by Shirley Gutkowski, RDH, BSDH
My high school friend is suffering. During the last 25 years, our paths have gone in different directions. She became a mother of two; I became a mother of more than two. She chose a factory job; I went to college. She stayed in the big city; I moved to a bedroom community of a small city. When our kids were exceptionally naughty, we looked to each other for support. We don't talk every week, but we do keep in touch.
Three years ago, she had a large tumor removed from a lymph node against her spine. She wouldn't walk again, they said. They did not know Renate. Chemother-apy and surgeries did not bring her down. She rallied, she bounced, she did not lose a single pound, although she did lose her eyebrows. Most importantly, she conquered her attacker, Non-Hodgkin's Lymphoma, the exact cancer my own son overcame when he was 15. At her age Renate was supposed to die, but they don't know Renate.
The Monday after her remission pronouncement (six months later), Renate found a lump on the base of her tongue. By Thursday it was getting in the way of air exchange, and she had the nasty thing removed with emergency surgery. It was a metastasis, a recurrence. She had a skimpy dance with remission. Somberness overcame us all.
What the readers of this magazine know about cancers and cancer treatments of the mouth is a world different than what lay people or even medical professionals know. Doctors had whisked her off for radiation of the invader shortly after the diagnosis was made. When she told me about the treatment, my mouth dried up, and my chin bounced off my knee on the way to the floor. I wondered to myself as she described the torture. How do I say it? How do I ask if they protected her teeth? How do I ask if she even had an oral exam or films before the "big guns" were brought in to save her life?
With Renate, I find it safe to ask it outright: "Did anyone take care of your teeth?"
"Shirley," she said to me in the exasperated tone of someone talking to a total moron, "we're trying to save my life. We didn't have time to think about teeth."
I knew it. For the duration of her time on the planet, they left her with a quality of life forever altered in a way that would remind her that she was a cancer survivor. Xerostomia would be the worst of her symptoms, and the cascade of events that would precipitate from that condition would be merciless.
Last year, she explained to me exactly how she recovered from her life-saving procedures. Because the tumor on her tongue grew so fast, the unanimous thought was that it was unstable, and therefore would be easier to kill. Regardless of this notion, the treatment plan was radiation and stem cell transplant. The artillery was assembled, and the deployment was on.
To deliver the radiation, a plaster cast is made of the recipient's head and coordinates are drawn onto it so the technician has a place to aim the beam. The tumor host is placed prone onto a table. The plaster mask is placed over the face, and secured with screws into the table. The tumor is blasted with radiation, and the host is set free until the next day. The radiation dose burns the skin, and kills all cells in the path of the deadly beam.
A stem cell transplant is a valiant effort to kill all cancer cells, inadvertently killing all cells in the human body. Essentially, a stem cell transplant brings the person to the fringe of death then brings them back to life at the last possible moment with non-cancer cells harvested from the hip-bone of the cancer host before the poisoning. For this treatment to work, the line between life and death is invisible.
Visitors are not allowed in the room as the host is pumped with toxic chemicals carrying her to death's door. Any germ unaccounted for could cause plenty of unwanted problems. Renate lived alone in the hospital room for days. Her only company were floor nurses and her doctors. When faux death is achieved, they start replacing cells from the ones harvested from her hip before the treatment. They take three times as much as they think they'll need. For Renate, they almost didn't have enough; the procedure was not flawless.
The stem cell transplant left her with no basic immune system. A superficial scrape 10 months later caused an abscess that required surgery to remove. Antibiotics are a permanent part of her medicine regimen. Any little bump or paper-cut is potentially deadly. Dental hygienists know that the mouth, with its 500 species of inhabitants, is the dirtiest place on the body. Saliva in the normal mouth keeps the number at bay by rinsing, rebuilding and lysing the troublemakers.
Renate's mouth was no longer normal. Radiation caries set in, which manifested itself as broken teeth. A sharp tooth against oral mucosa teeming with germs is an infection waiting to happen. Somewhere I read that this problem can be fatal. Surviving the disease only to be killed by the treatment is the bane of modern medicine.
Shortly after finishing all of the treatments, she called me, wondering what she could do to relieve the xerostomia. I got out the usual information, the short list of helpful aids to those suffering with desert mouth. Her dentist prescribed fluoride gel. She found that it burned, and used it sporadically. It was much later when I found the reason it burned. Someone had dispensed cinnamon-flavored gel. She uses Salagen, a prescription medication to increase saliva manufactured by the body. It has a list of adverse reactions associated with its use.
When she called last year, a secondary oral health problem emerged. Cancer treatments of this magnitude take time as well as money. Her employer has a provision for extended sick time, which holds the position open for the infirm employee for 18 months. She was over that time. The insurance coverage she had through her work had an incident limit of $1 million, and she had exhausted that. Her husband's employer had terminated all dental coverage as a money-saving measure. Renate's teeth were hurting, breaking, and cutting, and she could not afford to have them repaired. And here I sit.
Quality of life matters are like a bobber within the medical community. They lurk under the surface then every so often resurface. It seems as if medicine grapples with the importance of QOL, then becomes sidetracked with life-saving issues. If only her radiation therapy could have been postponed for a week, or a little longer for an odontologist, or physician of the mouth, to take a look. The oral sequela from treatment could have been foreseen; future tragedies could have been interrupted. Time was short in the minds of Renate's oncologist and radiologist. They wanted to bust the invader, which they did. In their haste, they moved forward without regard to how she was going to live without the intruder.
Shortly after the radiation therapy, she presented with an abscessed tooth. Treatment rendered: extraction. Under these circumstances, especially for someone in a large city where fantastic medical advances are within arm's reach, hyperbaric oxygen treatments before surgeries of any kind are highly recommended. Osteoradionecrosis (ORN) is a very real possibility with this background. ORN occurs 61 percent of the time in these situations. Having exhausted her funding from insurance, this step was skipped.
