Oral Health Care for Cancer Patients – By Dr.Triveni Padale

In 21^st Century, Cancer can be crowned as the most deadly disease and second most leading cause of death. In recent time, there is increased patient survival rate because of advanced diagnostics and treatment modalities. As a result of which there is increased possibility of a Dentist treating patients in various stages of cancer and different phases of antineoplastic therapy.

It is commonly seen that oral health care is often neglected by cancer patients and they fail to understand the need for proper oral hygiene before, during and after their cancer treatment. For them these two treatments are nowhere connected, but it is not what it looks like!

Why is dental check-up/treatment necessary before cancer treatment?

Awareness of complications– Various studies have shown that approximately 80% people receiving chemotherapy and/or radiotherapy experience oral complications as a result of the cytotoxic effects of the cancer treatment. The Dentist plays a major role in educating the patients and providing solutions for these complications.

Psychological benefit– Once the patient is aware of the complications it is easy for them to understand what to expect during and after the cancer therapy. Also it is easy for them to deal with it emotionally.

Prophylactic protection of teeth, bones and soft tissues in adult patients as well as in children. Children need special protection for their growing teeth and facial bones and organs too. Dentist can properly plan and help achieve this goal.

When to call a dentist?

Patients should call dentist and cancer care team when

If the patient want to take precautionary measures.
If the patients want to get information on complications and clinical findings.
When he/she first notices the oral problem
When the old problem gets worsened
If he/she experiences changes in mouth and the patient is not aware of what it is.

Recognition of cancer in dental settings:-

A) Patient History: Early recognition of disease is vital in dental treatment planning. It is utmost important to take detailed medical history, dental history as well as genetic history. Following questions can help-

Have you noticed any changes since your last visit?
Are you aware of any lump developing under your arms or in neck?
Did you notice any lesion changing colour? Is there pain associated with it?
Is there any abnormal bleeding from any site or is there is blood in the stools?
Have you ever chewed tobacco, consumed alcohol and have implemented dietary changes? If the answer is yes then ask “how much and what type?”
Is there any family history for cancer?

It is Dentist’s primary duty to encourage cancer screening, if we suspect development of cancer.

B) Clinical Examinations–

Perform detailed head and neck and intraoral examinations ( Clinical and Radio graphical).
Lymph nodes must be palpated
If the patient has cancer in sites other than head and neck then please check for presence of metastasis in oral sites. Also patients with Oral cancer are at increased risk for metastasis in respiratory system, upper digestive tract and oral cavity. It is necessary to examine for this.
Oral lesions which fail to heal in 2 weeks despite providing adequate treatment measures must be biopsied by skilled clinician.
Consult with patient’s oncologist for more information and for planning treatment.
Blood tests such as complete blood count, total RBC- WBC count, Differential WBC count, smear cell cytology, Hb, platelet count, bleeding time, clotting time and PTT should be performed. These tests suggest possibility of cancer.

Why is it important to have a pre-treatment evaluation done?

To rule out oral disease that may exacerbate during therapy.
To provide baseline for comparison and monitoring the sequel of cancer therapy.
To detect metastatic lesions.
To minimize oral Discomfort during therapy.

Oral Care for Cancer Patients:-

Pre-treatment Oral care should start at least 1 month prior to the beginning of cancer therapy.

Oral care in cancer patients can be divided into three phases-

Pre ‘Cancer- Treatment’ Phase –

Following care can be taken in this phase:-

Oral hygiene instructions to the patients
Encouragement of anti-cariogenic diet.
Calculus removal and prophylaxis.
Consult the patient’s oncologist regarding the need for prophylactic antibiotic prescription.
Removal of all sources of irritation and infections. Perform alveoloplasty whenever necessary.
Fluoride treatments to prevent demineralisation and radiation caries. Fluoride treatments can be given in the form of gel and delivered through customized tray which does not cover gingiva or tooth paste containing higher concentration of fluorides can be prescribed for brushing. In case of people having porcelain crowns neutral fluorides are prescribed.
Extraction of teeth which may not survive the cancer treatment
Reduce radiation exposure for radio sensitive organs like salivary glands, thyroid glands with the use of lead lined stents, collars and beam sparing procedures.
Prioritize treatment of infections, extractions, periodontal care and other invasive surgical procedures before the treatment of carious teeth, root canal therapy and replacement of faulty restorations.
Conduct prosthetic surgeries before treatment since elective surgical procedures are contraindicated on irradiated bone.
Educate the patient scrupulously regarding the outcomes and side effects of the cancer therapy especially about decreased salivary flow, osteoradionecrosis of jaw and mucositis.
Symptomatic non-vital teeth should be endodontically treated at least 1 week prior to starting the head and neck radiation therapy as well as chemotherapy.
Orthodontic bands should be removed before initiation of chemotherapy.
Allow at least 14 days of healing after any oral surgical procedure and before the start of radiation therapy.
In case of Chemotherapy and stem cell transplantation, any oral surgical procedures must be completed at least 7-10 days prior to the start of the therapy.

