Patients with cancer

Treatment considerations for patients battling cancer

by Dawn E. Kasper, RDH

“Cancer is a word, not a sentence.” John Diamond, a British broadcaster and journalist who passed away from throat cancer in March 2001, uttered those inspirational words. In his book “Because Cowards Get Cancer Too,” he wrote, “What can the chances be of any organ doing anything a billion and a half times and never making a mistake? Your 30 trillion or so cells have each replicated themselves a few thousand times: how could it possibly not be that a few of these cells would band together in that state of cytological anarchy that leads to cancer and death? Accidents happen but illness creeps up on you. Only in retrospect do you realize that you’d been ill all along.”

Cancer is one of the most significant fatal diseases around the world, although factually it’s a collection of about 100 similar diseases. Cancer can be cured, but the cure rate depends on which variety, a quick diagnosis, and the person’s health. Optimal management of the oncology patient involves an interdisciplinary approach that requires assessment, communication, and interaction among the health care team during all stages of cancer therapy.

Let’s understand the truth about cancer’s survivability. In the United States, one in three people will get some form of cancer. One in four people will die of cancer. Cancer is a very serious problem, with about 1,500 Americans dying from some form of the disease each day. In fact, it is the number one cause of death for Americans over age 85. The American Dental Association (ADA) reports that of the 1.4 million people receiving treatment for cancer, about 400,000 will experience oral complications.

There are more than 100 different kinds of cancer. It can affect almost any organ in the body: kidneys, lungs, pancreas, throat, brain, and many more. The body is comprised of cells that normally divide and multiply according to the body’s needs. There are times, however, that cells multiply uncontrollably, producing more cells than the body needs and resulting in the production of a growth or mass (tumor). Although the cells of a benign tumor do grow abnormally, they do not affect other parts of the body. The cells of a malignant tumor, however, have the ability to invade nearby tissues and travel to distant parts of the body (cancer). A benign tumor is rarely life threatening and is often easily removed. Malignant tumors are far more dangerous and harder to get rid of. In addition, cancer cells can sometimes break off from the tumor, enter the blood stream, and spread to other organs (metastasis). One kind of tissue is different: leukemia affects the person’s blood and the organs that create the blood, and then invades nearby tissues.

Since each cancer is different, the precise form of treatment will vary depending on the type of cancer and how advanced it is. The success of cancer treatment depends on the correct diagnosis. It would be a tragic thing for one form of cancer to be mistaken for another, causing the wrong treatment to be used.

Oral complications from cancer therapy

The likelihood is high that aggressive cancer treatment will have toxic effects on normal cells as well as cancer cells. The gastrointestinal tract, including the mouth, is particularly prone to damage, whether the treatment is radiation or chemotherapy. Most patients experience some oral complications, and while most of these are manageable, they can sometimes become severe enough to stop treatment. Surgical solutions may lead to oral and nutritional problems as well.

Oral complications of cancer treatment arise in various forms and degrees of severity, depending on the individual and the 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 have toxic effects on the oral tissues (stomatotoxic). Following are lists of side effects common to both chemotherapy and radiation therapy, and complications specific to each type of treatment. As dental professionals, there is a need to consider the possibility of these complications during each evaluation and treatment of an oncology patient.

Oral care before, during, and after treatment

Oral care is a crucial component of cancer therapy, affecting both quality of life and cost of care. As clinicians, we must be aware of the unending complications that arise in the oral cavity, and the steps we can take to help our patients get through this very difficult time.

Preexisting or untreated oral disease can complicate cancer treatment. The goals of dental care before cancer treatment are to provide early detection and diagnosis of premalignant and malignant disease, and to prepare the patient for cancer treatment by managing preexisting dental and mucosal diseases and instituting preventive programs. Problems such as supragingival or subgingival plaque and biofilm, periodontal disease, cracked/chipped teeth or restorations, crowns, implants, bridges, fixed or removable prostheses, orthodontics or other removable appliances can make therapy more difficult later on. Bacteria and fungi in the mouth may develop into an infection when the immune system is not working well, or when white blood cell counts are low. Irritated tissues can thin and waste away, causing sores in the mouth (ulcerative oral mucositis). These complications can result in a significant reduction in the patient’s quality of life.

