DENTAL ONCOLOGY

Caring for the Oral Health of Patients Battling Cancer Part III: Oral Care After Cancer Treatment

Fri, 15 Jun 2012 12:48:48 -0400

Dennis M. Abbott, D.D.S.

The following is the final installment of a three-part series addressing oral health concerns that ideally should be addressed before, during, and after cancer treatment. This segment focuses on oral health care needs after cancer treatment.

To say a battle with cancer changes one’s life is perhaps one of the most profound understatements ever made! Few experiences leave their indelible mark on health, relationships, and spirituality as deeply as cancer. From the moment the diagnosis is verbalized by the physician, lives are changed forever…the life of the patient, the lives of family and friends, the lives of those not even yet born who will benefit from the lessons learned from the care given. There is little argument to be made - cancer changes lives!

People who have met cancer face-to-face understand that the disease expects much and adaptations in daily life must be made to meet those demands. So it is with the oral health of the survivors. Truly, there is still much to learn with regard to cancer survivorship in many areas of health care, and dentistry is no different. There are, however, tenets of care that must be followed for the cancer survivor. Some of these simply make life more pleasant; others are fundamental courses of care to which the patients must strictly adhere.

To the cancer survivor, I would say…because your experience with cancer has been a personal journey, there is no single adage that applies to all. There are, however, recommendations that are applicable to most. Always consult with your dentist or dental oncologist to customize a continuing care plan that is suited for your needs. Do not be afraid to begin a dialogue with your oral health care provider. Let him or her understand what is working for you, and what isn’t. Together, you and your dental oncologist can develop a regimen that is tailored to your needs and helps ensure your prolonged oral health as you live life as a survivor.

Dental Care Following Chemotherapy

Because many of the direct cytotoxic effects of chemotherapy subside after infusions have ended, much of the oral health care recommendations directed towards the post-chemotherapy patient focus on dealing with possible lingering side effects. Granted, the severity of enduring complications is usually contingent on the specific chemotherapeutic agents used, their dose, and the duration of treatment. Usually, however, the patient who has completed chemotherapy will notice a return to normal in the oral cavity. Dysgeusia (abnormal taste) and dysphagia (difficulty in swallowing) most often resolve without further intervention from the dentist. As white cells and platelets recover, mucositis is usually no longer an issue.

Xerostomia, or dry mouth, can continue to be a problem for many treated with chemotherapy alone, especially if medication for comorbidities continue after chemo has concluded. As long as the salivary flow is reduced, as determined by either a “feeling” of dry mouth or quantitative analysis by a dentist or dental oncologist, the xerostomic patient should commit to a professional dental cleaning and recall visit every three months. Dry mouth can lead to dental complications including rampant caries, periodontal disease, and oral infections. This condition should continue to be monitored and managed until normal salivary flow has returned and the patient has demonstrated a proficiency in home care that reduces the risk of extensive generalized decay.

During times of xerostomia, caries control is paramount. In some cases, it may be necessary to place the patient on microbial reduction therapy. The level of streptococci mutans can be reduced below a pathological level for three to six months by instructing the patient to use aqueous chlorhexidine gluconate 0.12% as an oral rinse: 1/2 oz. twice a day for two weeks. (This timeframe of bacterial load reduction has only been demonstrated in non-cancer patients. Patients battling cancer should continue using aqueous chlorhexidine gluconate on an ongoing basis and should be closely monitored if the oral rinse is reduce or discontinued as rapid recolonization has been documented in this population.) Similarly, the regular application of fluoride should be considered as long as patient remains at-risk for rampant caries.*

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Detailed instructions for fluoride application can be found in the second installment of this series.

Dental and Oral Health Care Following Head and Neck Radiation

Dental care following head and neck radiation is perhaps one of the most complicated areas of dental oncology as many of the side effects of radiotherapy linger for the remainder of the patient’s life. As is the case during treatment, it is imperative that the dental professional be thoroughly familiar with the dose of radiation the patient has received. An isodose map showing dosage according to anatomical structures must be considered prior to treatment planning for dental and oral health care following radiation. While most radiation therapy is now administered by intensity modulated radiation therapy (IMRT), some patients may have received treatment through a fixed beam of conventional radiation therapy or brachytherapy, which involves insertion of radioactive wires directly into the tumor. The dental professional must be familiar with not only the cumulative dose and the structures involved, but also with the radiation modality and the treatment schedule.

Perhaps one of the post-radiation risks most familiar to dental professionals is that of osteoradionecrosis (ORN). ORN is a late side effect of radiation where damage to the small blood vessels in the mandible, and more rarely the maxilla, impairs the bone’s ability to heal. Those who have received brachytherapy are particularly at-risk for developing this condition. Typically, ORN is not seen within the first year following treatment and the risk of ORN increases with time. Most often, bone necrosis of the jaw in the head and neck cancer survivor follows a traumatic event, such as an extraction or dental surgery; however, spontaneous exposure and necrosis of the bone - especially in the posterior mylohyoid ridge - has been reported. Although it can occur after lower doses, ORN usually occurs with doses greater than 60 Gy. All future oral health care treatment planning must consider radiation exposure to the bony structures of the face to minimize the risk for ORN.

Because of the risk of ORN, endodontic therapy should be considered as a viable treatment option for carious lesions with pulpal involvement. Root banking may be necessary when insufficient tooth structure remains supragingivally. For carious lesions, fluoridated glass ionomer is the restorative material of choice for the cancer survivor.

Exposure of the salivary glands to therapeutic radiation causes atrophy of the secretory cells resulting in xerostomia, the severity of which is related to the cumulative dose. Doses as low as 25 Gy can result in dry mouth. Although IMRT has reduced much of the widespread damage to the salivary glands seen in conventional radiation therapy, xerostomia continues to be the most widespread complication seen in head and neck radiation patients. The dental professional treating patients with a history of head and neck radiation should realize that long-term survivors who experienced conventional fixed beam radiation may present with more severe xerostomia that is a permanent side effect of their treatment.

