This course was published in the May 2016 issue and expires 05/31/19. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Implement an initial oral evaluation and provide treatment for patients presenting with cancer.
- Identify and understand appropriate assessment strategies, and the types of oral conditions that arise from cancer therapies.
- Appropriately plan and revise dental therapies throughout a patient’s cancer treatment regimen.
The approach to managing cancer is based on the type of malignancy, site of the cancer, and individual patient factors — such as age and possible medical comorbidities. Patients’ oral health status is also important. Recent advances in cancer therapy have led to increased survival rates, which underscores the need for these patients to maintain optimal oral health.1 In light of this, the dental team plays an important role in providing treatment to patients with cancer as part of the comprehensive care continuum from diagnosis through survivorship.
Oral assessment and implementation of basic oral care protocols should be provided before, during and after cancer therapy, and clinicians should remain vigilant in recognizing oral complications.2 Basic oral care for patients with cancer includes preventing infection, treating active infection, controlling pain, maintaining oral function, managing oral complications, and improving quality of life.1,3,4 Ideally, all patients with cancer should have a cancer pretreatment oral assessment — especially those diagnosed with head and neck cancer or hematologic cancer, patients undergoing hematopoietic stem cell transplantation (HSCT), and those with poor oral health. The pretreatment assessment should be completed as soon as possible following a cancer diagnosis, and at least two to three weeks prior to starting cancer therapy.
The evaluation should include an examination of the head and neck, oral soft tissue and oral cavity. In addition, a periodontal evaluation should be completed and a full series of dental radiographs captured. Nonemergency dental treatment can be delayed until the patient’s overall health status is stable.5,6 Each patient should receive an individualized care plan based on the specific type of cancer he or she has. The dental team needs to understand the prescribed cancer therapy in order to create this treatment protocol.7 Communication with the oncology team is essential to providing successful oral care; in unique or complex cases, consultation with dental specialists who specialize in oncology may be necessary.
Prior to the start of cancer treatment, patients should receive a dental prophylaxis, which may reduce the severity of oral complications (specifically oral mucositis).8 Small or incipient caries lesions may be treated with fluoride, temporary restorations and/or sealant application until definitive care can be provided. Caries lesions involving the pulp, however, require active intervention. Patients who need teeth extracted due to periodontitis or other causes must undergo surgery before cancer treatment begins because the risk of osteonecrosis is elevated when surgery is performed post-treatment.
Patient education is an integral part of the pretreatment evaluation. Affected individuals must understand how to perform effective self-care to safeguard their oral health. Dental teams can also counsel patients about adopting healthy diets and avoiding tobacco and alcohol use. Patients should likewise be assessed for xerostomia, change or loss of taste, and mucosal sensitivity.
PROTOCOLS DURING TREATMENT
Oral complications during active cancer treatment negatively impact patients’ quality of life. These problems can become so severe that the cancer therapy has to be altered, delayed or interrupted — which may affect treatment outcomes. Patients should be monitored closely during cancer treatment to manage oral changes and to reinforce preventive strategies. During therapy and follow-up care, management of complications associated with mucositis, oral infection, altered salivation and sensory changes (e.g., pain or taste) is critical.
The use of mouthrinses, atraumatic toothbrushing and flossing twice a day, along with daily administration of fluoride gels, is recommended.1,9 The use of prescription-strength fluoride toothpaste may be warranted. Patients with mucositis, however, may not be able to tolerate high levels of fluoride due to oral discomfort, so switching to mild-flavored nonfluoride dentifrice and suggesting a fluoride mouthrinse may be helpful. If patients cannot tolerate a regular soft toothbrush due to mucositis, super-soft brushes may be indicated; another alternative is to use foam brushes to deliver chlorhexidine to the tissues.10 If patients are skilled at flossing without traumatizing the tissues, they should continue flossing throughout cancer treatment. In order to avoid tissue trauma, however, toothpicks and water irrigation devices should not be used in patients who are neutropenic and/or thrombocytopenic.11
Clinicians should encourage patients to eat healthy diets and advise them about the caries risks associated with consuming dietary supplements rich in carbohydrates, as well as medications sweetened with sucrose (such as nystatin suspension), which are sometimes used to suppress opportunistic fungal infections.12
The frequency of recall appointments depends on the patient’s oral health status. The dental care plan should be based on the presence of oral disease, effectiveness of the patient’s self-care regimen, risk of progression of oral disease, and oral complications caused by cancer therapy.
