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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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