Not only does ionizing radiation affect the function of the secretory cells in the glands, it also changes the composition of the saliva when some salivary function is retained. Serous glands are impaired much more readily than mucous glands. The result is a saliva that is much more viscous and acidic and lacks much of the protective qualities normally seen. Clinically, the patient may experience impaired remineralization capacity, taste alteration and difficulty swallowing, difficulties in mastication and speech, and decreased protection against microbes. These in addition to the increased propensity for dental caries makes xerostomia a side effect that cannot be ignored. Unfortunately for some head and neck cancer survivors, the damage of the salivary glands is permanent. These patients require close monitoring by the dental professional and should follow the guidelines for the post-chemotherapy patient as outlined above.

Fungal infections are more prevalent in this population, and the dentist or dental oncologist must be comfortable diagnosing and treating these conditions should they arise. When treating a Candida infection, both the patient and the denture should be treated, when applicable. Fluconazole 100 mg, twice a day, is an effective means of treating a yeast infection in the patient that can be used long term, if necessary. Nystatin suspension is not recommended due to its high sugar content. Alternatively, clotrimazole 10 mg troches, five times per day for two weeks, or mycostatin 200 mg oral pastilles, four times per day for two weeks, can be used. Dentures can be treated using bleach diluted in water (2 teaspoons per 1 cup water) for 30 minutes each day.

Beyond the teeth and oral mucosal tissues, many lingering side effects often plague the head and neck survivor. Permanent taste loss can occur at a dose of 60 Gy or higher. In lower doses, taste loss is often temporary although it may take several months to fully recover. Decreased salivary flow can cause taste alteration as can damage done by mucositis. Chemoreceptors on the tongue can take months to years to return to normal function if they have been affected by mucosal ulceration. Trismus can cause limited opening for three to six months following radiation therapy. Caused by contraction of the muscles of mastication and the TMJ capsule, trismus can occur with an unpredictable frequency and severity. Physical therapy (opening the mouth to maximum and closing 20 times, three times per day) can bring some relief and improve opening, but this condition must be considered when planning treatment and formulating an at-home oral hygiene regimen.

Long-term head and neck cancer survivors may also experience occlusion of the carotid arteries. Consideration must be given to this fact when using dental anesthetics with epinephrine. The dentist or dental oncologist should be familiar with signs and symptoms of a transient ischemic attack (TIA) or stroke and monitor these patients closely for signs of distress during dental procedures. Sometimes, head and neck survivors suffer degeneration of cervical vertebrae and may experience fatigue with minimal exertion. Fibrosis of the musculature in the radiation field may yield unusual results in head and neck examinations. Careful observation must be made during oral cancer screenings and head and neck examinations as “normal” may feel different to the dental professional examining the patient. For patients who have just completed treatment, radiation burns may still exist on the skin. Even long-term, a patient may complain of the tissue that was in the field of radiation as feeling “hot.”

The dental professional should be prepared to help the head and neck patient understand that many of these changes will affect the way he or she is accustomed to eating. The patient should avoid sharp or crunchy foods that can cause mucosal damage, hot and spicy foods, foods that are highly acidic, foods that are sticky or highly cariogenic, and drinks that contain alcohol. Patients should choose foods that are easy to chew and swallow, learn to take small bites and chew slowly, and sip liquids with meals. While many of these changes were necessary during treatment, most will need to continue these practices for several months following the completion of radiation therapy. When necessary, the dental professional should be ready to refer the patient to a registered dietician or professional nutrition therapist.

Other Post-Treatment Oral Health Care Considerations

Patients who have received bisphosphonate therapy via an intravenous route of administration are at risk for developing bisphosophonate-related osteonecrosis of the jaw (BRONJ). Medications used to treat metastatic disease in the bone include Zometa (zoledronic acid), Aredia (pamidronate), and Xgeva (denosumab). It is believed that the risk of developing BRONJ is directly related to the dose and duration of the bisphosphonate therapy. While the specific etiology of BRONJ is not fully understood, the dental professional treating patients with a history of bisphosphonate therapy should understand the risks associated with these medications and care for the patient in a manner similar to patients at risk for ORN. Since the half-life of some of these medications is in excess of ten years, a history of bisphosphonate therapy should be considered for all future oral health care planning in these patients.

Patients who are post-transplant, either for bone marrow or hematopoietic stem cells, are at high-risk for infection due to continued immunosuppression. In addition to bacterial and fungal infections, these patients are susceptible to viral infections including herpes simplex virus type 1, herpes varicella zoster virus, and cytomegalovirus. Moreover, these patients are at-risk for graft-versus-host disease (GVHD) and other autoimmune problems. GHVD and autoimmune issues can be very complicated. The dental professional seeing these patients should seek out continued education related to the specific care of autoimmune patients or refer to a dental oncologist experienced in their care.

Caring for patients before, during, or after their fight with cancer can be the most rewarding experience of a lifetime. More dental professionals are needed to commit to meeting the unique dental and oral health care needs of patients battling cancer. As the epidemiological forecasts continue to predict an increase in the number of new cancer cases as well as an increase in the population of survivors, now is the time for dental professionals to become part of a cancer care team. You can make a difference!

Dental Oncology Professionals of North Texas

Web: www.dopnt.com

Twitter: @DentalOncology

Facebook: facebook.com/dentaloncology

Blog: dentaloncology.blogspot.com

News Feed: dentaloncology.tumblr.com/rss

Dennis M. Abbott, D.D.S. is the founder and CEO of Dental Oncology Professionals of North Texas, an oral medicine practice dedicated to meeting the unique dental and oral health needs of patients battling cancer. He holds a Bachelor of Arts in biology from Rice University in Houston, and is an honor graduate of Baylor College of Dentistry. After dental school, Dr. Abbott studied immunology, microbiology, and oral medicine at the School of Dental Medicine, State University of New York at Buffalo. In addition to private practice, he is a member of the dental oncology medical staff at Baylor Charles A. Sammons Cancer Center and Baylor University Medical Center in Dallas. Dr. Abbott also serves as a consultant to the national American Cancer Society in the development of oral monitoring guidelines for post-treatment cancer survivors.