Evaluation

A comprehensive oral evaluation should take place one month before cancer treatment starts, allowing recovery time from any required invasive dental procedures. It should include a thorough examination of hard and soft tissues, and appropriate radiographs and periodontal charting to detect possible sources of infection and pathology. It should also include:

• Identify and treat existing infections, caries, and tissue injury or trauma.
• Stabilize or eliminate potential sites of infection.
• Extract teeth in the radiation field that are nonrestorable or may pose a future problem to prevent later extraction-induced osteonecrosis.
• Conduct a prosthodontic evaluation. If a removable prosthesis is worn, make sure it is clean and well adapted to the tissue. Instruct the patient not to wear the prosthesis during treatment, if possible, or at least not to wear it at night.
• Perform oral prophylaxis if indicated.
• Time oral surgery to allow at least two weeks for healing before radiation therapy begins. Oral surgery should be performed at least seven to 10 days before the patient receives myelosuppressive chemotherapy. Medical consultation is indicated before invasive procedures.
• Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.
• Consider extracting highly mobile primary teeth in children 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.

Oral hygiene regimen

• Give a thorough dental prophylaxis and oral hygiene instruction.
• Use fluoride gel, 1.1% neutral sodium or 0.4% stannous fluoride, delivered with custom trays seven days before radiation treatment. Gel may be brushed on if patient prefers. This can be done before, during, and after cancer treatment.
• Use 5% NaFl varnish (22,600 ppm) before, during, and after cancer treatment every two to three months to decrease tooth sensitivity and prevent carious lesions.
• Provide a regular three- to four-month recall schedule after cancer treatment.

Supplementary adjuncts

• Relief of oral dryness — Saliva can be stimulated by mechanical (masticatory), chemical, electronic, and pharmacologic methods along with oral moisturizers and salivary substitutes.
• Reducing caries — Xylitol induces salivary enzymes that have been shown to inhibit bacterial growth in the oral cavity, preventing or stabilizing caries.
• Relief of mucositis — Mixture of 1/3 Benadryl elixir with 1/3 Kaopectate and 1/3 viscous lidocaine, rinsing every two hours.
• Chlorhexidine gluconate 0.12% — Reduces the level of S. mutans, helps control plaque accumulation, and reduces the microbial load. It can be used for a two-week interval only and not while the patient is undergoing cancer therapy.
• Treat trismus — Jaw exercises to help stretch muscles properly. A series of opening and closing exercises can be used with six tongue depressors taped together. Muscle relaxers, cyclobenzaprine, anti-anxiety medications and Valium can help.

Recommendations for patients

• Brush teeth, tissue, and tongue gently with an extra-soft toothbrush and fluoride toothpaste after every meal and before bed. If brushing causes pain, soften the bristles in warm water.
• Floss teeth gently every day. If tissue becomes sore or is bleeding, avoid those areas but continue flossing remaining teeth.
• Follow instructions for using fluoride gel.
• Avoid mouthwashes containing alcohol.
• Rinse the mouth with a baking soda and salt solution, followed by a plain water rinse several times a day. (Use 1/4 teaspoon each of baking soda and salt in one quart of warm water.) Omit salt during mucositis.
• Exercise the jaw muscles three times a day to prevent and treat jaw stiffness from radiation. Open and close the mouth as far as possible without causing pain, repeat 20 times.
• Avoid candy, gum, and soda unless they are sugar-free and contain xylitol.
• Avoid spicy or acidic foods, toothpicks, tobacco products, and alcohol.
• Use a saliva substitute as needed.
• Topical anesthetic may be used as needed.
• Suck on ice chips and sugar-free or xylitol mints or candy.
• Keep the appointment schedule recommended by dental professionals.

