Oral Health for Head and Neck Patients: HNCSA Zoom Meeting 28 Sept 2022

Our speaker for the night was Glenda McMan. Glenda is an oral health therapist, a role requiring a three year degree which qualifies her to work in children’s dentistry and in adult gum care.

She has been at the Hospital and Specialist Dentistry department for two years. This is run by the board formerly known as ADHB which serves the northern region for head and neck cancer patients. Glenda’s is a new role for New Zealand and very welcome for the Auckland team which has been been keen to get a hygienist on board for decades.

Glenda runs the weekly mucositis clinic for people going through radiation, mucositis being the inflammation and ulceration of the oral mucosa which gives us so much pain. She assesses the level of mucositis and decides on a course of action. “My role is to keep people out of hospital.”

The following notes are based on questions our Facebook members asked before the meeting and some questions asked during the meeting. The questions are in italics and the rest of the text is a summary of Glenda’s answers.

Seeing Glenda after treatment

I’m interested to hear what follow-up dental care is covered by the DHB for us Head and Neck Cancer patients post treatment.

Glenda sees patients two months after treatment for Auckland based patients. All HNC patients have one appointment with ongoing appointments on a case by case basis. This is often a combined clinic with the hospital dentist doing a post treatment review.

Clinical nurse specialist Karen Shaw advised the group to ask for help if they are having trouble with their teeth and their community dentist doesn’t seem to be taking their HNC history seriously. She or their doctor can refer them to the hospital dentistry department. Alternatively if the dentist is prepared to do the work, especially with extractions, the hospital can give advice about radiation fields.

The same would apply to people outside Auckland. It is helpful to visit a hygienist but shop around to find one who is interested in post radiotherapy care. Follow up by oral health departments across the country is “DHB dependent”. Contact your clinical nurse specialist if you feel you need to see a hospital dentist as stated above.

For Auckland patients, or if your own dentist requires further information about your treatment here is an email address: ARHSD@adhb.govt.nz

Toothbrushing after treatment

No water, no rinsing with water? Keen to hear the reasoning on this one. How long after using the high fluoride toothpaste should we wait before a salt and baking soda rinse?

Don’t dilute the good ingredients in the paste. Use a dry toothbrush and place a pea sized lump onto your soft bristled brush. Place dry toothbrush with toothpaste straight into your mouth, brush all tooth surfaces, spit and don’t rinse afterwards. Avoid eating or drinking for half an hour afterwards to allow the fluoride to do its magic. Even small amounts of saliva help deliver the fluoride into the teeth. You can stimulate saliva with sugar free gum or xylitol containing products (see below for more information).

What toothpastes should we use?

  • Colgate Neutrafluor 5000 or 3M Clinpro 5000 can only be purchased from behind the counter at the pharmacy or online, and are the best option for post radiotherapy patients. They contains 5000 parts per million of fluoride compared to ordinary toothpastes which range from 1000–1450 parts per million of fluoride. (These work well for the general population. High strength toothpastes can be expensive.  However, you only need a small amount and they will strengthen and protect teeth more effectively and act as a desensitizing toothpaste too.
  • Don’t use the high fluoride toothpastes during treatment because most of these toothpastes have sodium lauryl sulphate, the foaming agent, which can dry the mouth. After treatment the benefits of fluoride outweigh the more negative aspects of SLS.
  • Berry–licious with fluoride from Grin has natural ingredients and is designed for children but is suitable for adults.
  • Post- treatment, if your mouth isn’t feeling dry Colgate Total toothpaste is another good choice. It has amino acids that contribute to gum care, and fluoride to protect your teeth.
  • Whichever toothpaste you decide to use remember to spit out the paste. Don’t rinse with water afterwards to allow the ingredients to do their work.
  • Alternate the sides you approach your mouth from. And if the toothpaste makes your mouth sting, do a little rinse out but try not to rinse all the toothpaste off.
  • Make sure any toothpaste you buy has fluoride in it. Glenda can notice a difference when patients switch to non-fluoridated toothpaste like Red Seal.

Should people who have had radiation clean their teeth after everything they eat?

Don’t brush your teeth straight after everything you eat. Eating makes your mouth pH acidic and attacks the outer enamel surface, it becomes more open (porous). Instead, straight after eating or drinking (anything except plain water or milk) have a rinse with plain water, or even better, your baking soda rinse.