Dr. Abbott has most recently conducted studies focusing on bisphosphonate-related osteonecrosis of the jaw and xerostomia in patients with cancer. He is the previous recipient of the Dentist Scientist Award and the National Research Service Award, both granted by the National Institutes of Health. Dr. Abbott has been a visiting faculty lecturer for the University at Buffalo School of Dental Medicine continuing education program and has lectured throughout the United States.

CURE Magazine hosts Dr. Dennis M. Abbott for its First Facebook Chat

Mon, 16 Apr 2012 15:33:45 -0400

Our thanks to CURE Magazine for inviting Dr. Dennis Abbott to be a part of its first ever Facebook chat. Dr. Abbott discussed the importance of oral health before, during, and after cancer treatment.

See a transcript of the chat at: http://curetoday.com/index.cfm/fuseaction/blog.showIndex/elizabethwhittington/2012/04/13/Dental-health-Facebook-chat-A-recap

When Spit Doesn’t Happen: Dry Mouth Risks and Remedies

Wed, 28 Mar 2012 09:16:00 -0400

Dennis M. Abbott, D.D.S.

“Sometimes my mouth gets so dry that I wake up with my tongue stuck to the roof of my mouth. It’s been so bad that I’ve had to get a drink of water to get it unstuck!” - B.D., Mesquite, TX

Dry mouth. Xerostomia. Hyposalivation. Cotton mouth. Call it what you will…but very few people really understand what a severely dry mouth is all about better than someone battling cancer.

Dry mouth is a common unwanted companion for many oncology treatments. For patients undergoing chemotherapy, xerostomia is a pharmacological side effect of the cytotoxic drugs used to combat the cancer. In head and neck radiation therapy, hyposalivation is a direct effect of ionizing radiation administration on the salivary glands. At best, dry mouth is annoying; but in severe cases, the potential effects of xerostomia on teeth and soft tissues of the mouth can be devastating for years.

The story begins with spit, or saliva. Under normal conditions, the average human produces about one liter of saliva per day. Saliva functions as a protector of the oral cavity. It keeps the tissue moist. It neutralizes the acidic by-products of intraoral bacteria. It begins the digestion process, by moistening what we eat and breaking down starchy foods. It lubricates the moving parts of the mouth allowing us to smile and speak. In short, saliva is a big deal…and it is greatly missed when it’s gone!

A loss of saliva can lead to a host of problems: difficulty chewing or swallowing; changes in taste; nutritional compromise; intolerance to oral medications, such as pills and capsules; increased susceptibility to dental decay; higher risk for oral infections; increased likelihood of injury to oral tissues; and an inability to wear dentures or partials. Often, patients find the consequences of dry mouth annoying; while sometimes, they can be devastating. Some may even become emotionally depressed after not being able to carry on with what had previously been daily routine activities such as eating and tasting food.

From a dental health perspective, severe dry mouth can be very damaging to the teeth and increase the risk of intraoral infections. Teeth in a dry mouth are especially susceptible to decay at the gum line. A cavity at this location can be especially problematic since decay does not have to travel far to infect the center of the tooth, leading to a dental abscess. Likewise, a patient with diminished saliva has an increased risk for intraoral bacterial, viral, or fungal infections that can become a systemic health problem if the patient has mouth sores, as in mucositis.

The solution comes by first identifying the problem. Like many areas in medicine, there are several ways to manage dry mouth. A dental oncologist, a dentist that specializes in oral medicine as it relates to cancer care, can help decide which is right. Treatment can range from systemic medication to mouth rinses or topically applied intraoral gels. A neutral rinse can be made by combining 1/4 teaspoon salt, 1/4 teaspoon baking soda and 1 quart water. This simple mouth rinse can be used to moisturize the mouth by following the directions to swish and spit. Again, a dental oncologist can determine which method of management is best for you.

Fluoride is an essential element for management of dry mouth. Carrier trays for localized delivery of fluoride make it possible to get the tooth-strengthening gel right where it needs to be. Patients with dry mouth must commit to meticulous oral hygiene including brushing and flossing two to three times a day, regular use of prescription-strength fluoride, and professional dental cleanings at least once every three months. When dental restorations are required, the dentist can even choose a fluoride-containing filling material.

Food choices often change when dry mouth is a factor. Frequent consumption of highly acidic foods should be avoided as this can be harmful to tooth enamel and increase the risk of decay. Foods that are high in sugar and sticky foods must also be controlled. When these foods are enjoyed, a proper dental hygiene regimen should immediately follow to minimize the time these damaging foods have contact with the teeth.

Understanding the risk and seeing dry mouth as more than just an inconvenience is a big part of the battle. Knowing there are healthcare professionals who understand the struggle and can help manage not only the xerostomia but also the treat any infection or pain that might arise should encourage patients facing dry mouth to ask questions and seek help. So, when spit doesn’t happen…call your dentist or dental oncologist.

WTF is Magic Mouthwash or Miracle Mouthwash?

Tue, 13 Mar 2012 10:42:36 -0400

By CancerHawk

Our favorite cancer advocate and patient education blogger, CancerHawk, did an excellent job of covering the mouth rinse dilemma for patients! She ROCKS!!! Follow @CancerHawk or visit her at www.cancerhawk.com for great, straight-up patient information.

Many people undergoing treatment for cancer experience oral problems such as mouth sores or ulcers (technical term is either oral mucositis or stomatitis) at some point in their battle. These sores can make everyday activities like eating or speaking difficult to nearly impossible. They can be quite painful and cause an increased risk of infection that can enter the bloodstream. Conditions in the mouth can even deteriorate to the point where they actually interfere with scheduled cancer therapies. OMG!

To treat the pain associated with such mouth sores & ulcers, oncologists typically prescribe either Magic Mouthwash or Miracle Mouthwash to give patients temporary relief. Although these mouthwashes are quite different from each other, many doctors use the terms interchangeably.

Here’s the dealio (as my daughter always says)…

Magic Mouthwash (n): A mouth rinse that usually consists of viscous lidocaine, diphenhydramine, & an antacid like Maalox®. Some formulas add in antibiotics, antifungals and/or steroids to the formula. There is no one “standard” formula so different pharmacists will use different ingredients.

