Hi
Recently, a colleague asked for advice on precautions his patient should take before starting radation therapy foillowing the removal of a malignant tumor from his neck (might have been parotid gland).

There are two issues here: 1) the need to improve the mineralisation of the teeth before oral hygiene gets difficult owing to an uncomfortable mouth and 2) the need to compensate for risk of 'tooth-decay' that arises from decreased salivary gland function (as a consequence of surgery or radiotherapy).

Patients should start using fluoride mouthrinse and gels several days before radiation therapy begins. I advise the use of thin custom gel-applicator trays, similar to that used for whitening teeth, with the advice to smear the inside of it with the fluoride gel. The trays should cover all tooth structures without irritating the gingival or mucosal tissues.
The advice is to start with a daily 5-minute application of a 1.1% neutral pH sodium fluoride gel or a 0.4% stannous fluoride (unflavored) gel. Patients with porcelain crowns or resin or glass ionomer restorations should use the neutral pH fluoride. We use Colgate's Gel Kam which is 0.63% stannous fluoride, but there are other brands.

The trays should be placed on the teeth and left in place for 5 minutes. If gel oozes out of the tray, you are using too much. After 5 minutes, remove the trays and spit out any excess gel. Do not rinse. Do not eat or drink for 30 minutes , preferably one should to go to bed!

Alternatively, I advise brushing the gel onto the teeth for 5 minutes after the brushing, using the interspace and interdental brushes , at night. Spit out any excess gel. Do not rinse.

I also advise my patients to brush four times daily and to follow that with using a fluoride mouthrinse to prevent tooth demineralization . The message is that a low fluoride (from the toothpaste and mouthrinse) application several times daily to the teeth is more effective than a high concentration used once at night!

The danger is 'radiation' caries caused by changes in the quantity (reduced) and quality (less buffering ability) of your saliva.

I advise patients about to undergo radiotherapy to have a very high standard of oral hygiene : brushing four times a day (after meals?) using interspace and interdental brushes , followed by 1 minute of fluoride mouth rinse ( FluoriGard ), and additionally at night before bed a 5-minute scrub of the teeth with a Fluoride gel(e.g. Colgate's Fluorigard GelKam) or high fluoride toothpaste (e.g. Duraphat 5000 ) and then not rinsing out in order to leave the teeth lightly coated overnight.

A new product that may help remineralise the teeth is GC Tooth Mousse. See page 13 of this brochure.

GC Tooth Mousse is a topical, water based, sugar free creme that contains Casein Phosphopeptide – Amorphous Calcium Phosphate under the brand name of Recaldent. It helps remineralise teeth and is supposed to help with 'radiation caries'. Tooth Mousse can be applied at any time during the day or night. After cleaning teeth in the normal way, remove excess saliva from the mouth (via spitting, swallowing, or patting teeth dry with tissue) and apply the creme using a clean finger or cotton tip. It should be left undisturbed for three minutes for day application then spread around mouth with tongue and held for another two minutes before being spat out. Avoid food or drink for 30 minutes. Tooth Mousse can also be applied just before going to bed and the entire application can be left to slowly dissolve overnight.

It isn't sold in pharmacies so try this online shop.

The water-pik is useful in washing out food debris, but it won't shift plaque. Brushes used properly are still the best.


Unfortunately, patients with radiation-induced salivary gland dysfunction must continue these regimens for life . There is some good advice at the links given on the PROFESSIONALS > COMPLICATIONS page

Best wishes
Vinod


Update from Colgate-Palmolive (UK) Ltd (12/11/2011):

• Colgate Fluorigard Gel (previously known as Colgate Gel-Kam) is being discontinued with immediate effect. You are now advised to use Colgate Duraphat 5000ppm (sodium fluoride toothpaste 1.1% DPF) for the prevention of caries.
• Colgate Duraphat 900ppm mouthrinse is also being discontinued by the end of 2011 due to low and declining demand and Coldgate Fluorigard Alcohol Free rinse 0.05% (225ppm) is advised instead.

This message has been edited. Last edited by: Dr Vinod K Joshi,

HIO Dr Joshi, I was not prepared what was going to happen to me while and after my operation the Radiotherapy is a real stinker it ruins your appetite,voice and speech and makes you VERY tired and I guess it all adds up to me being angry.

Paul

Hi

Yes Paul as angry as I am about the surgery so god knows what i would have been like if I had had radio
My biggest gripe is they dont teel you the aftereffects as they are no pussy footing are they afraid people will say no is thats the case but is our lives our bodies we should make the decisions especially as in my case there was no immediate rush the mark had been there for at least seven months

Then I think Eileen you would have complained if you were in a fit state to do so, I was not.I say count your blessing you did not need Radiotherapy.It has ruined my speech.

Paul

Good day to Eileen and Paul.

You know I sure I've said all this before. But reading both of your experiences makes me realise just how lucky I've been.

The team looking after me (and God forgive me I can't remember all their names) explained to me, in detail, what would be done to me, what the most likely effects would be both short and long term. I was warned what I might encounter from the radiotherapy, in fact I was told most likely not """might""".

In the event nothing was as bad as I had expected.

One complaint, nobody warned of the effect on my upper left arm (bit of muscle taken from my chest that side, plus apparently a particular nerve severed in the neck dissection). I now have very little strength there, not that I was ever a Charles Atlas (that's an ageist reference).

No, all in all I'm quite happy to still be here.

HI Pikeman, My worst complaint is I am always tired and feel drained all of a sudden without warning. Also I cannot lift my arrms up so it is difficult to paint the walls and ceiling

did I hear an offer of help

Like you Pikeman I was told on 4 different occasions very clearly what radiotherapy would do to my throat both inside and out as well as how awful it would be during radio and in the immediate weeks after as well as the probale long term effects such as oral dryness and later occuring thyroid damage.

I was told to get a dental check prior to radio, but feel the hospital should have dealt with this on site. Despite having an excellent dentist, nothing he could say reassured me about osteoradionecrosis later. I think the hospital would have been more departmentalised to deal with my questions.

The only thing that was worse than explained was the physical burn on my face and neck. I think even they thought it severe. I was supposed to have 36 treatments at first, but later this was dropped to 30 and the consultant said """I think you've had enough."""

Paul sudden tiredness is a post treatment problem for us all. I get it when I shop till I drop!!!!!!!!!!!!!!!!! two days running.....

Pau; - help painting walls etc. - in your dreams!

And I am DEFINITELY not my sending wife on loan

Why nor try Pauline's route of retail therapy. Far more rewarding.

Good to hear you all sounding somewhat more positive

HI Pikeman and Pauline sorry about my manners it should have been ladies first
Yes I take on board what you both have told me,
I do go for Retail Therapy every month when I go for a check up I go down to Oxford St and Soho but I buy things I do not like when I get home or think they will fit and when I get them home too big, I think I am 32inch waist but I am 28inch(thankyou Radiotherapy) now and I just find it hard to find that size, I was told to go to MotherCare!!!

Have a good evening guys

Paul

Hi Paul.

Oxford Street I understand, but Soho in this day and age. Mind you, I suppose it depends what you're shopping for.

In my youth Soho was a good place for bargains, but last time I was in London (about 4 years ago now) other than the food shops I didn't see any """bargains""" that interested me.

But whatever you enjoy.

Incidentally, I've gone right the opposite way to you. When admitted to hospital my waist was 30 inches - now it's 36. And you've got problems?

Cheers Paul, have fun

we sometimes go to Soho to a Chianese eat as much as you like (with chop stick) I shove it all down with pints of water I do get looks but I think paid for it will eat it.

cheers

Paul