According to the National Institutes of Health,1 nearly all patients with head and neck malignancies receiving high-dose radiation therapy; approximately 80% of patients undergoing stem cell transplantation; and about 40% of patients receiving chemotherapy will experience oral complications that may occur only during treatment or persist long after their cancer therapy is completed, compromising their general health and quality of life.
The list of oral complications related to these therapies is long and may include mucositis; taste alterations; gum infections and bleeding from decreased platelets; xerostomia and salivary gland dysfunction; an impaired ability to eat, taste, swallow, and talk; and abnormal dental development. All of these complications can lead to poor nutrition for patients and may result in compromised cancer care if therapy has to be delayed or discontinued altogether.
The ASCO Post talked with Lauren Levi, DMD, Clinical Assistant Professor at the New York University (NYU) Bluestone Center for Clinical Research at NYU College of Dentistry and Clinical Instructor of Dentistry at the Icahn School of Medicine at Mount Sinai Hospital in New York, about the need to recognize the potentially devastating consequences cancer treatment can have on patients’ oral health and the preventive measures that can reduce their risk of developing oral complications during and after cancer treatment.
Oral Side Effects
Can you describe some of the oral side effects related to bone marrow transplantation, radiation therapy, and chemotherapy.
All treatment for cancer carries a risk for the development of oral complications. For patients undergoing hematopoietic stem cell transplantation, the intensive conditioning chemotherapy regimens can result in pronounced immunosuppression, increasing patients’ risk for oral infections and oral graft-vs-host disease. These problems may result in mucosal inflammation, ulceration, and xerostomia.
High-dose radiation therapy is associated with mucositis as well as trismus (lockjaw), which reduces the elasticity of the masticatory muscles, restricting patients’ ability to open their mouth, making it difficult for them to eat normally. Xerostomia is also a side effect of radiation therapy and may be permanent—although usually a temporary side effect of chemotherapy—and can increase the risk of dental cavities.
Chemotherapy may be associated with many of these same side effects as well as neuropathy, a persistent, deep aching and burning pain that is similar to a toothache and oral bleeding.
Reducing the Risk of Oral Problems
How can oncologists help their patients reduce their risk for oral problems during and after cancer treatment?
The best advice oncologists can give their patients is to see their dentist, or preferably a dental oncologist, for a thorough oral evaluation and dental cleaning before cancer treatment begins to reduce the risk and severity of oral complications. During the examination, the dentist will be able to identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease, which could contribute to oral difficulties once cancer treatment begins.
The best advice oncologists can give their patients is to see their dentist, or preferably a dental oncologist, for a thorough oral evaluation and dental cleaning before cancer treatment begins to reduce the risk and severity of oral complications.— Lauren Levi, DMD
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For patients planning to undergo radiation therapy to the head and neck, any teeth that need to be extracted should be extracted at least 2 weeks prior to the commencement of treatment to allow the area to heal. Oral surgery should be performed 7 to 10 days before a patient receives myelosuppressive chemotherapy. Extracting teeth in the field of high-dose radiation after completion of radiation therapy is contraindicated, as it poses a risk for the development of osteoradionecrosis of the jaw.
To prevent or reduce the risk of trismus, I always recommend that patients begin physical therapy before head and neck radiation therapy starts. I review some basic exercises they can perform themselves, such as massaging and exercising their jaw muscles. To prevent cavities, I prescribe a high-potency fluoride gel, which can be applied via a custom gel-applicator tray or brushed directly on the teeth following daily brushing with regular toothpaste and flossing. All of this preparation is designed to prevent problems for patients following their treatment, keep them comfortable during and after treatment, and improve their quality of life.
How can patients find a dental oncologist?
Unfortunately, it is not so easy to find a dental oncologist. Dental oncology as a medical field is growing, but dental oncology fellowship training is mostly limited to the major academic cancer centers, and there are only a few dentists specializing in dental oncology in the community practice setting. Still, many oral complications from cancer treatment can be reduced with the pretreatment oral care described here.
Once a patient is diagnosed with cancer, he or she should be referred to a dentist for a dental evaluation, and the medical oncologist should communicate the patient’s treatment plan with the dentist, so pretreatment oral care can begin and precautions taken to prevent oral problems. ■
Disclosure: Dr. Levi reported no potential conflicts of interest.
1. National Institute of Dental and Craniofacial Research: Oral Complications of Cancer Treatment: What the Dental Team Can Do. Available at http://www.nidcr.nih.gov/oralhealth/Topics/CancerTreatment/OralComplicationsCancerOral.htm. Accessed November 23, 2016.