d'autres modalites, telles la chirurgie ou la radiotherapie. Elle a pour objectif de guerir un cancer, de soulager des symptomes ou apporter un soutien palliatif et d'ameliorer ainsi la qualite de vie. En consequence, les hygienistes dentaires qui exercent en clinique peuvent raisonnablement s'attendre a prodiguer parfois des soins a des patients atteints de cancer ou recevant des traite-ments pour la maladie. Dispensatrices de soins buccodentaires primaires, les hygienistes dentaires se doivent de prodiguer des soins complets, securitaires et efficaces a divers clients. Les effets secondares sur les plans buccal et medical ainsi que les problemes psychosociaux affectant les patients sous traitement chimiotherapique auront un impact sur devaluation, le diagnostic, la planification et la prestation des soins en hygiene dentaire. L'information fournie par revaluation intra-buccale, I'examen des antecedents medicaux, la consultation avec le medecin, I'oncologiste et le dentiste ainsi que I'ecoute du patient permettront a I'hygieniste dentaire de reconnaftre certaines des complications buccales de la chimiotherapie et de conseiller les patients sur les soins a appliquer a la maison pour pallier aux symptomes.

Keywords: chemotherapy; oral complications; medical side-effects; psychosocial considerations; dental hygienist; oral care

INTRODUCTION

Cancer is a cellular disease (1). Chemotherapy is the systemic chemical treatment of cancer; it involves using a drug or combination of drugs to kill, slow, or stop cancer cells from multiplying or metastasizing (2), Goals of chemotherapy include destroying cancer, shrinking the tumour prior to adjunctive surgical or radiation treatment, destroying remaining cancer cells following surgery or radiation treatment, or both. (3) Although chemotherapeutic agents attack rapidly-dividing cancerous cells, they also damage healthy cells and tissue, including the highly sensitive oral mucosal lining and bone marrow, causing numerous temporary and potentially permanent side effects. (2), (4) The incidence of oral complications in adults undergoing chemotherapy averages 40 per cent (5), (6), with a range of 12%-80% of patients affected. (7), (8) Incidence and severity of complications are often dependent on the degree of stomatotoxicity and myelosuppression caused by the various chemotherapeutic agents.9-10

Roles of primary oral healthcare providers

A clean, healthy oral environment can substantially reduce the oral and systemic side effects and complications of chemotherapy. (11) Consequently, the oral healthcare team collaborates with the client and their multidisciplinary medical team to obtain optimal results of medical treatment with minimal side effects. Goals and objectives fall into two broad categories: 1) Assessment, diagnosis, treatment and management (including eradication or stabilization) of existing oral diseases (including caries, apical and periodontal infections) and oral complications secondary to chemotherapy. (8) (11-13) (2) Education of clients, their families and their caregivers regarding the importance of optimal oral health, effective self-care strategies prior to, during and following cancer treatment, and possible short- and long-term side effects (11-13). *

Central venous lines

Chemotherapy drugs may be administered in a variety of ways. Although oral delivery causes the least disruption of normal daily activities, it does require a high degree of patient compliance (14). Chemotherapeutic agents given by injection requiring the patient to visit a medical clinic or a physician's office will also cause minimal interruption to daily life. A third way of administering chemotherapy is via a central venous line.

A central venous line--also referred to as a 'Hickman'[R] line, peripherally inserted central catheter (PICC line), or 'Port-a-Cath'[R] (14)--is a catheter inserted into a large vein (often the subclavian vein just inferior to the clavicle).(15) Central venous lines are used to administer chemotherapy drugs and withdraw blood for analysis. Dental hygienists need to be aware that clients, who are preparing for or undergoing chemotherapy, may have a central venous line or catheter inserted. These catheters are susceptible to blood borne infections, and although there is little scientific evidence showing a direct causal link between oral bacteria introduced systemically via invasive dental procedures and the infection of central lines (8), (12), literature indicates that infected lines are frequently colonized by Staphylococcus aureus and Staphylococcus epidermidis (16). Because these pathogens are commonly found in the oral cavity(17'18) as well as within periodontal pockets,(18), (19) the mouth may be considered a portal of entry for the systemic infection of these microorganisms. (19) Consequently, it is frequently recommended that people with central venous lines be prescribed prophylactic antibiotic coverage as outlined by the American Heart Association (AHA) prior to invasive dental or dental hygiene treatment (8), (11-13).