Miracle Mouthwash (n): A mouth rinse made up of dexamethasone (steroid), tetracycline (antibiotic), nystatin (anti-fungal) & diphenhydramine (antihistamine).

There is no “standard” formula for either of these mouthwashes (in terms of ingredients & composition) and as you can see they are quite different from each other. Yet it’s important that both you and your medical team know what you are taking.

WHY? Well, you and your doctor need to know exactly what’s being taken to minimize the potential for drug interaction & the possibility of drug allergy. (Check out www.chemo101.com to learn more about the different drug interactions.) If the formula you are using contains an antibiotic or anti fungal and you don’t have an infection per se, you’re then increasing your mouth’s resistance to that medicine which makes treating future bacterial infections more difficult. And if your mouthwash contains lidocaine, be careful when eating- biting your tongue or cheek while numb can open a whole host of other problems.

THE BOTTOMLINE: ASK your pharmacist what’s his or her “recipe”… or ask your Oncologist to specifically write the prescription indicating exactly what ingredients he or she wants used. Better yet, try to find a dentist that specializes in cancer care. Yes, there are dentists (sometimes referred to as “Dental Oncologists” even though they are not prescribing oncologists) who specifically treat oral side effects resulting from cancer treatments. They may have other options that are specifically designed to help you.

******Many thanks to my very favorite dentist Dr. Dennis Abbott of Dental Oncology Professionals of North Texas (www.dopnt.com) for being a trailblazer in the world of dental oncology. YOU rock Dr. Abbott!

All Mouth Rinses Are NOT Created Equal

Tue, 13 Mar 2012 10:34:49 -0400

Dennis M. Abbott, D.D.S.

This blog entry is written for the dental professional to give insight into the need for personalized oral healthcare during cancer and to increase awareness of the differences of mouth rinses commonly prescribed by oncologists.

Unfortunately, many people undergoing treatment for cancer experience oral problems at some point in their battle. Mouth sores can make everyday activities like eating or speaking difficult or impossible. Sometimes these ulcers, known as mucositis or stomatitis, can be very painful or increase the risk of infection spreading into the blood. Conditions in the mouth can even deteriorate to the point that they interfere with scheduled cancer therapies.

Often when people mention mouth problems to their oncologist, they are given a prescription for a compounded concoction and told to swish and spit. But what exactly is in these intraoral elixirs? And are they really what’s needed?

Two of the mouthwashes most popular with oncologists are Miracle Mouthwash and Magic Mouthwash. Despite the similar names, the two are not identical.

Miracle Mouthwash is made up of dexamethasone, tetracycline, nystatin, and diphenhydramine. Dexamethasone is a corticosteroid that is included in the mixture to decrease inflammation, but it also suppresses the immune system - which can be counterproductive. Tetracycline, an antibiotic that is generally safe even for people allergic to penicillin, kills a wide variety of bacteria. Bacteria can, however, develop a resistance to tetracycline, like many other antibiotics if it is used too frequently or in an inconsistent manner. Nystatin is an anti-fungal that is used to treat oral “thrush” or candidiasis. Diphenhydramine, the active ingredient in Benadryl®, is an antihistamine that is commonly used to treat allergy-related reactions such as itching or swelling. It is included in Miracle Mouthwash as an anti-inflammatory and to help manage minor pain.

Magic Mouthwash is a non-specific name for a rinse that is usually made up of at least three ingredients: viscous lidocaine, diphenhydramine, and an antacid like Maalox®. Lidocaine is an anesthetic commonly used in medicine and dentistry to control pain. Diphenhydramine is an anti-inflammatory; and the Maalox® is an antacid used as a coating agent. There is, however, no set formulation for Magic Mouthwash. In fact, Pharmacist’s Letter/Prescriber’s Letter #230703 gives recipes for 17 different rinses - all known as Magic Mouthwash. Some of these formulas add antibiotics, antifungals, and/or steroids. Some say “swish and spit”. Others say “swish and swallow”. So how do you know which one you will get; and more importantly, how do you know the Magic Mouthwash you pick up at the pharmacy will be the formula that is right for you?

Let’s face it…these mouth rinses are a shotgun-approach solution to a specific problem. While using a rinse with lidocaine may temporarily relieve the pain, biting your tongue or cheek while numb can open a whole host of other problems. Using one of these mouthwashes to simply manage pain subjects the user to what could be unnecessary antibiotics or antifungals and increases the risk that bacteria within the mouth will develop a resistance to the tetracycline, making treatment of future bacterial infections more difficult.

While there are definite benefits to each of the ingredients used individually, their efficiency in combination is inconclusive. The only well-designed study to test whether these mouthwashes improved chemotherapy-induced mucositis showed no difference between them and a saline rinse that could be made from simple household ingredients¹. Furthermore, Magic Mouthwash was shown to be ineffective at shortening the healing time of oral mucositis related to cancer therapies², which is what people with mucositis are really concerned about. Concern has also been expressed over the absorption of anesthetics such as lidocaine when applied to damaged mucosa³.

The modern approach to cancer care is to address the problem and minimize the collateral damage. We grow tumor cells in mice to understand patient-specific treatment. We evaluate genetic profiles to render a more unique approach to therapy. We utilize proton therapy and targeted cell drugs to minimize damage to anything but the tumor cells. Why then would we still expect a broad-range approach to dealing with mucositis? Why not manage the pain, if pain is present; treat the inflammation, if necessary; or care for the infection, if that is indicated?

The truth is, medical oncologists and radiation oncologists treat cancer. While some oncologists address the issue of mucositis, others do not. To compound the problem, there is not just one single causes of mucositis; therefore, there is not just one way to treat an outbreak. Mucositis can be a direct cytotoxic effect of a chemotherapeutic agent or a side effect of radiation to the head or neck. Mucositis can follow a bone marrow transplant or plague an individual with graft-versus-host disease. Managing only the pain misses the point that open sores in the mouth are a pathway into the bloodstream for infections of all types: bacterial, viral, or fungal. Treating only the infection without addressing pain management is neither kind nor conducive to improving quality of life. Care for mucositis is, therefore, often multi-faceted; but rather than taking a one-size-fits-all approach, the better answer is personalized treatment…just like you want for your cancer care. That’s where the specialized service of a dental oncologist can prove invaluable.