When a tooth is removed from under-oxygenated bone, the surrounding bone can die, becoming necrotic and unbearably painful. Technically, ORN occurs when the rate of cell death is exceeded by cell rate of repair. The extraction site has an oxygen requirement for healing. After radiation therapy, the tissues surrounding the trauma site cannot provide it. Death is a likely outcome and disfigurement is assured.
Hyperbaric oxygen chambers infuse tissues with oxygen, providing this needed ingredient for cell repair. Each visit is called a dive and each dive is 90 minutes. The protocol is 30 dives, evaluation of the tissue, and then 30 more dives to determine if healing is progressing.
If the bone isn't healing, then the necrotic bone is subjected to curettage and the remaining 30 dives are postponed until the procedure is completed. If that is unsuccessful, more invasive surgery is required. The bone is removed to a point where bleeding healthy bone is encountered, then 30 more dives into the HBO chamber, reconstructive surgery and another 30 dives. That's a total of 5400 minutes or 90 hours of dive time, if everything goes well. If a second surgery is required, protocol calls for a total of 16,200 minutes in the chamber. All of this can be initiated from a simple extraction.
Renate is contrary; she did not suffer this problem. She tells me today that the extraction site is getting bigger over the two years since the tooth was removed; other symptoms of ORN are not evident. She is not safe, however, because ORN can occur as early as two years after the assault and even five years later. It's likely that a full mouth series or a panoramic X-ray would have revealed the abscess time bomb before the radiation treatment commenced.
Today she is working at a fabric shop. Her teeth continue to break and she continues her quest for oral lubrication while she screws up her courage to apply the last of her cinnamon-flavored fluoride gel. I keep her abreast of things that offer her relief and keep my ears open for a chance for her to get her teeth repaired. If only there was an answer to this quandary: life vs. quality of life.
I guess my quality of life is better because she has a life. Is that selfish? Renate's spirits are always high. She's happy to be able to play with her grandson and agonize over the decisions her grown children make. She is forever anemic from the treatments and she is in constant fear of infection or recurrence. Her teeth provide a constant painful distraction.
That's her life.Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].
Before head and neck radiation therapy,
• Refer patient to dentist for pretreatment oral health exam.
• Tell dentist the treatment plan and timetable.
• Help prevent tooth demineralization and radiation caries by making sure the patient has a good oral hygiene program and has received instruction on fluoride gel application.
• Allow at least 14 days of healing for any oral surgical procedures.
• Surgical procedures are contraindicated on irradiated bone, so make sure pre-prosthetic surgery is done before treatment begins.
During radiation therapy
• Make sure the patient follows the recommended oral hygiene regimen, whether the patient is at home or hospitalized.
• Monitor patient for trismus: Check for pain or weakness in masticating muscles in the field of radiation. Instruct patient to exercise jaw muscles three times a day, opening and closing the mouth as far as possible without pain; repeat 20 times. Also, exert gentle pressure against midline mandible; then open the mouth.
After radiation therapy
• After mucositis subsides, consult with oral health team about dentures or other appliances. Patients with friable tissues and xerostomia may never be able to wear them again.
• Make sure that the patient follows up with a dentist for fluoride gel/home care compliance and trismus management. Lifelong, daily applications of fluoride gel are needed for severely xerostomic individuals.
• Advise against oral surgery on irradiated bone because of osteoradionecrosis risk. Tooth extraction, if unavoidable, should be conservative; use antibiotic coverage and possibly hyperbaric oxygen therapy.
• For pediatric patients, consult the dentist to monitor irradiated craniofacial and dental structures for abnormal growth and development.
• Refer patients to a dentist for pretreatment oral health examination.
• Tell the dentist the treatment plan and timetable.
• If oral surgery is needed, allow seven to 10 days of healing before the patient becomes meylosuppressed.
• In patients with hematologic cancers, check for immunosuppression or thrombocytopenialbefore any oral procedures.
• Consult with oral health team to schedule dental treatment.
• Conduct blood work 24 hours before any dental procedure. Postpone if:
• Platelet count is < 50,000/mm3
• neutrophil count is less than 1,000/mm3
• Consider implementing the American Heart Association endocarditis prophylactic antibiotic regimen in patients with indwelling central venous catheters before any invasive or prophylactic dental procedures.
• When fever is of unknown origin, consult a dentist to explore possible oral source of infection.
• Ask patients frequently about their oral health.
• Patient can resume regular dental recall schedule when chemotherapy is completed and all side effects, including immunosuppression, have resolved.
Bone marrow transplantation
Before bone marrow transplantation
• Refer all patients to a dentist for pretreatment oral health examination
• Schedule oral surgery to allow at least seven to 10 days of healing before expected date of bone narrow suppression (absolute neutrophil count of < 1,000/mm3 and or platelet count of less than 50,000/mm3)
• Make sure the patient follows the prescribed oral hygiene regimen and fluoride gel application schedule.
• Watch for infections on the tongue and oral mucosa. Herpes simplex and Candida Albicans are common oral infections.
After bone marrow transplantation
• Make sure that the patient follows up with a dentist for control of plaque, tooth demineralization, dental caries, and infection.
• Delay elective oral procedures for one year.
• Follow patients for long-term oral complications indicating chronic graft vs. host disease. (Stem cell transplants are auto-transplants, and do not have this problem.)
• Follow BMT patients carefully for second malignancies in oral region.
Sources: The Centers for Disease Control and Prevention, National Cancer Institute, National Institute of Nursing Research, and the U.S. Department of Health and Human Services National Institutes of Health.