Oral complications of chemotherapy

Oral complications related to chemotherapy are complex and multifaceted (8), (12). "Primarily, the stomatotoxicity of the treatment regimen causes direct injury to oral mucosa. Secondarily, oral complications arise from indirect toxicities, including those caused by myelosuppression (i.e., suppression of the bone marrow's ability to produce immune cells such as neutrophils, considered one of the body's primary defenses against harmful bacteria) (9), (21), (23). Myelosuppression can interfere with normal healing processes and inhibit the control of infections (7), (9), (21). Oral complications may include mucositis, infection, bleeding, xerostomia, dysguesia (impaired taste), dysphagia (difficulty swallowing) and neurotoxicity (pain) (8), (9).

Oral mucositis

Healthy oral epithelial tissues turn over every 7-16 days (6), (8), (24). Because chemotherapy agents affect rapidly dividing cells,4 ulcerative mucosal changes appear approximately 4-14 days following initiation of stomatotoxic chemotherapy (8), (25), (26). Inflammation and severe ulceration of oral mucosal tissues that occur secondary to cancer therapy is known as oral mucositis (4), (9), (25), (27), an acute side effect. (25) Variables affecting its severity may include the patient's medical diagnosis, age, level of oral health, type and dose of cytotoxic agent used, and the frequency and duration of treatment (29). For example, patients with hematological neoplasms, or who are undergoing bone marrow transplantation, are more likely to develop severe mucositis than patients receiving treatment for solid tumours (9). This relationship is likely due to the disease process itself, the immunosuppressive nature of the drug therapy, the cytotoxic dosage and frequency of administration.(7-9), (21) Furthermore, because the ulcerations associated with mucositis may become entry portals for bacterial, fungal and viral microorganisms, the risk of developing septicemia is a very serious concern (7), (8), (25), (26), (28). Patients with oral mucositis often experience unrelenting pain27 that may be accompanied by an inability to take any nutritional substances by mouth, contributing to nutritional deficiencies and dehydration.7'2529 Oral mucositis has often been described as the most significant and debilitating complication associated with chemotherapy; it may affect overall quality of life.9'11'26'29'30 Consequently, because patients may not be able to tolerate side effects accompanying optimal therapeutic doses of chemotherapy, oral mucositis is often considered a dose limiting factor of effective cytotoxic cancer therapy (7), (9), (25), (27), possibly affecting treatment outcomes (5), (9).

Although the role of oral micro organisms in the development and resolution of mucositis is not fully understood,2''29 it is theorized that myelosuppressed patients are predisposed to oral infections that may prolong or aggravate the course of mucositis.29 Altered oral flora, gram-negative bacteria and related endotoxins, potent inflammatory propagators (29), and Herpes Simplex Virus (HSV)9-25 may all influence the development and severity of oral mucositis (29). Outcomes of research studying the effect of oral care in the prevention and reduction of mucositis are contradictory (25), (27), (28); however, investigators from multi-disciplinary teams suggest that optimal oral care prior to chemotherapy, including treatment of dental caries, periodontal disease and periapical infection (25), (29), will minimize the pathological effects of oral microflora, thereby preventing or diminishing discomfort and risk of systemic sequelae associated with oral mucositis (29), (35).

The treatment and management of mucositis has been extensively studied (25), (29), however, most research has focused on palliation of symptoms. (10) Although treatment options have also been investigated, there are currently conflicting reports regarding the effectiveness of the various modalities.zs Management strategies may include effective oral care (both professional and self-care), infection prevention, anti-inflammatory agents, cryotherapy (i.e., sucking on ice chips) (27), laser therapy and treatment with such protein based growth factors as Paliferimin.34 Palifer-imin is a modified laboratory manufactured version of the keratinocyte growth factor (KGF), a human growth protein approved by the FDA,34 and recommended by the Multinational Association of Supportive Care in Cancer (MASCC) and the International Society for Oral Oncology (ISOO) to prevent or reduce the severity of oral mucositis resulting from high dose chemo therapy.

As professionals dedicated to the promotion of oral and overall health, dental hygienists play an integral role in the management of chemotherapy-induced oral mucositis. Dental hygienists help people in the preparatory stages of chemotherapy, during active treatment and post-treatment. Their responsibilities are both clinical and educational in nature. There is little scientific evidence to support that optimal oral self care is necessary for the prevention of oral mucositis. However, caries prevention, the treatment and control of periodontal disease (29), nutritional counselling, and self care education (33-36) have all been determined to be beneficial in the successful management of mucositis. The removal of calculus and subgingival biofilm has been shown to help optimize oral health by minimizing the oral complications of chemotherapy including mucositis, bleeding, local and systemic infection and pain (24).