A dental oncologist is a dentist focused on meeting the unique oral health care needs of individuals battling cancer and trained to address the specific issues of cancer-related oral conditions like mucositis. Often, a dental oncologist can take a more specific approach to oral health care before, during, and after cancer therapy than other members of the oncology care team. A good dental oncologist will function as a team player, communicating directly with medical and radiation oncologists on your behalf, to ensure optimal care with a comprehensive approach.

Putting a team of professionals to work for you is the best approach. The result is personalized care that is specific to your needs: all your needs…from head to toe…inside and out.

References

1. Dodd MJ, Dibble SL, Miaskowski C, MacPhail L, et al. Randomized clinical trial of the effectiveness of 3 commonly used mouthwashes to treat chemotherapy-induced mucositis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90:39- 47.

2. Clarkson JE, Worthington HV, Eden OB. Interventions for treating oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 2007;(2):CD001973.

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

Dennis M. Abbott, D.D.S. is the founder and CEO of Dental Oncology Professionals of North Texas, an oral medicine practice dedicated to meeting the unique dental and oral health needs of patients battling cancer. He holds a Bachelor of Arts in biology from Rice University in Houston, and is an honor graduate of Baylor College of Dentistry. After dental school, Dr. Abbott studied immunology, microbiology, and oral medicine at the School of Dental Medicine, State University of New York at Buffalo. In addition to private practice, he is currently on the dental oncology medical staff at Baylor Charles A. Sammons Cancer Center and Baylor University Medical Center in Dallas.

Caring for the Oral Health of Patients Battling Cancer Part II: Oral Care During Cancer Treatment

Sun, 11 Mar 2012 23:18:31 -0400

Dennis M. Abbott, D.D.S.

The following is the second of a three-part series written for the dental professional addressing various forms of oral health therapy that ideally should be addressed before, during, and after cancer treatment. This segment focuses on oral health care needs during cancer treatment.

A diagnosis of cancer comes with many questions and emotions. “You have cancer.” That one quick sentence made up of just three little words embarks a patient and his or her family on a journey down long roads of uncountable doctor visits, unknown terminology, and unwanted uncertainty. Often, in the midst of this storm, oral health and dental care are overlooked or placed on a back burner - until there is a problem.

Patients actively undergoing cancer treatment present to the dental office with an unique set of medical concerns and potential complications. Immunosuppression, radiation, and cytotoxic drugs can alter the normal healing process expected after dental procedures. The dental practitioner committed to seeing patients at this most vulnerable time must have a clear understanding of the systemic effects of cancer treatments, be willing to communicate effectively with other members of the oncology team, and realize if the necessary care is within the scope of his or her proficiency. Still, there is much that the dentist or hygienist can do to improve the health and increase the quality of life of patients with cancer.

Because a pre-treatment oral assessment can not be completed after treatment has begun, patients presenting in the dental office for the first time who are currently undergoing cancer therapy must be evaluated in light of the cancer care regimen they are receiving. Each therapy has its unique side effects and concerns; but in virtually all cases, the patient undergoing cancer treatment is immunosuppressed. The dental professional caring for these patients must always keep this fact in mind and design the patient’s treatment plan accordingly.

Dental Care During Chemotherapy

The ideal time for oral care is before chemotherapy begins; however it is not always possible to seek the services of a dental professional before cancer treatment has commenced. Chemotherapy is given in cycles. A cytotoxic drug or combination of drugs is administered - usually through a surgically-placed venous port - and then the patient undergoes a time of recovery. This process, known as the chemotherapy cycle, is repeated according to the needs of the patient and the nature of the cancer. Unfortunately, chemotherapy is often toxic to normal cells; so during treatment with chemotherapeutic agents, the patient is often very ill. The number of peripheral white blood cells drops dramatically after receiving chemotherapy, placing the patient at an increased risk of infection. Similarly, the platelet count decreases and bleeding issues must be taken into account. The lowest point of this cyclical rise and fall of cell counts is known as the patient’s nadir. It is at this point that the patient is most at risk of infection, septicemia, and bleeding. The nadir occurs approximately 10-14 days after the infusion of chemotherapeutic drugs. If dental work is required during chemotherapy it is imperative that the dental professional know the cycle of the regimen, review current blood work, consult directly with the medical oncologist, and document the findings before proceeding with care. Treatment should be delayed until the patient’s absolute neutrophil count and platelet count have recovered.

As a general rule, the absolute neutrophil count (ANC) should be equal to or greater than 1,000/mm³. Patients with ANC’s between 1,000/mm³ and 2,000/mm³ should receive antibiotic prophylaxis according to the American Heart Association’s recommendation. Platelet count should be equal to or greater than 75,000/mm³. Clotting factors (PT, PTT, fibrinogen) should be normal. Any invasive dental procedures, such as oral surgery, should be avoided if the ANC is expected to drop below 1,000/mm³ within two weeks of the procedure.

Dental Care During Head and Neck Radiation

Dental care during head and neck radiation most often focuses on treating and managing the side effects associated with the radiation. The dental professional seeing head and neck radiation patients during treatment must have a thorough understanding of oral infection treatment, pain management and oral pathology. Conditions not usually encountered in routine patient care are experienced frequently in this population of patients. Although necessary for the treatment of the cancer, radiation wreaks havoc on the oral mucosa, salivary glands, teeth, bone, and perioral structures.