EARLY AND LONG-TERM COMPLICATIONS
Patients undergoing cancer therapy are at increased risk of mucositis, oral mucosal infections, xerostomia, osteonecrosis and cancer recurrence. Mucositis care focuses on alleviating symptoms and managing the secondary factors that affect its severity.11 Optimal management typically includes good oral hygiene, topical anesthetic/analgesic agents, nonmedicated oral rinses, mucosal coating agents, film-forming agents, nutritional supplements and systemic analgesics. Patients with mucositis may experience relief from symptoms by rinsing with a mixture of a teaspoon of baking soda and a teaspoon of salt dissolved in water.
Opportunistic fungal, viral and bacterial infections are common among individuals undergoing cancer therapy. Oral and oropharyngeal candidiasis presents as cracking at the corners of the mouth and erythematous or white mucosal patches.13 Candidiasis may also cause a coated sensation in the oral cavity, oral burning and changes in taste sensations. Patients may present with a variety of fungal species that may prove resistant to standard antifungal therapy.13 While topical antifungal agents are commonly prescribed to prevent candidiasis, their effectiveness is inconsistent and systemic agents may prove more effective for treatment of infection.14,15
Herpes simplex virus (HSV) infections may arise during cancer care. Varicella, Epstein-Barr and cytomegalovirus infections are not uncommon, particularly in patients with hematological malignancies undergoing chemotherapy and HSCT. Acyclovir and valacyclovir are equally effective in preventing and treating HSV, but resistant virus and breakthrough infection can occur.16,17
Local or systemic infections can be caused by normal oral flora in patients who are immunosuppressed. Infections may also be caused by nosocomial and bowel microbes not normally found in the oral cavity. Culturing (to identify likely causal organisms) and sensitivity testing (to possible antimicrobial drugs) may be helpful in terms of selecting one or more appropriate therapeutic antimicrobials.12 Other potential complications in patients undergoing HSCT include graft-versus-host disease (GVHD), osteonecrosis of the jaw, and recurrent or secondary malignancies.
As a multiorgan disease that occurs following allogeneic HSCT, GVHD requires an interdisciplinary treatment plan that includes care from experienced dental and medical professionals working in concert. Common oral signs and symptoms of oral GVHD include lichenoid striations, erythema, ulceration, xerostomia, mucocele, dysgeusia, trismus and fibrosis.4 Management focuses on optimizing oral health to prevent progressive dental disease, and controlling symptoms, such as pain, sensitivity and oral dryness. Other oral maladies may require specialized treatment.
Patients who have undergone cancer treatment may experience long-term side effects, including hyposalivation and dysgeusia.18 Individuals with xerostomia and/or hyposalivation should be encouraged to sip water throughout the day and to avoid drying agents, such as caffeine, alcohol and sugar-containing products. Moisturizing mouthrinses, artificial saliva products, and water-based lubricants may help prevent the oral cavity from drying out. Patients may also gain relief from xerostomia symptoms by using toothpastes, mouthrinses and gels with a neutral pH. To prevent caries, an at-home, tray-based fluoride regimen should be considered. Prescription secretagogues may stimulate salivary gland tissue, boosting salivary flow. Chewing xylitol gum may also provide symptom relief and offer caries-prevention benefits.19
Individuals with blood-related cancers may have increased oral bleeding due to thrombocytopenia, disturbance of coagulation factors or damaged vascular integrity. They may also experience dentinal hypersensitivity stemming from decreased salivary flow, low salivary pH and neuropathic pain.1,20 Clinicians should focus on early identification of risk factors and symptoms, as well as clinical signs that may warrant referral for more specialized care.
Managing oral complications remains important upon completion of cancer treatment. Periodontal maintenance and effective oral self-care remain key goals. Patients who can tolerate power toothbrushes may use these devices. Keeping the mouth and lips lubricated is also helpful.
