CHAPTER 6 General and Oral Pathology
PATHOLOGY
General pathology includes the study of the destruction and repair of bodily tissues. Oral pathology is the study of the destructive conditions associated with the mouth, head, neck. Can be either primary or secondary (follows and results from an earlier disease), or there can be comorbidity, with more than one pathological condition present. MOST conditions and diseases go through periods of exacerbation (relapse, attack, flare-up), with an increase in the severity of a disease or its symptoms, as well as periods of remission (absence of disease activity).
• • See Chapters 9, Pharmacology: specific usage; 10, Medical and Dental Emergencies: emergencies in the dental setting; 11, Clinical Treatment, and 16, Special Needs Patient Care: related medical disabilities.
INJURY, INFLAMMATION, AND REPAIR
A. Injury can have various causes:
1. Hypoxia (lack of oxygen): from chemical, physical, or microbial agents, e.g., heart attack (myocardial infarction).
2. Immunological factors: such as anaphylactic reactions and reactions to self-antigens, e.g., asthma.
4. Nutritional imbalances: including lack of sufficient proteins or other nutrients and dietary excesses, e.g., high intake of animal fats.
B. Response to injury: inflammation:
2. Pathogenesis involves circulatory changes, alterations in blood vessel permeability, leukocyte response, chemical mediators.
D. Latent period: time elapsed between exposure to injury and first appearance of symptoms and signs.
Diagnostic Process
• See Chapter 11, Clinical Treatment: standards for clinical dental hygiene practice, contraindications, treatment planning.
Infectious Diseases
• See Chapters 8, Microbiology and Immunology: infectious diseases and microorganisms; 9, Pharmacology: drug usage for infections.
Metabolic Disorders
• See Chapters 3, Anatomy, Biochemistry, and Physiology: physiological processes; 8, Microbiology and Immunology: infectious agents involved in hepatitis; 9, Pharmacology: hormones and replacement therapy; 9, Pharmacology, and 11, Clinical Treatment: alcoholic patient, hyposecretion of salivary gland with geriatric patient.
A. Endocrine gland disorders:
1. Pituitary:
2. Thyroid:
b. Hyperthyroidism: MAINLY associated with Graves’ disease, autoimmune hypertrophy of gland, with hypersecretion of thyroxine; causes exophthalmos (protruding eyes), tachycardia (increased pulse rate), severe weight loss, sweating, tremors, heat intolerance, frequent bowel movements:
(2) In adults: aggressive periodontal disease, dental caries, osteoporosis of jaws, burning tongue, increased salivation.
(3) Treatment: radioactive iodine (MOST common) or antithyroids, such as methimazole (Tapazole) or propylthiouracil (PTU); possibly partial surgical gland removal.
(4) Risk factors: thyroid storm (thyrotoxicosis) if undiagnosed or uncontrolled; emergency with fever, elevated blood pressure, heart dysrhythmia, tachycardia, hypermetabolism, can result in death; vasoconstrictors should NOT be used.
(5) No barriers to care; professional care and homecare: thorough extraoral and intraoral examination for increases in thyroid gland and lymph node size; home and professional fluoride to reduce incidence of caries as well as calcium products; frequent examination and oral prophylaxis to manage bone loss, caries, periodontal infection.
c. Hypothyroidism:
(1) Associated with hyposecretion of thyroxine; MOST common is Hashimoto’s thyroiditis, autoimmune disorder that attacks gland; LESScommon are secondary forms (iodine therapy, thyroid surgery, developmental disturbances, iodine deficiency [uncommon in United States, where salt is iodized], pituitary disease).
(2) Also associated with cretinism, congenital lack of thyroxine; causes dwarfism with stocky stature, protruding abdomen, underdeveloped sex organs, misshapen face.
(4) In adults: symmetrically enlarged thyroid gland, may have nodules; signs and symptoms include myxedema (fatigue and weight gain from slow metabolism), skin dryness, hair coarseness, face puffiness, intolerance to cold temperatures, constipation, muscle cramping, mental slowness, low blood pressure, slow pulse; sometimes confused with Sjögren’s syndrome.
(5) Oral signs:
(6) Treatment: thyroid hormone supplementation (e.g., with levothyroxine [Synthroid, Levoxyl, Levothroid, Unithroid]).