Guidelines for extraction of teeth in patients schedules for Cancer treatment:

Check the patient’s laboratory reports.
Extractions can be delayed if the WBC count is less than 2000/micro metre, if the neutrophil count is less than 1000/micro metre or platelet count is less than 50,000/cubic metre or are expected to be this level within the treatment and recovery period.
Prophylactic antibiotics (cephalosporin or penicillin vk preferably) can be prescribed.
Extractions must be performed at least 2 weeks prior to the initiation of radiation therapy. In case of chemotherapy, extractions must be performed at least 5 days prior in maxilla and at least 7 days prior in mandible.
Extractions must be performed with minimal trauma and alveoloplasty must be performed to eliminate sharp edges and to obtain primary closure.
Do not use intra-alveolar haemostatic packaging agent which can serve as nidus for microbial growth.

On-going ‘Cancer- Treatment’ Phase –

Monitor the patient’s oral hygiene. Fluoridated mouth rinses must not be prescribed but regular use of fluoride gel is advisable.

Watch for mucositis, secondary infections and salivary flow reduction.
Advise patient not to wear removable appliance during the radiation therapy.
If the patient experiences decreased salivary flow – then prescribe sugarless lemon drops, sorbitol based chewing gum, buffered solution of glycerine and water or salivary substitutes.
Frequent dental visits are required to cope up with possible oral complications.

Post ‘Cancer-Treatment’ Phase:-

In post ‘cancer treatment ‘phase following steps should be taken:

Check for the outcome of the cancer therapy.
Check for the possible complications of the therapy and provide treatment accordingly.
Usually patients experience oral soreness during and after cancer treatment. So to reduce the oral soreness prescribes oral balance or biotene.
Antibiotic therapy is necessary if there is presence of secondary infection and if the immunity is suppressed. Refer the patient back to his physician for the treatment of suppressed immunity.
Patients should be advised to continue the fluoride treatment for their teeth and maintain good oral hygiene.
If the patient is experiencing xerostomia, then advise patient to drink water or chew sugarless gums, or use over the counter salivary substitutes to keep the oral cavity moist.
Proper treatment must be provided for muscular dystrophies caused because of the cancer therapy.
In case of stem cell transplantation, the oral surgical procedure must be delayed for at least 1 year.
Advise patients to perform daily oral muscle exercises to relieve trismus and apply local moist heat.
Dentist must maintain everything on record for future referral.

What are the complications/ Adverse effects of radiation and chemotherapy?

During a thorough clinical examination it is important to watch out for the following adverse effects of cancer therapy:-

Xerostomia / salivary gland dysfunction
Nausea and Vomiting
Mucositis- inflammation and ulceration of mucous membrane that starts about the second week of the therapy
Bleeding Gums and oral mucosal bleeding as a result of decreased platelet count and clotting factors
Altered taste sensation which starts about 2nd week of the therapy and eventually loss of taste.
Secondary Infections such as fungal, bacterial and viral infections.
Nutritional Deficiency as a result of impaired ability to taste, eat , swallow and speak.
Radiation Caries- Rampant caries which may begin within 3 months of completing radiation treatment.
Hypersensitive teeth
Muscular dysfunction, trismus and tissue fibrosis.
Stenosis of the blood vessels.
Pulpalgia and pulpal necrosis/ gangrene which usually has a delayed onset (ortho-voltage related and not found with cobalt-60)
Neurotoxicity – persistent deep aching pain that mimics toothache but has no dental origin.
Impaired Healing
Osteoradionecrosis of the jaw– more common in mandible and less common in maxilla . Compromised blood vessels leading to necrosis of the bone and reduced ability to heal. It has delayed onset so at first it looks all normal and later on it develops all of a sudden so keep a frequent check- ups. Risk of osteoradionecrosis is more in patients who have received radiation more than 6500cGy.

