What the Oral Health Team Can Do

Oral Complications of Cancer Treatment: What the Oral Health Team Can Do

With more than 1 million new cases of cancer diagnosed each year, and the shift to outpatient management, it is likely that you will see some of these patients in your practice. Because cancer treatment can affect the oral tissues, you need to know about potential oral complications. Moreover, pre-existing or untreated oral disease can complicate cancer treatment. Your role in patient management can extend benefits beyond the oral cavity.

Oral complications from radiation to the head and neck or chemotherapy for any malignancy can seriously compromise patients’ health and quality of life, as well as affect their ability to complete planned cancer treatment. The complications can be so debilitating that patients may tolerate only lower and less effective doses of therapy, may postpone scheduled treatments, or may have to discontinue treatment entirely. Oral complications can also lead to potentially life-threatening systemic infections. Medically necessary oral care prior to, during, and after cancer treatment can prevent or reduce the incidence and severity of oral complications, enhancing both patient survival and quality of life.

Oral Complications Related to Cancer Treatment

Oral complications of cancer treatment arise in various forms and degrees of severity, depending on the individual and the cancer treatment.

Chemotherapy often impairs the function of bone marrow, suppressing the formation of white blood cells, red blood cells, and platelets (myelosuppression). Some cancer treatments are described as stomatotoxic because they have toxic effects on the oral tissues. Following are lists of complications common to both chemotherapy and radiation therapy, and complications specific to each type of treatment. You will need to consider the possibility of these complications each time you evaluate a cancer patient.

Oral complications common to both chemotherapy and radiation

* Mucositis/stomatitis: inflammation and ulceration of the mucous membranes; can increase the risk for pain, oral and systemic infection, and nutritional compromise.

* Infection: viral, bacterial, and fungal; results from myelosuppression, xerostomia, and/or damage to the mucosa from chemotherapy or radiotherapy.

* Xerostomia/salivary gland dysfunction: dryness of the mouth because of thickened, reduced, or absent salivary flow; increases risk for infection and compromises speaking, chewing, and swallowing. Persistent dry mouth also increases the risk for dental caries.

* Rampant dental decay and demineralization: rapid decay or erosion of the tooth’s surface as a result of changes in both the quality and quantity of saliva following cancer treatment.

* Functional disabilities: impaired ability to eat, speak, and swallow because of mucositis, dry mouth, trismus, and infection.

* Taste alterations: changes in taste perception of foods, ranging from unpleasant to tasteless.

* Nutritional compromise: poor nutrition from eating difficulties caused by mucositis, dry mouth, dysphagia, and taste loss.

* Abnormal dental development: altered tooth development and/or craniofacial growth in children secondary to radiotherapy and/or high doses of chemotherapy prior to age 9.

Additional complications of chemotherapy

* Neurotoxicity: persistent, deep aching and burning pain that mimics a toothache, but for which no dental or mucosal source can be found.

* Bleeding: oral bleeding from the decreased platelets and clotting factors associated with the effects of therapy on bone marrow.

Additional complications of radiation therapy

* Radiation caries: lifelong risk of rampant dental decay that may begin within 3 months of completing radiation treatment.

* Trismus/tissue fibrosis: loss of elasticity of masticatory muscles that restricts normal ability to open the mouth.

* Osteoradionecrosis (ORN): blood vessel compromise and necrosis of bone exposed to high-dose radiation therapy; results in decreased ability to heal if traumatized and in extreme susceptibility to infection.

Who Has Oral Complications?

Oral complications occur in almost all patients receiving radiation for head and neck malignancies, in more than 75 percent of bone marrow transplant recipients, and in nearly 40 percent of patients receiving chemotherapy. Risk for oral complications can be classified as low or high:

Lower risk: Patients receiving mildly or nonmyelosuppressive chemotherapy.

Higher risk: Patients receiving stomatotoxic chemotherapy resulting in

prolonged myelosuppression; patients undergoing head and neck radiation for

oral, pharyngeal, and laryngeal cancer; and patients undergoing bone marrow

transplantation.

Some complications occur only during treatment; others, such as xerostomia, may persist for years afterward. Unfortunately, many cancer patients do not receive oral care until serious complications develop.

The Role of Pretreatment Oral Care

A thorough oral evaluation by a knowledgeable dental professional before cancer treatment begins is important to the success of the regimen. Pretreatment oral care achieves the following:

* Reduces risk and severity of oral complications.