B. Liver disorders:
1. Cirrhosis: chronic destruction of liver cells with fibrous, nodular regeneration.
b. Systemic signs: jaundice (yellow skin, sclera), puffy eyes, facial redness, hepatic encephalopathy, ascites, splenomegaly, bleeding.
c. Oral signs: xerostomia, reduced ability to taste, glossitis, increased risk of caries, periodontal disease, oral cancer, alcohol breath, enlargement of parotid gland, facial and dental trauma from falls and injuries.
d. Treatment for alcoholics: alcohol abstinence; occasionally involves surgical operations to relieve portal circulatory disruptions.
e. Risk factors: nutritional deficiencies, infections, trauma, oral cancer (especially if tobacco is also used); relative contraindication when administering amide local anesthetics (lowering amount) and nitrous oxide sedation (metabolism difficulties).
f. Barriers to care:
2. Viral hepatitis: caused by several viruses known as hepatitis A, B, C, D, or E (see Chapter 8, Microbiology: related discussion).
b. Systemic signs: anorexia, malaise, jaundice, enlarged liver, high levels of aspartate aminotransferase (AST, enzyme released into blood after liver injury), dark urine (contains bilirubin).
c. Types and pathogenesis:
(2) Hepatitis B (HB): dental healthcare personnel (DHCP) are at highest risk for contracting.
C. Pancreatic disorders:
1. Diabetes mellitus (DM, hyperglycemia): multifactorial disease leading to high blood glucose levels.
a. Types and pathogenesis: can be present for 10 to 20 years before diagnosis.
(1) Prediabetes: blood glucose levels are higher than normal but NOT yet at the high levels of type 2; includes BOTH impaired glucose toleration and impaired fasting glucose.
(2) Type 1 (insulin-dependent diabetes mellitus [IDDM], juvenile onset):
(4) Latent autoimmune diabetes of adulthood (LADA, type 1.5): slowly progressive form of type 1 DM, often diagnosed as type 2 DM, but positive for pancreatic islet antibodies, especially to glutamic acid decarboxylase (GAD); does not immediately require insulin for treatment; patients often not overweight, have little or no resistance to insulin UNLIKE type 2.
b. Signs and symptoms: polyuria (increased urination), glycosuria (sugar in urine), polyphagia (increased hunger), polydipsia (increased thirst), increased amount of ketone bodies in the blood, acidosis (increased acidity of blood plasma), weight loss, poor wound healing, risk for infections.
c. Oral complications (ALL at increased risk with poorly controlled blood sugar): Candida albicans infections, xerostomia (dry mouth), parotid gland enlargement, increased slight caries rate from dry mouth, as well as increased moderate to severe periodontal disease, tooth loss and mobility.
d. Systemic complications: related neural, visual, and kidney disorder because of fibrosis of blood vessels.
e. Diagnostic and monitoring tests (Box 6-1):
(1) Self-monitoring blood glucose (SMBG): recommended for ALL types; MORE frequently required for those on intensive insulin therapy or pregnant, having hard time controlling levels, with increased ketones in urine, or with intercurrent illness.
(2) Glycosylated hemoglobin (GHb): measures how much glucose attaches to hemoglobin (Hb) on red blood cells (RBCs) (HbA1c or A1c test); reflects average blood glucose levels over 3 to 4 months; >9% to 20% indicates poor control and the need to reassess the present treatment.
(3) Fasting plasma glucose (FPG): measures blood glucose levels after fast; ≥126 mg/dL is diagnostic; casual (nonfasting) of ≥200 mg/dL with classic symptoms is diagnostic but is confirmed on separate day; impaired glucose metabolism (prediabetes) has <126mg/dL.
g. Risk factors:
i. Professional care and homecare:
(1) Thoroughly assessing oral health, as well as monitoring diabetic control; including use of diabetes risk assessment test kit (BIOSAFE), FDA-approved home use or professional use diabetic test kit (includes immediate FPG and HbA1c test from self-collected finger-prick blood sent to lab, with patient consent form; professional lab report is faxed to the dental office and paper mailed to the patient).
2. Pancreatitis: inflammation of gland.
a. Etiology: protein- and lipid-digesting enzymes in pancreas that digest organ itself; severe cases are associated with alcoholism.
Figure 6-1 Goiter formation from thyroid gland disorder.
(From Fehrenbach MJ, Herring SW: Illustrated anatomy of the head and neck, ed 3, St. Louis, 2008, Saunders/Elsevier.)