Virtually all head and neck radiation patients will experience oral mucositis at least once in their fight with cancer. (Mucositis is also widely seen in patients undergoing hematopoietic cell transplants and very cytotoxic chemotherapy.) Oral mucositis is the inflammation and ulceration of the mucosal lining of the mouth and pharynx, although mucositis can take place anywhere along the GI tract. The affected tissue becomes thin and ulcerated, and can subsequently succumb to necrosis. The resulting lesions are often very painful and debilitating and can affect eating, drinking, and speaking. Mucositis lesions can even become so severe that the patient’s scheduled cancer treatments may be interrupted. In addition to diminishing quality of life, these intraoral sores may serve as portals into the blood for bacterial, viral, or fungal infections. The dental professional must be diligent to identify infections during this time of increased susceptibility and aggressively treat outbreaks systemically. Dentists should be aware that Candidal infections are common in head and neck radiation patients and treat the mouth and any dental prostheses accordingly. Pain should be managed with topical anesthetics or systemic pain medication. If the choice is made to use topically applied anesthetics, it should be stressed to the patient to guard against further damage to the tissue by self-biting.

Severe xerostomia, or dry mouth, is a major concern for all cancer treatments, but especially head and neck radiation patients when the salivary glads are directly exposed to measured amounts of ionizing radiation. Diminished flow has been reported with doses as low as 10 Gy and permanent hyposalivation at doses greater than 25 Gy. Loss of salivary function can lead to changes in taste, difficulty chewing and/or swallowing, nutritional compromises, intolerance to oral medications, increased intraoral mucosal injury, inability to wear dental prostheses, and rampant dental caries. Beyond these side effects, severe xerostomia greatly diminishes the patient’s quality of life. It can be the cause of irregular sleep habits, as many patients wake up often during a night’s sleep because of dryness of the mouth. Xerostomia can give rise to halitosis, which can affect social interaction and self-confidence. Ultimately, chronic dry mouth can prompt emotional challenges and even depression due to changes in social and physical well-being.

There are several products to manage dry mouth on the market today ranging from rinses to systemic sialogogues. Systemic medication should be considered only when residual salivary function remains. Gum, mints, and sprays are also included in the line-up of defense against dry mouth. One new promising product available is AO ProVantage, an antioxidant gel produced by PerioSciences, LLC, which has been shown to be effective on xerostomia and to promote intraoral healing through the reduction of reactive oxygen species in the mouth.

During head and neck radiation therapy, the patient should be reminded that eating will be more difficult. Some patients may even require a feeding tube. For those who can manage to eat on their own, the dental professional should recommend a non-cariogenic diet. Patients should be reminded not to use sugar-based drinks, lozenges or candies to repeatedly moisten the mouth. Patient education regarding the effects that head and neck radiation will have on their saliva and teeth should be reinforced throughout care. For patients who have elected to keep their teeth, they must understand that head and neck radiation places them at an increased risk for dental caries, and they must commit to a lifetime of meticulous oral hygiene. Such a regimen includes the continue use of fluoride trays for those patients who experience permanent hyposalivation.

Trismus is another unwanted side effect experienced by many patients undergoing head and neck radiation. Every effort should be made to maintain the patient’s vertical dimension of opening throughout treatment. An inexpensive effective way to increase vertical dimension is to use wooden tongue depressors taped together, gradually adding another depressor until desired opening is achieved. Daily exercise of opening and closing should be required with warm moist heat applied before and after the workout. Anti-inflammatory drugs and/or muscle relaxers can be prescribed as needed.

Oral Hygiene During Cancer Care

Patients undergoing treatment for cancer should maintain the fullest oral hygiene regimen possible. A soft or extra soft toothbrush should be used with a fluoride toothpaste, if the toothpaste can be tolerated. Alternatively, a sponge brush dipped in aqueous chlorhexidine gluconate may aid in plaque removal, or a washcloth damp with warm water may also be to clean the teeth during periods when a toothbrush is too abrasive to the intraoral tissues. Some patients may only be able to bear rinsing with warm water or saline. While rinsing is better than nothing, brushing should resume as soon as the patient can accept it. Again, the goal is to remove plaque and debris and keep the intraoral bacterial count as low as possible during times of immunosuppression.

Some patients may be able to floss during cancer treatment using a waxed floss or dental tape. It should be stressed, however, that care must be taken to not damage tissue and create a conduit for bacteria to enter the bloodstream. This is particularly important when the mouth is severely dry or in times of a known intraoral infection.

As mentioned before, patients should expect some degree of dry mouth during the course of their treatment. Fluoride trays should be fabricated for each patient, or at a minimum, a 5,000 ppm fluoride toothpaste prescribed for daily use. 1-1.1% neutral sodium fluoride is the fluoride of choice as it does not etch porcelain and glass ionomer restorations. The patient should place of thin ribbon of fluoride gel in the tray and seat the tray on the teeth, gently bite several times to distribute the gel between the teeth, and leave the tray in place for 5 to 10 minutes. The trays should then be removed and the patient instructed to spit but not rinse, eat or brush for at least 30 minutes.

Patients should not wear a dental prosthesis during chemotherapy or head and neck radiation. If the denture must be worn, it should be for as little time as possible. Patients should be encouraged to remove the denture at night to give intraoral tissues a rest. Likewise, wearing of appliances should be avoided if mouth sores are present. Patients should clean the denture at least twice a day, making sure to rinse all visible debris off the prosthesis. For decontamination, the denture can be soaked daily in a 1:25 dilution of bleach water, aqueous chlorhexidine, or a commercially available denture cleaner for 30 minutes.

The Benefits of Rinsing

Many patients find frequent rinsing soothing. Rinsing has many benefits including cleaning and lubricating the tissues in the mouth, preventing crusting, aiding in the care of mucosal wounds, hydrating and irrigating the mucosal tissues, soothing sore gums and oral mucosa, and removing debris. It should be noted, however, that rinsing should not be a substitution for brushing and/or flossing when brushing or flossing can be tolerated.

Some of the best everyday rinses can be made from ingredients commonly found in the pantry. For a neutral rinse, add 1/4 teaspoon salt and 1/4 teaspoon baking soda to one quart of water. This rinse can be used every two hours to help remove debris, soothe irritated tissue, and dissolve thick mucous secretions. In the presence mucositis or other mouth sores, the salt can be substituted with baking soda, making the recipe 1/2 teaspoon baking soda to one quart of water. For a saline rinse, add 1/2 teaspoon salt to an 8 oz. glass of water. The saline rinse helps reduce mucosal irritation, removes thickened secretions and debris, and is the recommended treatment for leukemic gingivitis.