Toothpaste recommendations

• ControlRx — 1.1% NaF Toothpaste 5,000 ppm, Omnii Oral Pharmaceuticals, West Palm Beach, FL www.omniipharma.com
• Prevident 5000 PLUS — 1.1% NaF Dental Cream 5,000 ppm, Colgate Oral Pharmaceuticals, Inc. Canton, MA, www.colgateprofessional.com
• Fluoridex — 1.1% NaF Toothpaste 5,000 ppm, Discus Dental, Culver City, CA, www.discusdental.com
• Clinpro 5000 — 1.1% NaF Anti-CavityToothpaste 5,000 ppm, 3M ESPE, St. Paul, MN, www.3m.com
• NUPRO NUSolutions — 5,000 ppm Remin & Desensitizing Toothpaste with NovaMin, Dentsply Professional, York, PA www.professional. dentsply.com
• Squigle — NaF Toothpaste 1,000 ppm, (nonprescription), Squigle, Inc. Narberth, PA, www.squigle.com

After completion of cancer treatment, regular visits to the dental office are still indicated. A complete prophylaxis should be scheduled six to eight weeks after therapy. Since the immune system is suppressed, any type of infection could be serious. Preventing and treating oral side effects of radiation or chemotherapy involves starting prevention measures before cancer therapy begins, treating complications as soon as they appear, and continuing care after therapy ends. Meticulous attention to oral microbial control, prophylactic use of fluoride gels, and palliative treatment of soft tissue lesions may significantly reduce the oral morbidity associated with radiation and cytotoxic chemotherapy, enhancing both patient survival and quality of life. Diligent personal oral health care and frequent dental recall appointments are recommended for the remainder of the patient’s life.

References

1. Barclay L, MD. (2008). Role of oral and dental care in cancer therapy: an expert interview with Joel Epstein, DMD, MSD, FRCD(C), FDS RCS (Edinburgh). Medscape Medical News, Medscape Today, Web MD, Retrieved from http://www.medscape.com/viewarticle/584318 Accessed May 26, 2010.
2. Colgate: Oral and Dental Health Basics, Initials. (2002, 2003). Oral complications of cancer treatment. Retrieved from http://www.colgate.com/app/Colgate/US/OC/Information/OralHealthBasics/MedCondOralHealth/CancerOralHealth/OralComplicationsofCancerTreatment.cvsp Accessed May 30, 2010.
3. Cutler E, PhD. Welcome to Squigle oral care. Retrieved from http://www.squigle.com/ Accessed May 30, 2010.
4. Diamond J. (1998). Because Cowards Get Cancer Too [A hypochondriac confronts his nemesis]. Retrieved from http://www.nytimes.com/books/first/d/diamond-cancer.html Accessed May 20, 2010.
5. eCancerAnswers.net (2008). Cancer — signs, symptoms, stages, types, and treatment. Retrieved from 3. http://ecanceranswers.net/ Accessed May 20, 2010
6. Ghassan S, DDS. Division of dentistry and oral surgery otolaryngology — head and neck surgery. (n.d.). Oral care protocol: for the head and neck cancer patient. Johns Hopkins Medicine: The Johns Hopkins Hospital, Retrieved from http://www.gbmc.org/documents%5CServices%5CDance%5Coralcare.pdf. Accessed May 30, 2010.
7. Christensen G, DDS. (2005). Special oral hygiene and preventive care for special needs. JADA: The Journal of the American Dental Association, 136(8, 1141-1143). Retrieved from http://jada.ada.org/cgi/content/full/136/8/1141 Accessed May 30, 2010.
8. Adams J, Blanchard C, Dudek K, Keller B. (2009). The effects of radiation therapy for cancer treatment on oral health. ADHA: The American Dental Hygienists’ Association, Strive - The Student View, 08(2009), Retrieved from http://www.adha.org/publications/strive/08-2009-strive.htm Accessed May 27, 2010.
9. Milmo C. (2001, March 3). John Diamond, the irreverent patient, dies after three-year ‘war.’ Retrieved from 2. http://www.independent.co.uk/news/media/john-diamond-the-irreverent-patient-dies-after-threeyear-war-694326.html Accessed May 20, 2010.
10. National Institute of Dental and Craniofacial Research. Oral complications of cancer treatment: what the dental team can do. Retrieved from 4. http://www.nidcr.nih.gov/nidcr2.nih.gov/Templates/CommonPage.aspx?NRMODE=Published&NRNODEGUID={4EA90DE8-8C85-4B59-AADA-4F5C231B4609}&NRORIGINALURL=%2fOralHealth%2fTopics%2fCancerTreatment%2fOralComplicationsCancerOral.htm&NRCACHEHINT=Guest#1 Accessed May 23, 2010.
11. Oral Cancer Foundation. Dental and oral complications. Retrieved from http://oralcancerfoundation.org/dental/dental-complications.html Accessed May 26, 2010.
12. Roth A. Manifestations and management of the cancer patient. Retrieved from http://www.dentistryiq.com/etc/medialib/platform-7/dentistryiq2/articles/online-articles/2010-documents.Par.86633.File.dat//Volumes/UserData/Users/vickic/Documents/DIQ/Anita%20Roth%20-%20Manifestations%20and%20mgmt%20of%20the%20cancer%20patient/rotheditedpdf.pdf Accessed May 28, 2010.
13. Wright W, Haller J, Harlow S, Pizzo P. (1985). An oral disease prevention program for patients receiving radiation and chemotherapy. JADA: The Journal of the American Dental Association, 110(1, 43-47). Retrieved from http://jada-plus.com/cgi/content/abstract/110/1/43 Accessed May 23, 2010.

