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Dental TEAM Oral Complications of Cancer Treatment: What the Dental Team Can Do

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Dental TEAM Oral Complications of Cancer Treatment: What the Dental Team Can Do DEntAL TEAM Oral Complications of Cancer Treatment: What the Dental Team Can Do With over 1.4 million new cases of cancer side effects common to both chemotherapy diagnosed each year and a shift to outpatient and radiation therapy, and complications management, you will likely see some of specific to each type of treatment. You will these patients in your practice. Because need to consider the possibility of these cancer treatment can affect the oral tissues, complications each time you evaluate a you need to know about potential oral side patient with cancer. effects. Preexisting or untreated oral disease can also complicate cancer treatment. Your Oral complications common to role in patient management can extend both chemotherapy and radiation benefits beyond the oral cavity. • Oral mucositis: inflammation and Oral complications from radiation to the head ulceration of the mucous membranes; can and neck or chemotherapy for any malignancy increase the risk for pain, oral and systemic can compromise patients’ health and quality infection, and nutritional compromise. of life, and affect their ability to complete planned cancer treatment. For some patients, • Infection: viral, bacterial, and fungal; results the complications can be so debilitating from myelosuppression, xerostomia, and/or that they may tolerate only lower doses of damage to the mucosa from chemotherapy therapy, postpone scheduled treatments, or radiotherapy. or discontinue treatment entirely. Oral complications can also lead to serious systemic • Xerostomia/salivary gland infections. Medically necessary oral care dysfunction: dryness of the mouth due before, during, and after cancer treatment can to thickened, reduced, or absent salivary prevent or reduce the incidence and severity flow; increases the risk of infection and of oral complications, enhancing both patient compromises speaking, chewing, and survival and quality of life. swallowing. Medications other than chemotherapy can also cause salivary Oral Complications Related gland dysfunction. Persistent dry mouth increases the risk for dental caries. to Cancer Treatment • Functional disabilities: impaired ability Oral complications of cancer treatment arise to eat, taste, swallow, and speak because of in various forms and degrees of severity, mucositis, dry mouth, trismus, and infection. depending on the individual and the cancer treatment. Chemotherapy often impairs the • Taste alterations: changes in taste function of bone marrow, suppressing the perception of foods, ranging from formation of white blood cells, red blood unpleasant to tasteless. cells, and platelets (myelosuppression). Some cancer treatments are described as • Nutritional compromise: poor stomatotoxic because they have toxic effects nutrition from eating difficulties caused by on the oral tissues. Following are lists of mucositis, dry mouth, dysphagia, and loss of taste. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Institute of Dental and Craniofacial Research • Abnormal dental development: altered • Lower risk: Patients receiving tooth development, craniofacial growth, or minimally myelosuppressive or skeletal development in children secondary nonmyelosuppressive chemotherapy. to radiotherapy and/or high doses of chemotherapy before age 9. • Higher risk: Patients receiving stomatotoxic chemotherapy resulting in prolonged myelosuppression, including Other complications patients undergoing hematopoietic of chemotherapy stem cell transplantation; and patients • Neurotoxicity: persistent, deep aching undergoing head and neck radiation for and burning pain that mimics a toothache, oral, pharyngeal, and laryngeal cancer. but for which no dental or mucosal source Some complications occur only during can be found. This complication is a side treatment; others, such as xerostomia, may effect of certain classes of drugs, such as persist for years. Unfortunately, patients with the vinca alkaloids. cancer do not always receive oral care until • Bleeding: oral bleeding from the decreased serious complications develop. platelets and clotting factors associated with the effects of therapy on bone marrow. The Role of Pretreatment Oral Care Other complications of radiation therapy A thorough oral evaluation by a knowledgeable dentist before cancer • Radiation caries: lifelong risk of rampant treatment begins is important to the dental decay that may begin within success of the regimen. Pretreatment 3 months of completing radiation treatment oral care achieves the following: if changes in either the quality or quantity of saliva persist. • Reduces the risk and severity of oral complications. • Trismus/tissue