Salt and baking soda rinses

I was told that the salt & baking soda rinses, while perfect during radiotherapy treatment are not good long term for the mouth’s natural PH environment

  • During treatment, salt and baking soda rinses four times a day are advised to start with. As the treatment increases it’s worthwhile rinsing, even just a mouthful, more regularly. After treatment, you can take the salt out.
  • Warm salt water rinses may be useful if you think there is a possibility of infection. Salt is a natural antiseptic.
  • During some treatments you will find your saliva thickens, salt will help break down the mucous and baking soda acts as an anti-inflammatory.
  • “Baking soda is amazing.” A lot of food and drinks are acidic and with a lack of saliva, “the teeth are constantly bathed in acid”. Baking soda is alkaline and neutralises the acid.
  • Rinse with baking soda in water and hold for 30 seconds. Take a little pump bottle with you when out and about.

Recipes for salt and baking soda rinses

½ teaspoon of salt and ½ teaspoon of baking soda in a cup of warm water (250mls)

If it’s stinging, use ¼ teaspoon of salt or cut salt out.

In short, if your salt and baking soda is stinging your mouth then keep decreasing the amount of salt you are putting in per glass of water until you reach a level where it is no longer stinging.

Do not confuse baking soda with baking powder!

Antibacterial mouth rinses 

When should we use Chlorhexidine or Savacol to kill the bugs and when should we use salt and baking soda?

These Chlorhexidine mouthwashes are short term measures after surgery or extractions. They kill naturally good bacteria in the mouth as well as the bad bacteria.

Chlorhexidine is no longer used routinely in the hospital and Glenda is not in favour of long term Savacol (the most common form of Chlorhexidine) use. It’s available in the supermarket and not only does it kill bacteria but it contains 12 to 14 % alcohol. There is an alcohol-free Savacol but it’s often more difficult to find.

“You don’t want ethanol containing mouth rinses (alcohol) with any dry mouth. The baking soda rinse is the rinse you want to use.”

Carbonated drinks 

The advice is not to have carbonated drinks, ie soda water, Sodastream – but what about brewed drinks such as beer?

Anything carbonated is acidic (carbonic acid) so yes; even beer is bad for the teeth. Have a drink of plain water afterwards or a piece of hard cheese to neutralise mouth acids!

Xylitol

Also if you could ask their thoughts on using Xylitol as a rinse, as well as or instead of baking soda and salt. I and people I know have used it for gum health and preventing tooth decay effectively. (The good Finnish birch bark one, not the one made from corn starch.)

Xylitol (pronouned Zy-litol) is another amazing product, a natural sugar alcohol that “starves plaque” and stimulates saliva. It’s made from birch trees or corn and there is no difference in efficacy. The xylitol from corn is cheaper. Pleasantly sweet, it is suitable for diabetics and can be used in baking. You can buy bags of it from the Binn Inn, health stores, or online i.e. HealthPost.. Health stores have xylitol gums and lozenges like the Spry products on their counters.

Xylimelts are tablets that stick to the gum and release xylitol for 5 – 6 hours are great for patients with a dry mouth. You can buy them from the Bargain Chemist or online from Belmont Pharmacy. Used at night, patients “get their sleep back.”

Gum disease

Is gum disease related to head and neck cancer?

Not necessarily but gum disease can be linked to other health issues. The thing about gum disease or periodontitis is that it can be silent and people can ignore a bit of bleeding from their gums. It’s not like tooth decay which alerts us because of pain.

There are two types of gum disease: reversible and non-reversible. A hygienist or oral health therapist, in a profession which is all about gum health, can help us deal with this condition.

Waterflossers

 What is the benefit of a water flosser?

We talked briefly about these and will have more info in future. One patient said she couldn’t clean her mouth without one because after flap surgery there were so many hard to reach places. We also talked briefly about dental floss and interdental brushes. If you don’t clean between your teeth, a large portion of each tooth is not being cleaned. More on this later.

Conclusion

A very informative session and a reminder that hygienists are not “pretend dentists” as Glenda said they have been called but specialists in the oh so important care of the teeth and gums.

Thanks to Toni Davis who organised the questions and wrote part of the summary. Thanks to Glenda McMan who braved some difficult Zoom issues to talk to us so enthusiastically. As someone who has struggled with her teeth and has a few left, I feel that I learnt a lot.

Maureen