The Mucositis Study Group Guidelines Panel (36) (a group that included dental hygienists) of the MASCC/ISOO stated that basic oral care is part of the foundation of supportive care for patients receiving cancer treatment. Consequently, clients undergoing chemotherapy are advised to attain and maintain optimal oral health despite the limited scientific evidence to support the need to do so.58'2937 The goal of basic oral care is to minimize the influence of microbial flora on oral mucosa and subsequently minimize resulting sequelae such as systemic infection and oral pain. (33) As suggested by McGuire et al. (2006) and the Basic Oral Care Group of the MASCC, (33) basic oral care includes brushing (with regular replacement of toothbrushes), flossing, rinsing with bland solutions (such as sodium bicarbonate and water) and using mouth moisturizers. Because severity of mucositis increases with high dose chemotherapy or increased duration of treatment, (8) dental hygienists in their role as clinicians and educators have a responsibility to help clients reduce the discomfort and the oral side effects associated with chemotherapy.

Hematological considerations

As noted, many chemotherapeutic protocols are myelo-suppressive in nature, causing patients to become neutropenic and thrombocytopenic, thereby increasing their risk for infection and hemorrhage. (38) Normally, chemotherapy is administered in cycles or phases, (12),(13) and several cycles are often required to achieve optimal treatment goals. The timing of medically necessary dental and dental hygiene treatment is crucial, completing dental care prior to chemotherapy is recommended. (13) Approximately 5-7 days after beginning a cycle of chemotherapy, blood counts (including red cells, white cells, and platelets) begin to fall and continue to fall until approximately day 14-21, At that time they begin to recover, reaching normal levels in the few days prior to the start of the next cycle. (12),(13) If dental or dental hygiene treatment is not completed prior to the initiation of chemotherapy, it is recommended that medically necessary or emergency treatment (i.e., in case of pain, infection, swelling or any combination) be carried out when the patient is hematologically stable just prior to the start of a cycle. (13) Determining hematological stability and safety to provide dental hygiene treatment is a collaborative process between dental hygienists, oncologists, family physicians, primary care nurses and dentists. (13) A complete blood count (CBC), ordered by the patient's oncologist or family physician, and used as an interpretive tool will ensure the dental hygienist is aware of any necessary treatment precautions. See Figure 1.

[FIGURE 1 OMITTED]

Infection

Infection is a very serious complication of chemotherapy. Because of the lack of neutrophils caused by myelo-suppression, neutropenic patients may not display classic signs and symptoms of inflammation and infection. (11), (19) It is hypothesized that periodontal infections may not be detected visually because deeper areas of the periodontium may be involved. (19) Therefore, systemic sepsis may result from unrecognized, and subsequently undiagnosed, infections with periodontal foci. (19),(39) It has been suggested that culturing possible areas of oral infection may be advisable if patients become febrile and the origin of infection is not known. (13) Although the degree to which subgingival microflora contributes to systemic infection is largely unknown, it is likely underestimated. (19) Further, there is evidence linking pre-existing gingivitis and periodontitis to fever. (19),(39) Research shows that people with severe periodontal disease develop an increased number of fevers--typically an indicator of systemic infection--over those with a healthy periodontal status.(19),(39)

In addition, neutropenia (or neutropenic dysfunction) may not only predispose a patient to infection, it may also contribute to extreme periodontal breakdown. (40) Because typical signs and symptoms of periodontal disease may be decreased, masked or absent in immunosuppressed clients, (11), (13) an accurate assessment of periodontal health cannot be made without taking the underlying medical condition and hematological status into consideration. Therefore, it is insufficient to consider the appearance of the gingivae as an indicator of periodontal health or disease.(19) Consequently, a comprehensive periodontal assessment--including measurement of clinical attachment levels and radiographic interpretation (19)- for all clients is required in order to accurately diagnose periodontal status.

When treating a client undergoing chemotherapy, the 'absolute neutrophil count' (i.e., the actual number of neutrophils present in circulating blood) is a medical consideration that will have a direct impact on the safe provision of dental hygiene care. Although recommendations vary, it is suggested that prophylactic antibiotic coverage (AHA guidelines) be prescribed if the neutrophil count is between 1,000/m[m.sup.3] and 2,000/m[m..sup.3]. Alternatively, it has been suggested that a neutrophil count above 1,000/m[m.sup.3] requires no antibiotics. If a neutrophil count is below 1,000/m[m.sup.3], deferral of elective dental and dental hygiene care is recommended. (8),(13) In cases of medically necessary treatment or dental emergencies, alternative or more comprehensive antibiotic protocol may be necessary. (8),(12) See Table 1. Consequently, consultation with the patient's oncologist is necessary to determine hematological status (blood cell counts and safety to proceed) related to disease process and myelosuppressive chemotherapy.