Box 6-1 Monitoring Levels of Blood Glucose
<70 mg/dL: Too low; tendency toward hypoglycemia. Take 15 mg of carbohydrates (glucose source) and wait 15 minutes. If this level continues, need for immediate medical consult. Risk for emergency.
CLINICAL STUDY
| Age | 37 YRS | SCENARIO |
| Sex |  Male  Female |
A patient new to the dental practice is at the end of the 2-hour afternoon appointment. She starts complaining of a headache, reports feeling weak, and becomes more nervous and somewhat confused. |
| Height | 5′;0″ | |
| Weight | 210 LBS | |
| BP | 112/68 | |
| Chief Complaint | “I was so nervous about this dental appointment that I forgot to eat lunch today.” | |
| Medical History | Diabetes mellitus (well controlled) for 2 years Osteopenia for 1 year | |
| Current Medications | 250 mg chlorpropamide (Diabinese) qd OTC calcium supplement with vitamin D qd | |
| Social History | Interior decorator |
1. What type of diabetes does the patient have? What type of drug is she taking? When should it be taken?
2. What is the American Society of Anesthesiologists (ASA) classification of this patient at the beginning of the appointment?
1. Patient has type 2 diabetes mellitus (DM), most often controlled by diet and exercise; in some more moderately involved cases by oral hypoglycemic drug(s) such as chlorpropamide (Diabinese); even by insulin in severe cases. DM occurs when body does not make enough insulin (type 1) or when insulin that is produced no longer works properly (type 2). Insulin works by helping sugar get inside the body’s cells, where it is used for energy. Physician will advise the patient of the dosage schedule depending on the time of onset of the particular insulin used to achieve best control over blood sugar levels.
2. Physical status shows that mild systemic disease such as type 2 DM equates to an ASA II classification. The ASA physical status classification determines risks and necessary modifications before dental treatment.
3. Emergency that has occurred is hypoglycemia (low blood sugar); she is now at ASA IV level. Condition is most often associated with lack of food intake; in this case she missed lunch because of anxiety associated with dental appointment. Headache, weakness, nervousness, confusion are symptoms of hypoglycemia. Condition typically occurs rapidly for patients who require insulin; onset of symptoms is slower for patients taking oral hypoglycemics.
4. Dental treatment must be stopped, and patient must be positioned upright. Source of glucose (orange juice or other glucose source such as glucose tablets or gel) should be given if patient is conscious. Source of glucose should be stored in easily accessible dental office emergency kit. If situation is allowed to progress, patient may become unconscious, in which case IM or IV administration of glucagon by the supervising dentist is indicated, if available, after EMS system is activated.
5. Both lack of lunch and stress related to appointment contributed to occurrence of hypoglycemia. It is essential to explain all dental procedures to this patient to alleviate anxiety about future appointments and encourage eating before the appointment; use of morning appointments after she eats a good breakfast and takes her prescription drugs is an effective way to deal with problem. May also want her to have a prescription to ease her dental anxiety (diazepam [Valium]) and help reduce risk of hypoglycemia.
Blood Disorders
• See Chapters 3, Anatomy, Biochemistry, and Physiology; 8, Microbiology and Immunology: vascular system and immunology.
A. Anemias: low hemoglobin and oxygen concentration in blood.
1. Etiology: excess bleeding, hemolysis, iron or other nutrient deficiency, improper formation of new RBCs.
2. Forms and pathogenesis:
a. Pernicious (B12 deficiency, type of megaloblastic anemia): too few RBCs; factor for RBC formation is missing; treated with injections of missing intrinsic factor.
b. Sickle-cell (sickle-cell disease): genetic hemolytic anemia; usually confined to African-Americans; RBCs are sickle (crescent) shaped and CANNOT function properly; lower level of anemia present with sickle-cell trait (person has ONLY one copy of mutation).
c. Hypochromic (iron deficiency anemia): too little hemoglobin per RBC; treated with iron supplementation.
d. Hemolytic: rupture of RBCs; may be genetic or environmental; NO effective treatment for genetic forms; treatment for environmentally induced forms centers on control of environmental factors.
3. Oral signs: bleeding oral tissues, angular cheilitis, pale skin and oral mucosa, erythematous burning tongue with loss of BOTH filiform and fungiform lingual papillae.