fibrosis: loss of elasticity of masticatory muscles that restricts • Allows for prompt identification and normal ability to open the mouth. treatment of existing infections or other problems. • Osteonecrosis: blood vessel compromise and necrosis of bone exposed to high-dose • Improves the likelihood that the patient radiation therapy; results in decreased will successfully complete planned ability to heal if traumatized. cancer treatment. • Prevents, eliminates, or reduces oral pain. Who Has Oral • Minimizes oral infections that could lead Complications? to potentially serious systemic infections. Oral complications occur in virtually all • Prevents or minimizes complications that patients receiving radiation for head and compromise nutrition. neck malignancies, in approximately 80 percent of hematopoietic (blood- • Prevents or reduces later incidence of forming) stem cell transplant recipients, bone necrosis. and in nearly 40 percent of patients receiving chemotherapy. Risk for oral complications • Preserves or improves oral health. can be classified as low or high: 2 What the Dental Team Can Do What the Dental Team Can Do 3 • Provides an opportunity for patient • Conduct a prosthodontic evaluation education about oral hygiene during if indicated. If a removable prosthesis cancer therapy. is worn, make sure that it is clean and well adapted to the tissue. Instruct the • Improves the quality of life. patient not to wear the prosthesis during • Decreases the cost of care. treatment, if possible; or at the least, not to wear it at night. With a pretreatment oral evaluation, the dental team can identify and treat problems • Perform oral prophylaxis if indicated. such as infection, fractured teeth or • Time oral surgery to allow at least 2 restorations, or periodontal disease that weeks for healing before radiation therapy could contribute to oral complications when begins. For patients receiving radiation cancer therapy begins. The evaluation also treatment, this is the best time to consider establishes baseline data for comparing the surgical procedures. Oral surgery should patient’s status in subsequent examinations. be performed at least 7 to 10 days before Before the exam, you will need to obtain the the patient receives myelosuppressive patient’s cancer diagnosis and treatment plan, chemotherapy. Medical consultation is medical history, and dental history. Open indicated before invasive procedures. communication with the patient’s oncologist is essential to ensure that each provider has the information necessary to deliver the best possible care. Supplemental Fluoride Evaluation Fluoride rinses are not adequate to prevent tooth demineralization. Instead, a high- Ideally, a comprehensive oral evaluation potency fluoride gel, delivered via custom should take place 1 month before cancer gel-applicator trays, is recommended. Several treatment starts to allow adequate time for days before radiation therapy begins, patients recovery from any required invasive dental should start a daily 10-minute application of a procedures. The pretreatment evaluation 1.1% neutral pH sodium fluoride gel or a 0.4% includes a thorough examination of hard and stannous fluoride (unflavored) gel. Patients soft tissues, as well as appropriate radiographs with porcelain crowns or resin or glass to detect possible sources of infection and ionomer restorations should use a neutral pathology. Also take the following steps pH fluoride. Be sure that the trays cover before cancer treatment begins: all tooth structures without irritating the gingival or mucosal tissues. • Identify and treat existing infections, carious and other compromised teeth, For patients reluctant to use a tray, a high- and tissue injury or trauma. potency fluoride gel should be brushed on the teeth following daily brushing and flossing. • Stabilize or eliminate potential sites Either 1.1% neutral pH sodium or 0.4% of infection. stannous fluoride gel is recommended, based on the patient’s type of dental restorations. • Extract teeth in the radiation field that are nonrestorable or may pose Patients with radiation-induced salivary gland a future problem to prevent later dysfunction must continue lifelong daily extraction-induced osteonecrosis. fluoride applications. 2 What the Dental Team Can Do What the Dental Team Can Do 3 • Remove orthodontic bands and brackets It is very important that the dental team if highly stomatotoxic chemotherapy is impress on the patient that optimal oral planned or if the appliances will be in the hygiene during treatment, adequate nutrition, radiation field. and avoiding tobacco and alcohol can prevent or minimize oral complications. To ensure • Consider extracting highly mobile primary that the patient fully understands what is teeth in children, and teeth that are required, provide detailed instructions on expected to exfoliate during
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