Hemorrhage

A client's potential risk of hemorrhage and bleeding emergencies resulting from thrombocytopenia (reduced platelets) is another potentially serious concern for dental hygienists. (38) To ensure that a patient's bone marrow is functioning adequately or has sufficiently recovered from a round of chemotherapy, dental hygienists should obtain a current platelet count (38) and clearance to proceed from the oncologist prior to initiating with dental hygiene treatment. Guidelines indicate there are no contraindications to invasive oral care if the platelet count is >75,000/mm3. A platelet count <40,000/mm3--75,000/mm may require platelet transfusion, and if >40,000/m[m.sup.3], it is recommended that dental hygiene and dental care be deferred. (8),(12) See Table 1. Because of the complexities involved in providing safe care to someone requiring a pre- or post-dental treatment blood transfusion, it would be appropriate to provide dental hygiene care in a hospital-based dental clinic. When thrombocytopenia or other clotting concerns, such as an elevated International Normalized Ratio (INR) which is the numeric value used to report blood coagulation, are evident scaling a 'test' site to observe bleeding response may help the dental hygienist determine whether or not it is safe to proceed. Spontaneous oozing8 may occur if the platelet count is below 30,000mm3, especially in the presence of pre-existing periodontal disease. Although patients may be directed to suspend oral home-care practices, it has been shown that minimal bleeding occurs during periods of thrombocytopenia if periodontal health has been attained and is maintained (6).

In the event of an oral 'bleed', several strategies can be utilized to control it, including locally applied pressure, anti-fibrinolytic rinses and such systemic measures as platelet transfusions (12), (38), (41).

Consideration                        Recommendation       Commentary

Clints with central venous         * AHA              * This precaution
catheters (i.e. Hickman [R],       prophylactic       is often
Port-a-Cath [R] PICC Line).        antibiotic         recommended in
                                   recommendations.   the absence of
                                                      firm scientific
                                                      support.

Hematological Variables

May be related to disease process
or medical treatment.

Absolute Neutrophil Count

> 2,000/m[m.sup.3]                 * Nt special
                                   considerations
                                   necessary.

1,000/m[m.sup.3]-2,000/m[m.sup.3]  * AHA              * Consultation
                                   prophylactic       is recommended
                                   antibiotic         as clinical
                                   protocol           opinion and
                                   recommended.       judgement may
                                                      vary.

< 1,000/m[m.sup.3]                 * Deferral if      * Consultation
                                   invasive           with the
                                   dental/dental      client's
                                   hygiene            oncologist is
                                   treatment.         crucial to
                                                      determine any
                                                      medically
                                                      necessary
                                                      invasive
                                                      dental and
                                                      dental hygiene
                                                      treatment and
                                                      appropriate
                                                      antibiotic
                                                      coverage.

                                   * Alternative or
                                   more
                                   comprehensive
                                   prophylactic
                                   antibiotics may
                                   be necessary.

Platelets **

> 75,000/m[m.sup.3]                * No special       * It may be
                                   precautions        prudent to
                                   necessary.         scale a 'test
                                                      site' and
                                                      observe
                                                      bleeding
                                                      response.

40,000/m[m.sup.3]                  * Locally applied  * If
                                   techniques to      transfusion is
                                   maintain control   determined to
                                   of bleeding i.e.   be required,
                                   pressure,          careful
                                   minimize trauma.   attention to
                                                      co-ordination
                                                      of treatment
                                                      is needed.

                                   * Platelet         * It may be
                                   transfusion may    prudent for
                                   be necessary.      the client to
                                                      receive.
                                                      treatment in a
                                                      hospital
                                                      dental clinic
                                                      setting.

< 40,000/m[m.sup.3]                * Transfusion of   * Careful
                                   platelets 1 hour   consideration
                                   prior to invasive  to comfort
                                   treatment.         level of
                                                      clinician in
                                                      providing DH
                                                      treatment is
                                                      crucial.

                                                      * Providing DH
                                                      care under
                                                      these
                                                      circumstances
                                                      may be
                                                      ill-advised in
                                                      a private
                                                      practice
                                                      setting.