Bis-phosphonates related osteoradionecrosis of the jaw is also one of the serious complications. Bisphosphonates are given in patients with osteoporosis, paget’s disease, multiple myeloma and in cancer patients to control the bone loss due to metastatic skeletal lesions. It is crucial to cure this disease because failure to provide appropriate treatment can compromise the nutritional, oncologic and oral treatment of affected patients.

Carotid Atheroma: Calcified atherosclerotic plaque can be formed in carotid arteries who have undergone radiation therapy.

Benefits of pre-treatment oral care:-

Some of the benefits of timely evaluation by dentist are-

Reduction in occurrence and severity of oral complications
Minimization and/or elimination of dental pain.
Prevention of bone death/necrosis.
Improvement of overall oral health
Improvement in quality of living

Importance of fluorides!!

Due to high incidence of radiation caries, fluoride regimen is essential to reduce the demineralization of enamel and tooth decay, although various fluoridated toothpastes are available for topical application by the patients but those cannot replace high strength fluoride delivered with help of trays prepared by the dentist.

Fluoride regimen should begin a few weeks before initiation of radiation therapy and should continue until the dental surgeon assesses the condition and chooses to discontinue the regimen.

General advice to the patients undergoing cancer treatment!

Brush your teeth with a soft bristled tooth brush and mild fluoride toothpaste after every meal, sugar drink and before bed along with regular flossing and maintaining proper oral hygiene.
Apply fluoride gel on teeth daily using tray delivery system.
Use an alcohol free mouth rinses or antimicrobial mouth rinse like chlorhexidine rinses.
Drink plenty of water or use salivary substitutes (if needed) to keep oral cavity moist.
Perform oral muscle exercises to relieve the trismus and apply heat.
Discontinue smoking and avoid consuming alcohol.
Avoid sweet food and candies. If consumed, follow brushing your teeth with fluoridated toothpaste. Eat healthy foods to avoid nutritional deficiencies.
Follow instructions of the dentist properly
Do not miss any dental check-up appointments.

Personal experience with cancer patients:-

While practicing I came across many patients undergoing cancer treatment or having a history of cancer treatment. One thing common to all of them was lack of initial dental care before starting Cancer therapy, owing to lack of awareness, careless attitude , and financial disability, leading to their complicated condition. Complications like Radiation caries, xerostomia, osteomyelitis, osteoradionecrosis of the jaws, altered taste sensations were commonly diagnosed in many of my patients. Therefore I believe that patient education, awareness and adequate treatment in timely manner is one of the key factors to make a patient’s life easier during and after cancer treatment. Let’s take care of our oral health before it is too late. Remember “Prevention is better than Cure.”

Dr. Triveni Padale

B.D.S, India

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Why is dental check-up/treatment necessary before cancer treatment?

When to call a dentist?

Patients should call dentist and cancer care team when

If the patient want to take precautionary measures.

If the patients want to get information on complications and clinical findings.

When he/she first notices the oral problem

When the old problem gets worsened

If he/she experiences changes in mouth and the patient is not aware of what it is.

Recognition of cancer in dental settings:-

A) Patient History: Early recognition of disease is vital in dental treatment planning. It is utmost important to take detailed medical history, dental history as well as genetic history. Following questions can help-

Have you noticed any changes since your last visit?

Are you aware of any lump developing under your arms or in neck?

Did you notice any lesion changing colour? Is there pain associated with it?

Is there any abnormal bleeding from any site or is there is blood in the stools?

Have you ever chewed tobacco, consumed alcohol and have implemented dietary changes? If the answer is yes then ask “how much and what type?”

Is there any family history for cancer?

It is Dentist’s primary duty to encourage cancer screening, if we suspect development of cancer.

B) Clinical Examinations–

Perform detailed head and neck and intraoral examinations ( Clinical and Radio graphical).

Lymph nodes must be palpated

If the patient has cancer in sites other than head and neck then please check for presence of metastasis in oral sites. Also patients with Oral cancer are at increased risk for metastasis in respiratory system, upper digestive tract and oral cavity. It is necessary to examine for this.

Oral lesions which fail to heal in 2 weeks despite providing adequate treatment measures must be biopsied by skilled clinician.

Consult with patient’s oncologist for more information and for planning treatment.

Blood tests such as complete blood count, total RBC- WBC count, Differential WBC count, smear cell cytology, Hb, platelet count, bleeding time, clotting time and PTT should be performed. These tests suggest possibility of cancer.

Why is it important to have a pre-treatment evaluation done?

To rule out oral disease that may exacerbate during therapy.

To provide baseline for comparison and monitoring the sequel of cancer therapy.

To detect metastatic lesions.