Patients previously treated for oral and head and neck cancer and upper aerodigestive cancers are at increased risk of recurrent or new cancers. Individuals who underwent HSCT, those who received total body irradiation or chemotherapy, and patients who had GVHD are at greater risk of secondary malignancies. In light of this, oral health professionals need to be especially diligent when screening these patients for oral cancer.
INFORMATION FOR DENTAL PROFESSIONALS TO GIVE TO CANCER PATIENTS REGARDING BASIC ORAL CARE
Dear Patient: This note is inform you of oral/dental changes that may occur before, during and after your cancer treatment. Although these guidelines are standardized, please remember that your individual needs may differ. Having a discussion with your dental team is important to develop an effective daily routine and implement preventive strategies to suit your individual needs. For any questions about pretreatment care or care following cancer therapy, and to integrate with the oncology plan, please contact the treating oncologist or an expert who is affiliated with your cancer center. This is particularly important for dental conditions that may require surgical management.
Goals of Oral Care Prior to Cancer Treatment:
- Treat conditions causing pain and swelling, and at risk of infection during treatment
- Treat dental conditions that may require surgery in the future if you are to receive head and neck radiation therapy to the jaw area
Oral Self-Care During Cancer Treatment:
- Important: Caring for your oral health during therapy is critical, as the side effects of treatment (listed below) affect more than just your mouth. They may cause pain, affect your nutrition, and, in turn, your overall well-being
- Basic Guidelines
- Brushing: twice per day with an ultra-soft toothbrush
- Flossing: once per day; be gentle in order to avoid floss cuts
- Rinsing: Avoid mouthrinses that contain alcohol. Or use this mouthrinse recipe: 1 teaspoon (5 mL) salt, 1 teaspoon (5 mL) baking soda, 4 cups (1 L) water. Mix, store in an air-tight container at room temperature; discard at the end of each day
- Supplements: Your dentist may recommend the use xylitol products, mouth-wetting products and fluoride therapies
- Hygiene Recall
- Have your teeth cleaned before cancer therapy
- Once cancer therapy is completed and you are cleared to return for dental treatment, more frequent hygiene recall visits may be recommended than prior to cancer treatment
Common Oral Side Effects of Cancer Treatment:
- Dry Mouth: Decreased salivary flow
- Effects: Ropey saliva, sticky sensation, less saliva, chapped lips, etc.
- Managing Side Effects: Sip water, xylitol products (available as mints, lozenges, gums and mouthrinses), mouth-wetting agents. Avoid alcohol-containing mouthrinses, and coarse, spicy or acidic foods. Sugar substitutes should be used instead of sugar, as your teeth may be more susceptible to decay. Prescription treatments may be indicated.
- Mucositis: Oral Pain
- Effects: Mouth ulcers (sores) can occur in any location in your mouth and throat
- Managing Side Effects: Use homemade mouthrinse recipe to sooth oral tissues, chlorhexidine rinse (available by prescription only), regular brushing and flossing. Avoid the same things as with dry mouth. Review oral treatment and pain medications (as needed) with a professional.
- Fungal Infections: Yeast
- Effects: White or red changes on tongue or oral tissues, taste change and mouth odor
- Managing Side Effects: Adequate at-home oral self-care, which should include brushing the tongue, antifungal medication (available by prescription only), and daily denture cleaning (avoid wearing dentures overnight)
- Taste Change:
- Effects: Lack or altered taste sensation
- Managing Side Effects: Ensure you are maintaining a balanced diet regardless of taste alteration, which could increase or decrease your appetite
- Review dietary instructions and treatments as needed with an experienced professional.
- Preventing Cavities:
- Ask your dental provider about oral hygiene, dry mouth products, fluoride, remineralizing products, chlorhexidine and diet
- Dietary Recommendations:
- Soft diet (atraumatic food); supplements if needed
- Limited jaw opening: Ask your dental provider about jaw exercises, active therapy, and possible prescription medications
- Jaw Bone Health:
- Local jaw radiation and a number of medicines used in cancer therapy can affect bone health; in turn, this can affect decisions to perform or avoid surgery. (If bone damage has occurred, case management can become complex) Note: Some of the oral considerations and treatments are complex, and may require special expertise and consultation with the oncology team.