Xerostomia

Approximately 40 per cent of people receiving chemotherapy will report xerostomia as a side effect of treatment. (8) Unlike xerostomia caused by head and neck radiation, chemotherapy induced dryness is usually temporary and resolves in 2-8 weeks following cessation of treatment. Although more studies are needed to definitively identify the overall affects of chemotherapeutic agents on salivary gland function and oral health, (20) hyposalivation is reported to cause changes in oral pH, decrease mucosal lubrication, and alter oral flora (20),(43) (including increases in levels of Streptococcus mutatis), Consequently, patients may experience difficulty in eating, swallowing and speaking, an increase in caries,(20),(42),(43)and a possible exacerbation of periodontal disease.(20),(43) Further, difficulty maintaining optimal oral health is amplified by increased plaque levels and a decreased ability to clear food from the oral cavity.(8),(20),(43) When attempting to manage xerostomia, client education is par-amount. (8) Discussing methods and products to minimize drying effects, exploring coping strategies, and providing oral home care information, may all help reduce the effects of xerostomia and improve comfort (8). Topical application of neutral sodium fluoride has been recommended to reduce or reverse the effects of dental demineralization caused by the proliferation of cariogenic bacteria and an acidic oral environment often associated with xerostomia.(8),(20),(42),(43) Palliation of symptoms may include sipping water, use of saliva substitutes and topical application of lubricating gels. Pilocarpine hydrochloride (Salagen), a drug therapy that has been used to stimulate saliva flow, also causes side effects such as sweating, increased urination with or without diarrhea (44) that may not be tolerable for some people. (43-44) Some mouth rinses may buffer pH (such as a solution of sodium bicarbonate and water) and reduce risk of infection caused by a change in flora (such as chlorhexidine). (45) Counselling clients to avoid foods that may damage fragile mucosa (such as highly spiced or hard/crusty foods) and substitute soft, bland foods that may be better tolerated may also help reduce xerostomia induced discomfort. (45)

Psychosocial considerations

In addition to coping with the physical side effects associated with cancer treatment, patients may experience numerous, and often serious, psychosocial issues (46). Studies have shown that up to 94 per cent of patients believe that issues pertaining to their cancer diagnosis and its treatment are emotionally distressing. (46) Distress attributable to chemotherapy treatment may centre on family and marital relationships, sexual relationships, financial concerns, and changes in activity levels (both generally and employment-related specifically) (46). According to the Canadian Cancer Society, the emotional effects of cancer may include denial, fear, panic, loneliness, sadness, and frustration, and are often accompanied by feelings of stress and anxiety (47). Clients may become depressed or very angry. The release of emotion that manifests as anger may be directed toward many things or people, including health care providers. Consequently, when working with clients who appear unduly angry, dental hygienists need to be mindful that the anger may be linked to their disease and situation rather than directed towards the clinician personally.

By providing information pertaining to some of the obstacles and oral complications they may face and strategies to minimize them, dental hygienists are in a position to help clients alleviate some of the anxiety that often accompanies fear-provoking elements of their disease and medical treatment. Because clients often substantially underestimate the impact of potential side effects, (48) having sufficient information enhances their understanding and preparation, and enables them to provide informed consent for dental hygiene treatment. (49) However, although dental hygienists can certainly acknowledge client distress, show empathy for their situation, and help them with some coping strategies, the management or treatment of severely distressed, depressed or angry clients may be beyond our scope of practice. In these cases, it is appropriate to refer clients to other healthcare providers who are more qualified to address their emotional needs.

Open communication is a key to helping clients stay informed and knowledgeable. However, sometimes providing too much information can be overwhelming and can inhibit informed decision making (49). Suggestions to facilitate communication include:

(1.) Ask clients to have someone accompany them to the dental hygiene appointment. The additional person may take notes during the discussion with the client or may think of additional points or questions.

(2.) Advise the clients to write down any questions (and subsequent answers), so they do not forget to discuss or ask about anything they believed was important. The client should be encouraged to ask questions. (50)

(3.) Involve the client and employ evidence-based decisions. (51) When a dental hygienist or a client has a question regarding the client's dental hygiene care, the dental hygienist should be prepared to research the literature and use critical thinking to evaluate the findings.(51),(54) Discussing viable treatment options with clients will help them make decisions that align with their best interests and reflect their preferences. (49),(51)

In addition to the emotional and physical distress experienced by people undergoing chemotherapy, the financial cost of cancer and cancer treatment are often significant, causing an additional and unexpected burden. (46),(55),(56) Even though provincial and federal health care sources and third party insurance plans may incur some of the costs, approximately 20 per cent of Canadians find the financial load problematic. (55) In Canada, indirect costs, such as lost production and employment income, have been shown to be considerably greater than those medical expenses incurred directly by the client. (55),(57) Consequently, some clients may find it difficult to pay for the additional expenses associated with accessing dental and dental hygiene care. For some, the cost of being ill can seem overwhelming. Referral to an education setting, such as a dental or dental hygiene school where care is often available at a substantially reduced cost, may be one cost saving solution.