Often times, the need for a specialty rinse may arise. Sunstar Americas, Inc. makes an alcohol-free version of chlorhexidine gluconate 0.12% that is extremely beneficial since the majority of patients undergoing cancer treatment experience dry mouth and alcohol-containing products are contraindicated. Aqueous chlorhexidine has broad-spectrum antimicrobial activity and can used whenever reduction of intraoral bacteria is essential. Caphasol^® (EUSA Pharma) is a two-part supersaturated calcium phosphate rinse that is mixed by the patient immediately before use. It has been shown to be effective in removing thick mucosal secretions and as an aid for treating oral mucositis and xerostomia. A new product, AO ProRinse by PerioSciences, LLC, is an alcohol-free antioxidant-containing mouth rinse that has shown promise in eliminating the metallic taste that many patients experience while undergoing chemotherapy.

Patients should be reminded that the instructions for all rinses is “swish and spit”. Even rinses made at home should not be ingested. Caution should be taken for hypertensive patients or patients on a sodium-restrictive diet when recommending salt-based rinses, including Caphasol^® .

The Role of the Dental Professional in Cancer Care

Making a difference in the life of a cancer patient can be extremely rewarding. A dental professional knowledgeable in cancer care should be a member of every oncology team. Understanding the unique needs of patients undergoing cancer therapy and keeping them safe during times of immunosuppression are critically important. Forecasting statistics show an expected increase in the incidence of cancer in the United States each year. Unfortunately, more and more people will hear those three little words, “You have cancer,” and their lives will be changed. These are patients that need the skills of an oral health professional who can understand the medical history, read the lab results, consult with the oncologists, diagnose the oral condition, treat the problem, and care. These are the patients that need you.

Dental Oncology Professionals of North Texas

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Caring for the Oral Health of Patients Battling Cancer Part I: Oral Care Before Cancer Treatment

Sat, 10 Mar 2012 15:25:20 -0500

Dennis M. Abbott, D.D.S.

The following is the first of a three-part series addressing various forms of oral health therapy that ideally should be addressed before, during, and after cancer treatment. This segment focuses on oral health care needs before the commencement of cancer treatment.

Cancer. The New Oxford American Dictionary defines it as “the disease caused by an uncontrolled division of abnormal cells in a part of the body;” but for the millions of people it has touched, cancer is so much more. Cancer is a constant unwanted companion that opens the door to an unchosen journey and demands to be followed. It affects individuals, families and friends. Cancer changes lives.

Beyond the emotional toll it imposes, cancer alters the well-being of those it afflicts. Modern treatment regimens given to combat this disease come with a host of deleterious side effects, many of which occur in the mouth. Dentists, dental hygienists and dental auxiliaries are in a unique and necessary position to make a positive impact in the lives of patients battling cancer.

Making a difference begins with a desire to help and a willingness to take a risk. It is followed by a commitment to learn about the unique oral health care needs of patients engaged in the fight of their lives and put into practice skills that can literally provide comfort and hope. We, as dental professionals, can and should be a part of a comprehensive cancer care team for an ever-growing number of people facing cancer.

Dental Oncology

Dental oncology is a focus of dentistry dedicated to meeting the unique dental and oral health care needs that arise as a result of cancer therapy. It is an area of oral medicine devoted to improving the well-being and quality of life of people battling cancer. Dental oncology goes beyond the scope of general dental treatment to include management of the soft tissues of the mouth and care for oral side effects specific to cancer therapy. A dental professional knowledgeable in dental oncology plays an important role throughout cancer treatment by preventing and managing mouth sores, dental needs, oral pain and infections. As a member of the patient’s oncology care team, the dental professional communicates directly with the medical oncologist, radiation oncologist and other team members to provide optimal comprehensive care before, during, and after cancer treatments.

Ideally, a patient’s relationship with a dental professional begins as soon as possible after receiving the diagnosis of cancer. Most of the present-day treatments for cancer involve the administration of cytotoxic drugs, radiation, myelosuppressive treatments or some combination thereof. Having a baseline assessment completed before the implementation of immunosuppressive therapies allows the dental professional to have a pre-treatment reference point to compare oral and systemic health at future visits.

For the newly diagnosed patient with cancer who has not received regular dental and oral health care, a prompt visit to the dentist’s office also allows for immediate attention to unaddressed periodontal issues and unresolved dental needs before immunosuppression begins. During cancer treatments, bacterial components of calculus, dental plaque and oral biofilm can easily become vehicles for bacteremia or oral infections. Properly addressing these oral health concerns at this pre-treatment stage can prevent or significantly reduce the severity of oral issues that could complicate or even interrupt the patient’s cancer treatment schedule.

Oral Health Care Before Chemotherapy

Chemotherapy is the treatment of choice for a wide range of cancers. It can be used either alone or in combination with other treatment modalities. The goal of chemotherapy is to eradicate the rapidly dividing cancerous cells, but unfortunately these drugs often cannot differentiate between cancer cells and other types of cells that divide rapidly under normal conditions within the body. These cells include bone marrow, hair, and the mucosa of the entire gastrointestinal tract, including the mouth. It is the direct cytotoxic effect of the drugs as well as side effects that can cause intraoral complications. Because chemotherapeutic agents are used to combat cancers of all types, the dental professional is needed to care for patients with most kinds of cancer, not just malignancies relevant to structures within the head or neck.

Optimally, the patient should see a dental professional well enough in advance so that all dental procedures can be completed one week before beginning chemotherapy. At a minimum, dental procedures that might introduce bacteria into the bloodstream should be completed in this timeframe. Close communication with the medical oncologist is of paramount importance as each member of the oncology team needs to be aware of the scheduling of all care related to the patient. Communication should include a summary of the present oral health of the patient, a treatment plan of essential dental care, and an anticipated timeline of when that care can be completed. The dental professional should also confirm that the medical colleagues on the oncology team understand the nature of anticipated oral complications during treatment and be prepared to function as the expert able to address those oral health issues.