B. Polycythemia: overproduction of circulating RBCs.
C. Thrombocytopenia: FEWER platelets (thrombocytes) in blood with SAME clinical signs as anemia; can be caused by decreased production in bone marrow, increased destruction, disease, or as a side effect of drugs.
D. Diseases of WBCs and bone marrow:
1. Agranulocytosis: severe reduction in number of granulocytes (basophils, eosinophils, neutrophils); results in greatly reduced immune system.
3. Neutropenia: abnormally low levels of neutrophils (granulocytic WBCs):
a. Etiology: congenital (discussed later), immunological, chemicals (drugs) or radiation therapy that suppresses bone marrow; acute disease is adverse reaction to toxic levels of drug or to bone marrow–suppressing radiation therapy.
b. Systemic signs: lymphadenopathy; fever and chills; prostration; jaundice; bleeding ulcers of rectum, oral cavity, vagina; proper identification of disease is by blood test; WBC counts drop to one fifth to one tenth.
d. Oral signs: infections, painful ulcerations, bleeding gingival lesions with rapid periodontal destruction.
4. Leukemia: cancer of red bone marrow, lymphatic tissue, or WBCs.
c. Systemic signs: pallor (pale color) of skin and lining mucosa, bone and joint pain, abnormal bleeding that leads to bruising, enlarged lymph nodes, hepatomegaly, splenomegaly, anemia.
5. Multiple myeloma (MM): cancer of plasma cells, which are immune system cells in bone marrow that produce antibodies and immunoglobulins (MAINLY IgG).
CLINICAL STUDY
| Age | 12 YRS | SCENARIO |
| Sex |  Male  Female |
During her initial intraoral examination, gingival bleeding, poor oral hygiene, three carious lesions, and two nearly exfoliated teeth are observed. Physician wants oral cavity checked for signs of infection. |
| Chief Complaint | “My grandmother is so scared since my gums are bleeding so much!” | |
| Medical History | Recent diagnosis of leukemia with intensive chemotherapy scheduled in 1 week | |
| Current Medications | None at this time | |
| Social History | Grade school student studying ballet Grandmother is guardian |
1. What information must be obtained from the patient’s oncologist before any dental treatment can be given?
1. Before dental treatment, oncologist should be consulted regarding blood tests (WBC count), clotting and bleeding factors (INR), placement of central venous catheter, when chemotherapy will begin, expected length of immunosuppression.
2. If blood counts are adequate and time is available before chemotherapy, all loose teeth and teeth close to exfoliation (shedding) should be removed, carious teeth should be restored, oral hygiene instructions and need for meticulous oral hygiene should be stressed, and oral prophylaxis should be completed. Since this is a child patient, it is important that her guardian be advised of all that is needed to maintain oral and related systemic health.
3. Dental treatment can be scheduled whenever blood counts have returned to safe levels. Safe levels are most common just before scheduled round of chemotherapy. Bleeding levels monitored by INR; INR ≤2.5 is safe for invasive dental work; older test is prothrombin time (PT). Antibiotic premedication will be needed before invasive dental procedures if catheter placement is permanent.
Bone Diseases
A. Osteoporosis: MOST common bone disease.
1. MORE common in women and with age; other factors include low levels of sex hormones (e.g., menopause), low body weight, ethnicity (e.g., white or Asian), family history, low dietary intake of calcium and/or vitamin D, smoking, alcoholism.
3. Reduced bone quantity and quality; loss in bone mass and decrease in bone density (i.e., increased porosity) cause the bone to weaken.
4. EARLY loss of bone density with osteopenia; as disease progresses, bone becomes MORE fragile and even slightest trauma can cause fracture (e.g., hip fracture); resulting spinal compression fractures may result in loss of height with stooped posture (dowager’s hump).
5. May be related to oral bone loss with periodontal disease, since quality and quantity of the jaws appear to be affected.
B. Paget’s disease (osteitis deformans): second MOST common bone disease after osteoporosis.
1. Systemic signs: BOTH destruction and formation of bone in patients >50 years of age; often asymptomatic; patients may have blindness (closure of neural foramina) or deafness; MOST striking is progressive enlargement of spine, femur, and skull, MAINLY the maxilla, with tendency for bone fracture.