Summary

Dental hygienists must remain vigilant when providing care for clients who are receiving or who have received chemotherapy. Through collaboration with oncologists, family physicians and dentists, dental hygienists can safely and effectively provide dental hygiene services for this client group. Consideration should be given to medical issues such as hematological stability, the presence of a central venous line, timing of care during cycles of chemotherapy, as well as oral complications such as mucositis, xerostomia, bleeding and infection. Preventive and therapeutic intervention (including clinical care, education, and counselling for coping strategies) will help address the physical and emotional needs of this unique group of clients.

When reviewing the literature, it became clear that few articles exist pertaining specifically to the role of dental hygienists in the oral care of cancer patients. Despite apparent lack of published information, it is evident that as primary health care professionals, dental hygienists provide valuable therapeutic and preventative care for clients diagnosed with cancer and receiving treatment. The elements included in a dental hygienist's scope of practice make this group of professionals ideally suited to providing oral care and counselling prior to, during and following cancer treatment. Consequently, despite the lack of reference to dental hygienists in the reviewed literature, it is apparent that dental hygienists are integral members of interdisciplinary teams providing care for cancer patients.

REFERENCES

(1.) Canadian Cancer Society. What is cancer? 2007 Feb [cited 2008 Apr 4]; Available from: http://www.cancer.ca/ccs/internct/ standard/0,3182,3172_562847522__langId-en,00.html

(2.) Canadian Cancer Society. Chemotherapy. 2006 Jan [cited 2008 Apr 4]; Available from: http://www.cancer.ca/ccs/internet/ standard/0,3182,3172_369257_langld-en,00.html

(3.) Canadian Cancer Society. The goals of chemotherapy. 2006 Jan [cited 2008 Apr 4]; Available from: http://www.cancer.ca/ccs/ internet/standard/0,3182,3172_369257_242765809_langld-en,00.html

(4.) Canadian Cancer Society. Managing side effects. 2006. [cited 2008 Apr 4|; http://www.cancer.ca/ccs/internet/stan-dard/0,3182,3172_210289022_langld-en,00.html

(5.) Djuric M, Hillier-Kolarov V, Belic, A., Jankovic L. Mucositis prevention by improved dental care in acute leukemia patients. Support Care Cancer. 2006;14:137-146.

(6.) Schubert MM. Measurement of Oral Tissue Damage and Mucositis Pain. Chap 15. [cited 2008 Jan 12J; Available from: http:// www.painresearch.utah.edu/canceTpain/chl5.html

(7.) Sonis ST. Mucositis as a biological process: a new hypothesis for the development of chemotheirapv-induced stomatotoxic-ity. Oral Oncol. 1998 Jan;34(l):39-43.

(8.) Complications of Chemotherapy and Head./Neck Radiation. [Monograph. Cited 2008 Apr 15.] Available from: http://www.cancer.gov/cancertopics/pdq/supportivecare/ oralcomplications/HealthProfessional.

(9.) Volpato L, Silva T, Oliveira T, Sakai V, Macbado, M. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otarrtmlaringol. 2007;73(4);562-68.

(10.) Sadler GR, Oberle-Edwards L, Farooqi A, Hryniuk W. Oral Sequelae of Chemotherapy: An Important Teaching Opportunity of Oncology Health Care Providers and Their Patients. Support Care Cancer.8:209-214

(11.) Westbrook SD, Paunovich ED, Freytes CO. Adult hemopoietic stem cell transplantation. / Am Dent Assoc. 2003 Sep; 134(9): 1224-31.

(12.) American Academy of Pediatric Dentistry Clinical Affairs Committee Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation. Pediatr Dent. 2005-2006;27(7 Suppl):170-5.

(13.) BC Cancer Agency. Oral/Dental Care [monograph on the Internet]. May 2003 [cited 2008 Apr 1|. Available from: http:// www.bccancer.bc.ca/Nil/exeres/578E62C9-12D8-446F-ABB8-D055AlECF0A6.htm

(14.) Canadian Cancer Society. How is chemotherapy given. 2008 Feb [cited 2008 Apr 4]; Available from: http://www.cancer.ca/ ccs/internet/standard/0,3182,3172_369257_242785660_lang-ld-en,00.html

(15.) Kaiser CW, Koomick AR, Smith N, Soroff HS. Choice of route for central venous cannulation: Subclavian or internal jugular vein? A prospective randomized study. / Surg Oncol. 1981;17(4):345-54.