Note: Some of the oral considerations and treatments are complex, and may require special expertise and consultation with the oncology team.
An aging population experiencing a growing number of cancer diagnoses, along with the increasing number of cancer survivors, demand careful professional attention to improving the oral health of this patient population. While all cancer patients should try to maintain good oral health, this is particularly important for head and neck cancer patients, as well as those whose cancer treatment causes immunosuppression or interferes with the protective capabilities of normal salivary flow. In addition, dental teams should consider oral treatment protocols throughout every stage of cancer therapy — and this includes post-treatment maintenance. Oral health professionals play a key role on cancer teams due to their important contributions to treatment and disease management outcomes.
- Epstein JB, Thariat J, Bensadoun RJ, et al. Oral complications of cancer and cancer therapy: from cancer treatment to survivorship. CA Cancer J Clin. 2012;62:400–422.
- Ganzer H, Epstein JB, Touger-Secker R. Nutrition management of the cancer patient. In: Touger-Decker R, Mobley C, Epstein JB, eds. Nutrition and Oral Medicine. New York: Human Press, Springer; 2014:235–253.
- Epstein JB, Güneri P, Barasch A. Appropriate and necessary oral care for people with cancer: guidance to obtain the right oral and dental care at the right time. Support Care Cancer. 2014;22:1981–1988.
- Elad S, Raber-Durlacher JE, Brennan MT, et al. Basic oral care for hematologyoncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology and the European Society for Blood and Marrow Transplantation. Support Care Cancer. 2015;23:223–236.
- Rankin K, Jones D, Redding S, et al. Oral Health in Cancer Therapy: A Guide for Health Care Professionals. Available at: http://www.exodontia.info/files/ Oral_ Health_in_Cancer_Therapy_- _A_Guide_for_Health_Care_Professionals _3rd_edition.pdf. Accessed April 4, 2016.
- Schubert MM, Peterson DE. Oral complications of hematopoietic cell transplantation. In: Appelbaum RF, Forman SJ, Negrin RS, Blume KG, eds. Thomas’ Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, United Kingdom: Wiley- Blackwell; 2009:1589–1607.
- Lalla RV, Brennan MT, Schubert MM. Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, Marrioti AJ, Neidle EA, eds. Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis: Mosby-Elsevier; 2011:782–798.
- Joshi V.K. Dental treatment planning and management for the mouth cancer patient. Oral Oncol. 2010;46:475–479.
- Jackson LK, Johnson DB, Sosman JA, Murphy BA, Epstein JB. Oral health in oncology: impact of immunotherapy. Support Care Cancer. 2015;23:1–3.
- Hong CH, daFonseca M. Considerations in the pediatric population with cancer. Dent Clin N Am. 2008;52:155–181.
- Keefe DM, Schubert MM, Elting LS, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007;109:820–831.
- Hong CH, Napeñas JJ, Hodgson BD, et al. A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer. 2010;18:1007–1021.
- Lalla RV, Latortue MC, Hong CH, et al. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer. 2010;18:985–992.
- Worthington HV, Clarkson JE, Khalid T, Meyer S, McCabe M. Interventions for treating oral candidiasis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2010;7:CD001972
- Gøtzche PC, Johansen HK. Nystatin prophylaxis and treatment in severely immunocompromised patients. Cochrane Database Syst Rev. 2002;2:CD002033.
- Reusser P. Management of viral infections in immunocompromised cancer patients. Swiss Med Wkly. 2002;132:374–378.
- Arduino PG, Porter SR. Oral and perioral herpes simplex virus type 1 (HSV-1) infection: review of its management. Oral Diseases. 2006;12:254–270.
- Nieuw Amerongen AV, Veerman EC. Current therapies for xerostomia and salivary gland hypofunction associated with cancer therapies. Support Care Cancer. 2003;11:226–231.
- Trushkowsky RD. Xerostomia management. Dimensions of Dental Hygiene. 2014;12(3):34–39.
- Saunders DP, Epstein JB, Elad SA, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3191–3207.
From Decisions in Dentistry. May 2016;2(5):30—33.