Dawn E. Kasper, RDH, is a published author, professional speaker, hygiene educator, and corporate consultant, and has been practicing dental hygiene for three decades. She speaks on numerous topics, specializing in pain management, dentinal hypersensitivity, salivary testing, optimizing whitening options, and communication. Dawn provides consulting/coaching services for dental practices. She has been an active member of the American Dental Hygienists’ Association, the American Academy of Dental Hygiene, the American Dental Education Association, and many other professional associations. Dawn is a member of the KOL Speaker Program for Sunstar/Butler and sits on many professional panels. She can be contacted at [email protected].

Defining cancer treatment

• Staging — a process that helps doctors discover the extent of the damage caused by the tumor.
• Surgery — the process of cutting out the tumor for diagnosis or complete removal of affected areas. Other treatment methods are often suggested in conjunction with surgery.
• Radiation therapy — using high-energy rays to destroy cancer cells.
• Chemotherapy — the use of anti-cancer medications/drugs to kill cancer cells (intravenous needle or pills). This method often results in unpleasant side effects.
• Hormone therapy — manipulates the body’s hormones to destroy or control cancer cells. This is often used to treat prostate and breast cancers, both of which are probably caused by hormonal problems.
• Immunotherapy — using the patient’s own immune system to fight cancer cells. This method is almost always used with other treatments.

Oral complications common to both chemotherapy and radiation

• Oral mucositis — 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 due to thickened, reduced, or absent salivary flow. Increases the risk of infection and compromises speaking, chewing, and swallowing. Medications other than chemotherapy can also cause salivary gland dysfunction. Persistent dry mouth increases the risk for dental caries.
• Functional disabilities — impaired ability to eat, taste, swallow, and speak because of mucositis, dry mouth, trismus (prolonged spasms of the jaw), 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 (difficulty in swallowing), and loss of taste.
• Abnormal dental development — altered tooth development, craniofacial growth, or skeletal development in children secondary to radiotherapy and/or high doses of chemotherapy before age nine.

More 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. This complication is a side effect of certain classes of drugs, such as the vinca alkaloids (anticancer medication that inhibits cancer cell growth by stopping cell division, or mitosis).
• Bleeding — oral bleeding from the decreased platelets and clotting factors associated with the effects of therapy on bone marrow.

Other complications of radiation therapy

• Radiation caries — lifelong risk of rampant dental decay that may begin within three months of completing radiation treatment if changes in either the quality or quantity of saliva persist.
• Trismus/tissue fibrosis — loss of elasticity of masticatory muscles that restricts normal ability to open the mouth.
• Osteonecrosis — blood vessel compromise and necrosis of bone exposed to high-dose radiation therapy. Results in decreased ability to heal if traumatized.