* Allows for prompt identification and treatment of existing infections or other problems.

* Improves likelihood that the patient will tolerate optimal schedule and doses of cancer treatment.

* Prevents, eliminates, or reduces oral pain.

* Minimizes oral infections that could lead to potentially fatal systemic infections.

* Prevents or minimizes complications that compromise nutrition.

* Prevents or reduces later incidence of bone necrosis.

* Preserves or improves oral health.

* Provides an opportunity for patient education about oral hygiene during cancer therapy.

* Improves quality of life.

With a pretreatment oral evaluation, the dental team can identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease that could contribute to oral complications when cancer therapy begins. The evaluation also establishes baseline data for comparing the patient’s status in subsequent examinations.

Prior to the exam, you will need to obtain the patient’s cancer diagnosis and treatment plan, medical history, and dental history. Open communication with the patient’s oncologist is essential to ensure that each provider has the information necessary to deliver the best possible care.

Evaluation

The pretreatment evaluation includes a thorough examination of hard and soft tissues, as well as appropriate radiographs to detect possible sources of infection and pathology. Also take the following steps before cancer treatment begins:

* Identify and treat existing infections, problem teeth, and tissue injury or trauma.

* Stabilize or eliminate potential sites of infection.

* In adults, extract teeth that may pose a future problem or are nonrestorable to prevent later extraction-induced osteoradionecrosis.

* Conduct a prosthodontic evaluation, if indicated.

* Perform oral surgery at least 2 weeks prior to the initiation of radiation therapy. For patients receiving radiation treatment, this is potentially the only time to consider surgical procedures. For patients receiving chemotherapy, oral surgery should be performed 7 to 10 days before the patient becomes myelosuppressed.

* Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.

* In children, extract loose primary teeth and teeth that are expected to exfoliate during treatment.

* Prescribe an individualized oral hygiene regimen to minimize oral complications. Patients undergoing head and neck radiation therapy should be instructed on the use of supplemental fluoride.

Education

Patient education is an integral part of the pretreatment evaluation. It is very important that the dental team impress on the patient the need for optimal oral hygiene during treatment, including proper care of the mouth and teeth, adequate nutrition, and the need to avoid tobacco and alcohol. To ensure that the patient fully understands what is required, provide detailed instructions on specific oral care practices, such as how and when to brush and floss, how to check for signs of complications, and other instructions appropriate for the individual. Patients should understand that good oral care during cancer treatment contributes to the success of cancer treatment.

Oral Care During Cancer Treatment

Careful monitoring of oral health is especially important during cancer therapy to prevent, detect, and treat complications as soon as possible. When treatment is necessary, consult the oncologist prior to any dental procedure, including prophylaxis.

* Examine the soft tissues for inflammation or infection and check for plaque and dental caries.

* Review with patients steps to keep the mouth moist and clean.

* Provide recommendations for treating dry mouth and other complications.

* Take precautions to protect against trauma.

* Provide analgesics as appropriate for oral pain.

Other factors to remember

Schedule dental work carefully. If oral surgery is required, make sure the oncology team knows to allow 7 to 10 days of healing before the patient becomes myelosuppressed. Elective oral surgery should not be performed in patients during radiation treatment.

Establish hematologic status. If the patient is receiving chemotherapy, have the oncology team conduct blood work 24 hours before dental treatment to determine whether the patient’s platelet count, clotting factors, and absolute neutrophil count are sufficient to allow oral treatment.

Consider oral causes of fever. Fever of unknown origin may be related to an oral infection. Remember that oral signs of infection or other complications may be altered by immunosuppression related to chemotherapy.

Consider prophylactic antibiotic treatment. If the patient has a central venous catheter, consult the oncologist about implementing the American Heart Association endocarditis prophylactic antibiotic regimen before any dental treatment. (You can see this regimen online at .)

Followup Oral Care

Chemotherapy

Once all complications of chemotherapy have resolved, patients may be able to resume their normal dental care schedule. However, if immune function continues to be compromised, determine the patient’s hematologic status before initiating any dental treatment or surgery. This is particularly important to remember for patients undergoing bone marrow transplantation.

Radiation therapy

Once the patient has completed head and neck radiation therapy and acute oral complications have abated, evaluate the patient regularly (every 4 to 8 weeks, for example) for the first 6 months. Thereafter, you can determine a schedule based on the needs of the individual. However, keep in mind that oral complications can continue or emerge long after radiation therapy has ended.