(16.) Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, Craven DE; Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis. 2001 May;32(9):1249-72.

(17.) Todar K.Online Textbook of Bacteriology: The Bacterial Flora of Humans. [Monograph. Cited 2008 May 1] Available at: http://www.textbookofbacterioloHy.net/

(18.) Loberto JCS, Martins CAP, Sanots SSF, Cortelli JR, Jorge AOC. Staphylococcus SPP. In the oral cavity and periodontal pockets of chronic periodontitis patients. Brazilian journal of Microbiology. 2004;53:64-68.

(19.) ber-Durlacher JE, Epstein JB, Raber J, van Dissel JT, van Win-kelhoff AJ, Guiot HF, van der Velden U. Periodontal infection in cancer patients treated with high-dose chemotherapy. Support Care Cancer. 2002 Sep;10(6):466-73.

(20.) Jensen SB, Pedersen AM, ReibeS J, Nauntofte B, Xerostomia and hypofunction of the salivary glands in cancer therapy. Support Care Cancer. 2003 Apr;ll(4):207-25.

(21.) Naidu MU, Ramana GV, Rani PU, Mohan IK, Suman A, Roy P. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia. 2004 Sep-Oct;6(5):423-31.

(22.) WilkesJD. Prevention and treatment of oral mucositis following cancer chemotherapy. Semin Oncol. 1998 Oct;25(5):538-51.

(23.) Piatkowska-Jakubas B, Darczuk D, Chomyszyn-Gajewska M, SkotnickiAB. Mucositis-a major non-hematologiccomplication of high-dose chemotherapy and radiotherapy-pathogenesi-., prevention and treatment. Przegl Lek. 2003;60(12):815-20.

(24.) Brennan MT, von Btiltzingslowen I, Schubert MM, Keefe D. Alimentary mucositis: putting the guidelines into practice. Support Care Cancer. 2006 Jun; 14(6):573-9.

(25.) Redding, SW. Cancer Therapy-Related Oral Mucositis. / Dent Educ. 2005 Aug;69(8):919-29.

(26.) Sonis ST. Pathobiology of oral mucositis: novel insights and opportunities. J Support Oncol. 2007 Oct;5(9 Suppl 4):3-ll.

(27.) Worthington HV, Clarkson JE, Eden OB. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews. 2007, Issue 4. Art. No.: CD000978. DOI: 10.1002/14651858.CD000978. pub3.

(28.) Lopez-Castano F, Onate-Sanchez RE, Roldan-Chicano R, Ca-brerizo-Merino MC. Measurement of secondary mucositis to oncolhematologic treatment by means of different scale. Med Oral Patol Oral CirBucal. 2005;10(5):412-21.

(29.) Plevorva, P. Prevention and treatment of chemotherapy- and radiotherapy- induced oral mucositis: a review. Oral Oncol. 1999Sep;35(5):453-70.

(30.) Cheng KK, Molassiotis A, Chang AM, Wai WC, Cheung SS. Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients. Eur J Cancer. 2001 Nov;37(16):2056-63.

(31.) Borowski B, Benhamou E, Pico JL, Lapianche A, Margainaud JP, Hayat M. Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: a randomised controlled trial comparing two protocols of dental care. Eur J Cancer B Oral Oncol. 1994;30B(2):93-7.

(32.) Levy-Polack MP, Sebelli P, Polack NL. Incidence of oral complications and application of a preventive protocol in children with acute leukemia. Spec Care Dentist. 1998 Sep-Oct;18(S):189-93.

(33.) McGuire D. Correa MEP, Johnson J, Wienandts P. The role of basic oral care and good clinical practice principles in the management of oral mucositis. Support Care Cancer. 2006;14:541-547.

(34.) U.S. Food and Drug Administration. Questions and Answers on Palifermin (Keratinocyte Growth Factor). 2004 Dec [cited 2008 Apr 4J; Available from: http://www.fda.gov/Cder/Drug/ infopage/palifermin/paliferminQA.htm

(35.) Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Rab-er-Durlacher JE, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007 Mar 1;109(5):820-31.

(36.) Rubenstein EB, Peterson DE, Schubert M, Keefe D, McGuire D, Epstein J, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer. 2004 May; 100(9 Suppl):2026-46.

(37.) Jansma j, Vissink A, Spijkervet FK, Roodenhurg JL, Panders AK, Vermey A, Szabo BG, Gravenmade EJ. Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy. Cancer. 1992 Oct;70(8):2171-80.