2. Oral signs: teeth may loosen and migrate with jaw expansion; dentures NO longer fit (NOR do hats).
Neoplasia
A. Etiology: exposure to adequate concentrations of carcinogens (cancer-causing agents) that alter cellular DNA and proteins:
B. Tissues at risk for neoplastic change: tendency for cells to undergo neoplasia is roughly related to cell’s involvement in physiological replacement; MUST have adequate time for initiation, transformation, growth of mass.
C. Classification:
1. Benign neoplasia (suffix “-oma” added after tissue type [e.g., osteoma]):
2. Malignant neoplasia (cancer) (“carcinoma” added to tissue type for epithelial tissue [e.g., squamous cell carcinoma] and “sarcoma” for nonepithelial tissue [e.g., osteosarcoma]):
a. Cells are neoplastic (new growth); capacity exists for invasion (going deeper in tissues) or metastasis (spread beyond original site).
c. TNM classification of malignant tumors: cancer staging system that allows determination of prognosis and treatment (T = size of tumor, N = nodes involved, M = metastasis).
D. Vascular neoplasias:
G. Soft tissue neoplasias: MOST often benign and without serious pathogenesis; occur in variety of tissues, including adipose (lipoma), muscle (myoma), blood, lymphatic:
H. Odontogenic neoplasias:
1. Ameloblastoma: aggressive benign epithelial tumor associated with cells of enamel organ.
a. MOST in posterior mandible; associated with presence of unerupted teeth, painless swelling, thinning periosteum with “egg shell” cracking when palpated.
I. Epithelial squamous cell neoplasias:
2. Squamous cell carcinoma (SCC): malignancy associated with squamous cells that invades through the basement membrane; MOST common oral cancer (90%) (Figure 6-4).
a. Etiology: chronic tobacco and/or alcohol use, human papillomavirus (HPV); because of HPV, may occur in younger group as well as those ≥40 years; varies in appearance:
b. Location: MOST on lower lip, lateral border or base of tongue, floor of mouth, soft palate complex (including tonsillar region); MAINLY hidden areas the clinician should access thoroughly during an intraoral examination; however, if HPV involved, can be present in ANY location.
c. Diagnostic dental office tests: brush biopsy (Oral CDx), ultraviolet (UV) light kit, toluidine blue dye kit; exfoliative cytology (not recommended anymore); ALL noninvasive tests do NOT take place of surgical biopsy.
d. Pathogenesis: does NOT heal or show response to palliative treatment; may metastasize to cervical lymph nodes.
3. Basal cell carcinoma (BCC): noninvasive malignancy with increase in basal epithelial cells; associated with sun exposure (actinic damage).
5. Malignant melanoma: dark-colored skin malignancy; occasionally occurs on masticatory oral mucosa (maxillary alveolar ridge and palate).
a. Etiology: excessive exposure to sunlight; usually at site of preexisting nevus, but can be initial lesion; greater risk with family history.
J. Salivary gland neoplasms:
K. Breast cancer: second MOST common cancer in women after lung cancer that starts in the cells of the breast.
2. FIRST symptom is lump that feels different from surrounding tissue; mammography or ultrasound tests for presence.
L. Prostate cancer: second MOST common cancer in men after lung cancer, within gland of reproductive system; may cause pain, difficulty in urinating, erectile dysfunction (ED); if undergoes metastasis to jaws, may be noted on radiographs as either radiolucency or opacity.
CLINICAL STUDY
| Age | 50 YRS | SCENARIO |
| Sex |  Male  Female |
The lesion noted on intraoral examination of the patient appears to be a preexisting mole that is 5 mm in diameter and has a raised, irregular, and reddened border on its anterior surface. |
| Height | 5′10″ | |
| Weight | 140 LBS | |
| BP | 105/70 | |
| Chief Complaint | “My mole becomes sore and bleeds and I think it is getting larger!” | |
| Medical History | Past history of repeated urinary tract infections Gallbladder removed 5 years ago | |
| Current Medications | OTC ginseng qd | |
| Social History | High school teacher who spends many hours sunbathing every summer and uses tanning booths in the winter to maintain her tan, since she has very pale skin |
1. Malignant melanoma, which is a malignancy of skin that occasionally occurs on masticatory oral mucosa (attached gingiva and hard palate); most occur on the skin at a site of existing mole (nevus) but can occur as initial lesion. Grows aggressively; dark in color; exhibits changes (ABCDs) such as asymmetry, border, color, or diameter. Caused by excessive exposure to sunlight as is shown by her lesion, which is on an exposed portion of her skin. Nevus, by contrast, is benign tumor of melanin and does not show any change in manner as this lesion does.