Points to remember

* High-dose radiation treatment carries a lifelong risk of osteoradionecrosis.

* Because of the risk of osteoradionecrosis, patients should avoid invasive surgical procedures, including extractions, that involve irradiated bone. If an invasive procedure is required, use of antibiotics and hyperbaric oxygen therapy prior to and following surgery should be considered.

* Lifelong daily fluoride application, good nutrition, and oral hygiene are especially important for patients with salivary gland dysfunction.

* Dentures may need to be reconstructed if treatment altered oral tissues. Some people can never wear dentures again because of friable tissues and xerostomia.

* A dentist should closely monitor children who have received radiation to craniofacial and dental structures for abnormal growth and development.

Special Considerations for Bone Marrow/Stem Cell Transplant Patients

Bone marrow/stem cell transplantation causes pronounced immunosuppression, greatly increasing a patient’s risk of mucositis, ulceration, hemorrhage, infection, and xerostomia. Although the complications begin to resolve when hematologic status improves, immunosuppression may last for up to a year after the transplant, along with the risk of infectious complications. Also, the oral cavity and salivary glands are commonly involved with graft-versus-host disease in allograft recipients. This can result in mucosal inflammation, ulceration, and/ or xerostomia, so continued monitoring is necessary. Careful attention to oral care in the immediate and long-term posttransplant period is important to these patients’ overall health.

Additional Readings

Barker, G. J., Barker, B. F., & Gier, R. E. (1996). Oral management of the cancer patient: A guide for the health care professional (5th ed.). Kansas City, MO: University of Missouri-Kansas City School of Dentistry.

Cooper, J. S., Fu, K., Marks, J., & Silverman, S. (1995). Late effects of radiation therapy in the head and neck region. International Journal of Radiation Oncology, Biology, Physics, 31(5), 1141-1164.

Epstein, J. B., & Scully, C. (1992). The role of saliva in oral health and the causes and effects of xerostomia. Journal of the Canadian Dental Association, 58(3), 217-221.

Epstein, J. B., Stevenson-Moore, P., & Scully, C. (1992). Management of xerostomia. Journal of the Canadian Dental Association, 58(2), 140-143.

Epstein, J. B. (1990). Antifungal therapy in oropharyngeal mycotic infections. Oral Surgery, Oral Mediciine, Oral Pathology Oral Radiology and Endodontics, 69(1), 32-41.

Fox, P. C. (1997). Management of dry mouth. Dental Clinics of North America, 41(4), 863-875.

Jansma, J., Vissink, A., Spijkervet, F., Roodenburg, J., Panders, A. K., Vermey, A., Szabo, B. G., & ‘s-Gravenmade, E. J. (1992). Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy. Cancer, 70(8), 2171-2180.

Lockhart, P. B., & Clark, J. (1994). Pretherapy dental status of patients with malignant conditions of the head and neck. Oral Surgery Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 77(3), 236-241.

Meurman, J. H., Pyrhonen, S., Teerenhovi, L., & Lindqvist, C. (1997). Oral sources of septicaemia in patients with malignancies. Oral Oncology 33(6), 389-397.

Morgan, E. R., & Haugen, M. (1997). Late effects of cancer therapy. Cancer Treatment Research, 92, 343-375.

National Institutes of Health. (1990). Consensus development conference on oral complications of cancer therapies: Diagnosis, prevention, and treatment. National Cancer Institute Monographs, 9.

Peterson, D. E., & D’Ambrosio, J. A. (1992). Diagnosis and management of acute and chronic oral complications of nonsurgical cancer therapies. Dental Clinics of North America, 36(4), 945-966.

Peterson, D. E., & D’Ambrosio, J. A. (1994). Nonsurgical management of head and neck cancer patients. Dental Clinics of North America, 38(3), 425-445.

Peterson D. E., & Schubert, M. M. (1996). Oral toxicity. In M. C. Perry (Ed.), The chemotherapy source book (pp. 571-594). Baltimore: Williams and Wilkins.

Scully, C., & Epstein, J. (1996). Oral health care for the cancer patient. Oral Oncology, European Journal of Cancer, 32B(5), 281-292.

Woo, S. B., Lee, S. J., & Schubert, M. M. (1997). Graft versus host disease. Critical Reviews in Oral Biology and Medicine, 8(2), 201-216.