(38.) Israels S, Schwetz N, Boyar R, McNicoI A. Bleeding disorders: characterization, dental considerations and management. / Can Dent Assoc. 2006 Nov;72{9):827.

(39.) Laine PO, Lindqvist JC, Pyrhonen SO, Strand-Pettinen IM, Teerenhovi LM, Meurman JH. Oral infection as a reason for febrile episodes in lymphoma patients receiving cytostatic drugs. Eur J Cancer B Oral Oncol. 1992 Oct; 28B (2):103-7.

(40.) Van Dyke TE, Hoop GA. Neutrophil function and oral disease. Crit Rev Oral Biol Med. 1990; 1(2): 117-33.

(41.) Gupta A, Epstein JB, Cabay RJ. Bleeding disorders of importance in dental care and related patient management. / Can Dent Assoc. 2007 Feb;73(1):77-83.

(42.) Turner MD, Ship JA. Dry mouth and its effects on the oral health of elderly people. / Am Dent Assoc. 2007 Sep;138 SuppI:15S-20S.

(43.) Holmes S. Xerostomia: aetiology and management in cancer patients. Support Care Cancer. 1998 Jul;6(4):348-55.

(44.) Papas AS, Sherrer YS, Charney M, Golden HE, Medsger TA Jr, Walsh BT, et al. Successful treatment of dry mouth and dry eye symptoms in Sjogren's Syndrome patients with oral pilocarpine: A randomized, placebo-controlled, dose-adjustment study. / Clin Rheumatol. 2004 Aug;10(4):169-177.

(45.) Nieuw Amerongen AV, Veerman EC. Current therapies for xerostomia and salivary gland hypofunction associated with cancer therapies. Support Care Cancer. 2003 Apr;ll(4);226-31.

(46.) Meyerowitz BE, Sparks FC, Spears IK. Adjuvant chemotherapy for breast carcinoma: psychosocial implications. Cancer. 1979 May;43(5):1613-8.

(47.) Canadian Cancer Society. The emotional effects of cancer, [onlinej. 2007 Apr 30 [cited 2008 May7j; Available from: URL:http://www.cancer.ca/ccs/internet/standard/0,3182,3172_369293_816477263 langld-en,00.html

(48.) Love RR, Leventhal H, Easterling DV, Nerenz DR. Side effects and emotional distress during cancer chemotherapy. Cancer. 1989 Feb 1;63(3):604-12.

(49.) Mappes TA, Degrazia D. Biomedical Ethics. 6" led. Chap 2. New York: McGraw-Hill, 2006.

(50.) National Cancer Institute. Your health care team: Your doctor is only the beginning. 2000 Apr [cited 2008 May7]; Available from: http://www.cancer.gov/cancertopics/factsheet/Support/ healthcare-team

(51.) DePalma AM, Adams T. Bringing patient education into full bloom. Dental Economics. 2007 Feb [cited 2008 May7]; Available from: http://www.dentaleconornics.com/articies/ar-ticle_display.html?id=285778

(52.) Lavigne S, Forrest J. Do no harm--are you? Is your dental hygiene practice evidence-based? Part 1. Canadian Journal of Dental Hygiene. 2004;38{(5]:210-219.

(53.) Dharamsi S, Cobban SJ, Compton S. Using qualitative research for evidence-based dental hygiene practice. Canadian journal of Dental Hygiene. 2004;38(5): 220-225.

(54.) Forrest JL, Miller SA. Evidence-based decision making in dental hygiene education, practice, and research. / Dent Hyg. 2001;75(l):50-63.

(55.) Longo CJ, Fitch M, Deber RB, Williams AP. Financial and family burden associated with cancer treatment in Ontario, Canada. Support Care Cancer. 2006;14:1077-1085.

(56.) Guidry JJ, Aday LA, Zhang D, Winn RJ, Cost considerations as potential barriers to cancer treatment. Cancer Pract. 6(3):182-187.

(57.) Public Health Agency of Canada (1998) Economic burden of illness in Canada. 2002 Nov. [Cited 2008 May 2] Available from: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/2002/2002_ebic-femc_e.html

*[section] BDSc (Dental Hygiene) students. University of British Columbia. Private clinical practice.[section] Board of Directors, ODHA

Resubmitted: 12 May 2008. Revised 29 June 2008. Accepted 18 July 2008.

This is a peer reviewed article.

Correspondence to: Janet Aquilina-Arnold, [e-mail]

Janet Aquilina-Arnold *, RDH; Catherine Grater-Nakamura [section], RDH