Cancer Treatment Impacts to Dental Health

Cancer treatment can significantly impact oral health and place the patient at risk for several dental diseases. Therefore, dental providers play an integral role in the prevention of oral diseases, in maintaining oral health throughout the cancer treatment journey, as well as managing any oral complications patients may experience.

Join Dr. Seena Patel and learn:

• The oral complications of cancer treatment
• The necessary steps required for rendering appropriate dental care before, during, and after cancer treatment
• Ways to prevent oral disease in patients undergoing cancer treatment

Cancer and Oral Health: Oral Complications and Dental Management

Cancer accounts for 23% of deaths in the US. It is a devastating disease that has many physical, emotional, and social implications. Specifically, head and neck cancers affect approximately 3% of the US population. These cancers can lead to severe oral complications, even when treated. Despite recent advances in imaging, surgery, radiation, and systemic therapies, the overall survival rate has only improved by about 15% in the last 50 years. Dental providers play an integral role in the prevention of head and neck cancers and in the dental management of patients going through cancer treatment. This course will review the epidemiology of head and neck cancers, prevention methods, treatment modalities, and the role of the dental professional.

Learning Objectives:

• Describe the epidemiology of head and neck cancers
• Describe the clinical characteristics of head and neck cancers
• Learn the characteristics of potentially malignant disorders
• Learn how to play an important role in primary and secondary prevention of head and neck cancers
• Explain the dental provider's role in helping to prevent oral cancer
• Define the necessary steps required for rendering appropriate dental care before, during, and after cancer treatment
• List the oral complications of cancer treatments

 

Dental Caries

Cancer patients face increased risk for dental caries during and following treatment, which can be attributed to changes in salivary flow rates, salivary composition, and bacterial dysbiosis. Cancer treatment—especially radiotherapy to the head and neck—changes the chemical composition of saliva by decreasing pH, increasing viscosity, and decreasing its buffering capacity. Clinically, it may present as rampant caries, with increased risk for smooth surface caries, including cusp tips, incisal edges, and cervical regions. Patients need to be educated about the benefits of a noncariogenic diet and maintaining optimal oral hygiene.

Professional fluoride application, along with optimal daily doses of fluoride, are both key in reducing caries risk. Additionally, xylitol products are useful, as they can inhibit Streptococcus mutans. Patients may wish to use milk and probiotic products, although there is a lack of substantial evidence to support an added benefit. The use of chlorhexidine mouth rinse has a beneficial effect, especially in patients with high streptococcal counts (> 106 colony forming units/ml of saliva). However, a recent guideline suggests that chlorhexidine should be avoided in cancer patients to prevent the systemic spread of alpha-hemolytic S. viridans and Candida albicans.
Products containing arginine bicarbonate and calcium carbonate may support the maintenance of a neutral pH in the oral cavity, as well as healthy enamel.

Therapies with amorphous calcium phosphate (ACP), casein phosphopeptide-ACP (Recaldent), calcium sodium phosphosilicate (NovaMin), and tricalcium phosphate may encourage remineralization and reduce caries risk.

Patients with cancer need to seek more frequent dental care during and after treatment are complete, as some of these effects are long-lasting.

 

Periodontal Conditions

Periodontal disease is known to progress during cancer treatment, especially radiotherapy. The periodontium is sensitive to the effects of cancer chemotherapy and radiotherapy because they not only affect the blood supply, but also the regenerative and reparative potential of the periodontium. Additionally, xerostomia and radiation-induced caries adversely impact preexisting chronic periodontitis.
Severe periodontal involvement of teeth can also lead to osteonecrosis. Additionally, other factors, such as hematopoietic changes and superimposed infections, affect the gingiva. Indeed, patients receiving chemotherapy can develop acute exacerbations of chronic periodontal disease due to neutropenia. With control groups, studies have reported that oral sources of septicemia can be reduced by 50% in patients receiving professional oral prophylaxis and reinforced oral hygiene.

Pretreatment assessment and prevention are key for patients before starting cancer therapy. Patients receiving chemotherapy (especially in individuals who can become neutropenic) and radiotherapy to the head and neck should receive pretreatment screening. Periodontal diseases should be treated either nonsurgically or via extraction of questionable teeth (although in noncancerous patients, those teeth may be kept under observation). Oral hygiene instruction and monitoring are also essential before, during, and after cancer treatment. A healing period of 2 weeks following dental treatment is recommended prior to the start of cancer therapy.

Some studies have dispelled the concern that periodontal maintenance increases the risk of systemic bacteremia in patients with leukemia. There is also evidence to suggest periodontal treatment prior to the start of cancer treatment can reduce the risk of mucositis. Antibiotic coverage for such treatment (in cases in which it cannot be delayed) should be considered if neutropenia is present and neutrophil counts are less than 500 cells/ml.

 

Management Summary 

A recurring theme in various practice guidelines for individuals receiving cancer treatment is that they should be seen before the start of cancer therapy and at regular recare visits (3 months or less) during the course of treatment. Although some forms of dental care should be postponed until after completing cancer treatment, maintaining oral hygiene, caries control, and managing incipient issues (as well as oral complications) should be performed during cancer treatment. Following the completion of cancer care, oral health conditions that could not be treated previously should then be addressed.

Management of patients with cancer should be based on broad knowledge of the oral complications that can arise from cancer treatment, as well as an understanding of the critical roles of prevention and pretreatment screening when caring for this population. When planning dental treatment, close communication between oral health professionals and the medical team is key to establishing personalized care strategies.