Dental management before chemotherapy should include a thorough baseline dental and periodontal assessment with close attentions paid to conditions that could be problematic during times of immunosuppression. Preemptive measures should be taken to correct or remove any possible sources of oral trauma. These might include broken teeth or ill-fitting existing restorations or prostheses. Non-restorable teeth that pose an infection risk in the short term should be extracted. This would include any tooth affected by severe periodontal disease or deemed to be of endodontic concern. Partially-erupted third molars should be evaluated and be extracted if they are at risk for for pericornitis. A thorough dental prophylaxis including scaling and root planing must be completed. Decreasing the existing intraoral bacterial load is one of the best preventive services that can be performed for the patient scheduled to undergo chemotherapy. Carious lesions and tooth-born fractures should be restored. Resin modified glass ionomer is a good restorative material choice for these patients as xerostomia is anticipated during cancer treatment. Any orthodontic bands and wires should be removed and orthodontic treatment postponed until cancer treatment is completed. Oral hygiene instructions should be reviewed, even for regular dental patients. Educating about possible or anticipated oral issues and reassuring the patient and the family they are not alone in this battle builds confidence and strengthens the dental professional/patient relationship.

Oral Health Before Head and Neck Radiation Therapy

Radiation therapy is routinely used to treat tumors in the head or neck, often in combination with chemotherapy or immunotherapy. Head and neck radiation, unlike radiotherapy in other parts of the body, creates issues of particular concern for the dental professional. Patients undergoing head and neck radiation therapy often experience permanent life-changing side effects from their cancer treatment. Understanding these complications at the pre-treatment assessment positions the dental professional to be of the most service.

The pre-treatment assessment appointment for the patient undergoing head and neck radiation begins with a full-mouth series of radiographs. A clinical examination including complete periodontal charting must be combined with the radiographic evaluation to assess periodontal condition, to diagnose periapical pathology and to identify teeth requiring immediate attention. All possible sources of intraoral trauma must be resolved. Because trauma to irradiated bone poses a risk for osteoradionecrosis, the dental professional must evaluate the current condition of the teeth and periodontium and anticipate the patient’s ability to maintain meticulous oral hygiene for the remainder of his or her life, often in challenging intraoral conditions. All non-restorable teeth should be extracted. Those teeth with moderate to severe periodontal disease and partially-erupted third molars within the anticipated field of radiation should also be removed. Other teeth in the planned field of radiation should be evaluated in light of the patient’s current hygiene status and dental history, the presence of high-risk deleterious habits or co-morbidities (e.g. smoking and diabetes mellitus), the patient’s commitment to regular professional dental visits, and the risk of osteoradionecrosis. Any decision by the patient to refuse to comply with the dental professional’s recommendation should be well-documented in the patient’s chart. All remaining teeth must be thoroughly cleaned. Dental impressions should be taken from which fluoride trays can be fabricated for the patient’s at-home use. The dental professional should counsel the patient and his or her family concerning the anticipated complications of head and neck radiation therapy and the life-long changes that must be made in oral health care.

Communication between the dental professional and radiation oncologist is extremely important. The dentist should understand the anticipated scheduling of radiation treatments and must know the amount of radiation planned for each of the jaws. Similarly, the radiation oncologist should be aware of all necessary dental treatment and the anticipated timeline to complete it. The timing of dental surgery is of utmost importance: at least 14 days should be available for healing following any surgery before radiation therapy commences. The dental professional should understand that tumors of the head and neck are often times fast moving and require expeditious treatment. Every effort should be made to accommodate head and neck patients for treatment as soon as possible. There are times, however, when the nature of the tumor may be such that radiation therapy must be initiated immediately and not allow adequate time for dental work to be completed. In these cases, dental care should be postponed until the completion of radiotherapy and the patient has sufficiently recovered. Dental care should be avoided while the patient is undergoing radiation therapy, but should be completed as soon after radiotherapy as possible since bone changes associated with radiation worsen over time.

Oral Health Before Bisphosphonate Therapy

Bisphosphonate therapy is used extensively in patients with metastatic bone disease. These drugs, which include Zometa®(zoledronic acid) and Aredia®(pamidronate), are administered intravenously through a portacath. They fall into a unique class of drugs that are characterized by their affinity for bone and the ability to inhibit bone resorption through decreased osteoclastic activity. Because they limit bone turnover, these drugs have been implicated in osteonecrosis following dental surgery subsequent to bisphosphonate therapy. Drug potency and accumulation seem to be important factors in assessing whether or not a patient is at risk for developing bisphosphonate-related osteonecrosis of the jaw.

If non-restorable teeth exist in a patient who will be undergoing bisphosphonate therapy, they should be removed at least 14 days before the introduction of the drug, if possible. Partially-erupted third molars and teeth with moderate to severe periodontal disease should be considered for extraction. Precautions similar to those for patients undergoing head and neck radiation should be considered in evaluating teeth for possible extraction as the half-life bisphosphonates can exceed ten years. All dental professionals should be aware that a history of bisphosphonate disclosed in a medical history should be carefully considered and evaluated to assess the risk for bisphosphonate-related osteonecrosis of the jaw.

Cancer in The United States Today

According to the North American Association of Central Cancer Registries, the estimated new cancer cases in the United States in 2011 was approximately equivalent to the population of the entire state of Idaho. From the same source, the estimated number of U.S. deaths in the same year approximated the population of the entire state of Wyoming. It is important to note that these are annual numbers. Currently, approximately 12 million people in the United States are living with cancer. This number does not include cancer survivors considered cancer-free. In 2010, the national cost for cancer care in the US was over $124 billion. That number is expected to more than double, and possibly triple, by the year 2020.

Cancer is a significant healthcare concern in the United States and around the world. As the Baby-Boomer generation continues to age, the incidence rate in the United States is expected to increase. Cancer treatment has evolved from a required visit to one of just a few major national cancer centers to care that can be received close to home. With more and more local cancer treatment centers, there is a greater need for local dental professionals to become an integral part of oncology teams and provide the care that these patients so desperately need.

Dental Oncology Professionals of North Texas

web: www.dopnt.com

Twitter: @DentalOncology

Facebook: facebook.com/dentaloncology