To minimize oral Discomfort during therapy.

Oral Care for Cancer Patients:-

Pre-treatment Oral care should start at least 1 month prior to the beginning of cancer therapy.

Oral care in cancer patients can be divided into three phases-

Pre ‘Cancer- Treatment’ Phase –

Following care can be taken in this phase:-

Oral hygiene instructions to the patients

Encouragement of anti-cariogenic diet.

Calculus removal and prophylaxis.

Consult the patient’s oncologist regarding the need for prophylactic antibiotic prescription.

Removal of all sources of irritation and infections. Perform alveoloplasty whenever necessary.

Extraction of teeth which may not survive the cancer treatment

Reduce radiation exposure for radio sensitive organs like salivary glands, thyroid glands with the use of lead lined stents, collars and beam sparing procedures.

Prioritize treatment of infections, extractions, periodontal care and other invasive surgical procedures before the treatment of carious teeth, root canal therapy and replacement of faulty restorations.

Conduct prosthetic surgeries before treatment since elective surgical procedures are contraindicated on irradiated bone.

Educate the patient scrupulously regarding the outcomes and side effects of the cancer therapy especially about decreased salivary flow, osteoradionecrosis of jaw and mucositis.

Symptomatic non-vital teeth should be endodontically treated at least 1 week prior to starting the head and neck radiation therapy as well as chemotherapy.

Orthodontic bands should be removed before initiation of chemotherapy.

Allow at least 14 days of healing after any oral surgical procedure and before the start of radiation therapy.

In case of Chemotherapy and stem cell transplantation, any oral surgical procedures must be completed at least 7-10 days prior to the start of the therapy.

Guidelines for extraction of teeth in patients schedules for Cancer treatment:

Check the patient’s laboratory reports.

Extractions can be delayed if the WBC count is less than 2000/micro metre, if the neutrophil count is less than 1000/micro metre or platelet count is less than 50,000/cubic metre or are expected to be this level within the treatment and recovery period.

Prophylactic antibiotics (cephalosporin or penicillin vk preferably) can be prescribed.

Extractions must be performed at least 2 weeks prior to the initiation of radiation therapy. In case of chemotherapy, extractions must be performed at least 5 days prior in maxilla and at least 7 days prior in mandible.

Extractions must be performed with minimal trauma and alveoloplasty must be performed to eliminate sharp edges and to obtain primary closure.

Do not use intra-alveolar haemostatic packaging agent which can serve as nidus for microbial growth.

On-going ‘Cancer- Treatment’ Phase –

Monitor the patient’s oral hygiene. Fluoridated mouth rinses must not be prescribed but regular use of fluoride gel is advisable.

Watch for mucositis, secondary infections and salivary flow reduction.

Advise patient not to wear removable appliance during the radiation therapy.

If the patient experiences decreased salivary flow – then prescribe sugarless lemon drops, sorbitol based chewing gum, buffered solution of glycerine and water or salivary substitutes.

Frequent dental visits are required to cope up with possible oral complications.

Post ‘Cancer-Treatment’ Phase:-

In post ‘cancer treatment ‘phase following steps should be taken:

Check for the outcome of the cancer therapy.

Check for the possible complications of the therapy and provide treatment accordingly.

Usually patients experience oral soreness during and after cancer treatment. So to reduce the oral soreness prescribes oral balance or biotene.

Antibiotic therapy is necessary if there is presence of secondary infection and if the immunity is suppressed. Refer the patient back to his physician for the treatment of suppressed immunity.

Patients should be advised to continue the fluoride treatment for their teeth and maintain good oral hygiene.

If the patient is experiencing xerostomia, then advise patient to drink water or chew sugarless gums, or use over the counter salivary substitutes to keep the oral cavity moist.

Proper treatment must be provided for muscular dystrophies caused because of the cancer therapy.

In case of stem cell transplantation, the oral surgical procedure must be delayed for at least 1 year.

Advise patients to perform daily oral muscle exercises to relieve trismus and apply local moist heat.

Dentist must maintain everything on record for future referral.

What are the complications/ Adverse effects of radiation and chemotherapy?

During a thorough clinical examination it is important to watch out for the following adverse effects of cancer therapy:-

Xerostomia / salivary gland dysfunction

Nausea and Vomiting

Mucositis- inflammation and ulceration of mucous membrane that starts about the second week of the therapy

Bleeding Gums and oral mucosal bleeding as a result of decreased platelet count and clotting factors

Altered taste sensation which starts about 2nd week of the therapy and eventually loss of taste.