Publications

This brochure is part of Oral Health, Cancer Care, and You: Fitting the Pieces Together, an awareness campaign sponsored by the National Institute of Dental and Craniofacial Research (NIDCR) through its National Oral Health Information Clearinghouse (NOHIC). The following publications are part of the campaign and can be ordered from NOHIC.

For patients:

–Chemotherapy and Your Mouth (brochure)

–Radiation Treatment and Your Mouth (brochure)

–Who’s on My Cancer Care Team? (wallet card for phone numbers)

–Three Good Reasons To See a Dentist (tip sheet for patients–available for professionals in pads of 25)

For professionals:

–Oral Complications of Cancer Treatment: What the Oral Health Team Can Do (fact sheet)

–Oral Complications of Cancer Treatment: What the Oncology Team Can Do (fact sheet)

–Oral Care Provider’s Reference Guide for Oncology Patients (pocket guide)

–Oncology Reference Guide to Oral Health (pocket guide)

Contact NOHIC at

ATTN: OCCT 1 NOHIC Way, Bethesda, MD 20892-3500 Phone: 1-877-216-1019 (Toll-free); Fax: (301)907-8830 E-mail: nidr@aerie.com; Internet: http://www.aerie.com/nohicweb

Name Address City — State — Zip code —

Supplemental Fluoride

Fluoride rinses are not adequate to prevent tooth demineralization. Instead, fluoride gel, delivered via custom gel-applicator trays, is recommended. Several days before radiation therapy begins, patients should start a daily 5-minute application of a 1.1% neutral pH sodium fluoride gel or a 0.4% standard fluoride (unflavored) gel. Patients with porcelain crowns should use a neutral pH fluoride. Be sure that the trays cover all tooth structure without irritating the gingival or mucosal tissues. Patients with radiation-induced salivary gland dysfunction must continue lifelong daily fluoride applications.

Instructions for Patients Using Supplemental Fluoride

[check] Place a thin ribbon of fluoride gel in each tray.

[check] Place the trays on teeth and leave in place for 5 minutes. If the gel oozes out of the tray, too much is being used.

[check] After 5 minutes, remove the trays and spit out any excess gel. Do not rinse.

[check] Rinse the applicator trays with water.

[check] Do not eat or drink for 30 minutes.

Advice for Patients

[check] Gently brush teeth, gums, and tongue with an extra-soft toothbrush after every meal and before bed. If brushing hurts, soften the bristles in warm water.

[check] Use a fluoride toothpaste.

[check] Follow instructions for using fluoride gel.

[check] Floss teeth gently every day. If gums are sore or bleeding, avoid those areas but keep flossing other teeth.

[check] Don’t use mouthwashes containing alcohol.

[check] Several times a day, rinse mouth with a baking soda and salt solution, followed by a plain water rinse. (Use 1/4 teaspoon of baking soda and 1/8 teaspoon of salt in i cup of warm water.)

[check] To prevent and treat jaw stiffness, exercise the jaw muscles 3 times a day by opening and closing the mouth as far as possible (without causing pain) 20 times.

[check] Avoid candy and soda unless they are sugar-flee.

[check] Avoid using toothpicks, tobacco products, and alcohol.

Advice for Patients With Dry Mouth

[check] Sip water frequently.

[check] Suck ice chips or sugar-free candy.

[check] Chew sugar-flee gum.

[check] If appropriate, use a saliva substitute spray or gel, or prescribed saliva stimulant.

[check] Avoid lemon glycerin swabs.

Normal Complete Blood Count(*)

Red blood cells 4.2 – 6.0 million/[mm.sup.3]

Hemoglobin 12 – 18 g/dL

Hematocrit 36 – 52%

Platelets 150,000 – 450,000/[mm.sup.3]

White blood cells 4,000 – 11,000/[mm.sup.3]

Differential WBC Count

Neutrophils (granulocytes)

“Segs” (or Polys or PMNs) 40 – 60%

“Bands” 0 – 5%

Eosinophils 1 – 3%

Basophils 0 – 1%

Lymphocytes 20 – 40%

Monocytes 2 – 8%

Absolute Neutrophil Count = total WBC X (% “Segs” + “Bands”)

(*) Source: Barker, G. J., Barker, B. F., & Gier, R. E. (1996). Oral management of the cancer patient: A guide for the health care professional (5th ed.). Kansas City, MO: University of Missouri-Kansas City School of Dentistry.

COPYRIGHT 1999 National Institutes of Health

COPYRIGHT 2007 Gale Group