2. Asymmetry of lesion (flat and raised portions); irregular borders; variation in color; relatively large diameter; preexisting nevus; prolonged, frequent exposure to the sun and pale skin that burns easily.
3. Treated by surgery, radiation, chemotherapy; if surgery, patient may want to let surgeon know about her OTC drug, since ginseng can promote bleeding and delay clot formation. Prevention includes reducing exposure to sun, using sunscreen, routine examination of existing lesions.
CLINICAL STUDY
| Age | 65 YRS | SCENARIO |
| Sex |  Male  Female |
The patient indicates that he noticed the sore several months ago. Intraoral examination reveals a 10-mm ulcerated red lesion located on the left lateral border of the tongue. |
| Height | 6′2″ | |
| Weight | 195 LBS | |
| BP | 112/72 | |
| Chief Complaint | “This sore in my mouth really hurts!” | |
| Medical History | Smokes a pack of cigarettes a day Started smoking when he was 15 Consumes alcoholic beverages on the weekends | |
| Current Medications | None | |
| Social History | Farmer Volunteer firefighter |
1. What additional information is required for a proper diagnosis for the patient? What is the most likely diagnosis of the lesion?
1. Surgical tissue biopsy is required for proper diagnosis. Surgical biopsy may confirm a squamous cell carcinoma (SCC) that is noted by its clinical signs.
2. Histologically, neoplastic squamous cells invade through epithelial basement membrane. Thus this is a carcinoma, since it involves the epithelium, unlike a sarcoma that involves nonepithelial tissues such as connective tissue like bone.
3. The SCCs of oral cavity are most likely to metastasize to lymph nodes of neck, cervical nodes, on the same side as the lesion.
4. Tobacco and alcohol use are two key risk factors associated with this case, as well as age; it is important to note that patients usually smoke or drink almost double the amount they report to their healthcare professionals.
Cancer Patient Care
A. Localized oral and/or pharyngeal cancer concerns:
1. Surgery:
B. Systemic cancer concerns (requiring chemotherapy and/or bone marrow transplantation, monoclonal antibody therapy):
1. Chemotherapy for systemic malignancies: higher risk for oral complications with leukemia, lymphoma, solid tumors than in chemotherapy for other malignancies (new therapies are using short-term higher dose therapy in some cases).
2. Monoclonal antibody therapy by infusion (along with drugs, radioactive materials): made in laboratory from a single type of immune system cell to kill or stop cancer growth; complications same as with other treatments.
3. Blood cell or bone marrow transplant: stem cells (immature blood-forming cells) are transplanted by infusion to replace cells that were destroyed during cancer treatment; for complications see below.
4. Complications associated with intensive chemotherapy and/or bone marrow transplantation:
a. Cytotoxic drug effects include temporary destruction of healthy tissues, including oral mucosa (mucositis).
C. Oral mucositis (OM): MOST common side effect of radiation and/or chemotherapy; painful inflammation and ulceration of mucous membranes lining digestive tract, including oral cavity.
1. Treatment is MAINLY palliative; palifermin (Kepivance), human keratinocyte growth factor (KGF) for severe OM, has been shown to enhance healing; sucking crushed ice (cryotherapy) is alternative.
2. Complications caused by ulcerations:
a. Can become infected by virus, bacteria, or fungus; may act as site for local infection and portal of entry for oral flora that, in some instances, may cause septicemia (especially in immunosuppressed).
D. Osteoradionecrosis: bone (can include jaws, onj) that has died as complication of radiation therapy; damage to the small arteries reduces circulation, depriving bone of oxygen and other necessary nutrients.
E. Barriers to oral care:
F. Dental hygiene care:
1. Before cancer treatment:
a. Assess condition of teeth, periodontal structures, oral hygiene, previous interest in dental care, psychosocial factors.
2. During cancer treatment:
a. Design alternative dental biofilm control measures for those with OM and forbidden by oncologist to use toothbrush and floss.
3. After cancer therapy:
a. If received radiation therapy to salivary glands and/or jaw bones:
(1) Encourage frequent recalls, scheduled according to individual need, for prophylaxis and homecare evaluation.
(2) Encourage palliative measures for xerostomia and stimulation of saliva or consider prescriptions (discussed earlier).
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
