Addressing the Oral Side Effects of Cancer

The course of cancer treatment is based on the type of malignancy, site of the cancer, and patient factors such as age and comorbidities. Patients’ oral health status is also important. Recent advances in cancer therapy have led to higher survival rates, emphasizing the need to maintain optimal oral health.¹ Dental hygienists play an important role in providing treatment to patients with cancer as part of the comprehensive oral care and oncology team.

Oral assessment, implementation of basic oral care protocols, and recognition of emerging oral complications should be provided before, ­during, and after cancer therapy.² Basic oral care for patients with cancer includes preventing infection, treating active infection, controlling pain, maintaining oral function, managing oral complications, and improving quality of life.^1,3,4 Ideally, all patients with cancer should have a pretreatment oral assessment—especially those diagnosed with head and neck cancer or hematologic cancer, those undergoing hematopoietic stem cell transplantation (HSCT), and patients with poor oral health. The pretreatment assessment should be completed immediately following diagnosis and within 2 weeks to 3 weeks prior to starting cancer therapy. The evaluation should include examination of the head and neck, oral soft tissue, and oral cavity, in addition to periodontal evaluation and the capture of a full series of dental radiographs. Nonemergency dental treatment can be delayed until the patient’s overall health status is stable.^5,6 Each patient should receive an individualized care plan based on the specific type of cancer he or she has. The dental team needs to understand the prescribed cancer treatment in order to create this treatment protocol.⁷ Communication with the oncology team is essential to providing successful oral care in this population. In unique or complex cases, consultation with dental specialists who specialize in oncology may be needed.

Prior to the start of cancer treatment, patients should receive prophylaxes, which may reduce the severity of oral complications, particularly oral mucositis.⁸ Incipient to small caries lesions may be treated with fluoride, temporary restorations, and/or sealant application until definitive care can be provided. Caries lesions involving the pulp, however, require active intervention. Patients who need teeth extracted due to periodontitis or other causes must undergo surgery before cancer treatment begins because the risk of osteonecrosis is elevated when surgery is performed post-treatment.

Patient education is an integral part of the pretreatment evaluation. Patients must understand how to perform optimal self-care to safeguard their oral health. Dental hygienists can also counsel patients on consuming healthy diets and avoiding tobacco and alcohol use. They should be assessed for xerostomia, taste change or loss, and mucosal sensitivity.

PROTOCOLS DURING TREATMENT

Oral complications during active cancer treatment negatively impact patients’ quality of life. These problems can become so severe that the cancer therapy has to be altered, which may affect treatment outcomes. Patients should be monitored closely during cancer treatment to manage oral changes and to reinforce preventive strategies. During therapy and follow-up care, management of complications associated with mucositis, oral infection, altered salivation, and sensory changes (pain, taste) is critical.

The frequent use of mouthrinses, atraumatic toothbrushing and flossing twice a day, and daily administration of fluoride gels are recommended.^1,9 Prescription-strength fluoride toothpaste may be warranted. Patients with mucositis, however, may not be able to tolerate high-levels of fluoride due to oral discomfort, so switching to mild-flavored nonfluoride dentifrice with the addition of a fluoride mouthrinse may be helpful. If patients cannot tolerate a regular soft toothbrush because of mucositis, foam brushes or super soft brushes can be used.¹⁰ If patients are skilled at flossing without traumatizing the tissues, they should continue flossing throughout cancer treatment. Toothpicks and water irrigation devices should not be used in patients who are neutropenic and/or thrombocytopenic to avoid tissue trauma.¹¹ Clinicians should encourage patients to eat healthy diets and advise them about the caries risks associated with consuming dietary supplements rich in carbohydrates and medications sweetened with sucrose, such as nystatin suspensions, which are sometimes used to suppress opportunistic fungal infections.¹²

The frequency of recare depends on the patient’s oral health status. The dental care plan should be based on the presence of oral disease, effectiveness of the patient’s oral hygiene, risk of progression of oral disease, and oral complications caused by the cancer therapy.

EARLY AND LONG-TERM ORAL COMPLICATIONS

Patients undergoing cancer therapy are at increased risk of mucositis, oral mucosal infections, xerostomia, osteonecrosis, and cancer recurrence. Mucositis care focuses on alleviating symptoms and managing the secondary factors that affect its severity.¹¹ Optimal management typically includes good oral hygiene, topical anesthetic/analgesic agents, nonmedicated oral rinses, mucosal coating agents, film-forming agents, nutritional supplements, and systemic analgesics. Patients with mucositis may experience relief from symptoms by rinsing with a mixture of 1 teaspoon of baking soda and 1 teaspoon of salt dissolved in water.

Opportunistic fungal, viral, and bacterial infections are common among individuals undergoing cancer therapy. Oral and oropharyngeal candidiasis presents as cracking at the corners of the mouth and erythematous or white mucosal patches.¹³ Candidiasis may also cause a coated sensation in the mouth, oral burning, and changes in taste sensations. While topical antifungal agents are commonly prescribed to prevent candidiasis, their effectiveness is inconsistent and systemic agents may be more effective for treatment of infection.^14,15 A variety of fungal species may present in patients that may be resistant to standard antifungal therapy.¹³

Herpes simplex virus (HSV) infections may arise during cancer care. Varicella, Epstein-Barr, and cytomegalovirus infections are also not uncommon, particularly in patients with hematological malignancies undergoing chemotherapy and HSCT. Acyclovir and valacyclovir are equally effective in preventing and treating HSV, but resistant virus and breakthrough infection can occur.^16,17

As noted earlier, local or systemic infections can be caused by normal oral flora in patients who are immunosuppressed. Infections may also be caused by nosocomial and bowel microbes not normally found in the mouth. Culturing (to identify likely causal organisms) and sensitivity (to possible antimicrobial drugs) testing may be helpful in terms of selecting one or more appropriate therapeutic antimicrobials.¹² Other potential complications in patients undergoing HSCT include graft-vs-host disease (GVHD), osteonecrosis of the jaws, and secondary malignancies.

GVHD is a multiorgan disease that occurs following allogeneic HSCT. Oral care of patients undergoing this treatment requires an experienced and interdisciplinary care management team, including oral health professionals. Common oral signs and symptoms of GVHD include lichenoid striations, erythema, ulceration, xerostomia, mucocele, dysgeusia, trismus, and fibrosis.⁴ Management of GVHD focuses on optimizing oral health to prevent progressive dental disease and controlling symptoms such as pain, sensitivity, and oral dryness. Other oral maladies may require specialized treatments.

Patients who have undergone cancer treatment may experience long-term side effects, including reduced saliva production (hyposalivation) and dysgeusia.¹⁸ Those with xerostomia and/or hyposalivation should be encouraged to sip water throughout the day and to avoid drying agents such as caffeine, alcohol, and sugar-containing products. Artificial saliva products, moisturizing mouthrinses, and water-based lubricants may help prevent the oral cavity from drying out. Patients may also gain relief from xerostomia symptoms by using toothpastes, mouthrinses, and gels with a neutral pH. To prevent caries, an at-home fluoride regimen using trays should be considered. Prescription secretagogues may stimulate salivary gland tissue, boosting salivary flow. Chewing xylitol gum may also provide symptom relief and offer caries-prevention benefits.¹⁹

Individuals with blood-related cancers may have increased oral bleeding due to thrombocytopenia, disturbance of coagulation factors, or damaged vascular integrity. They may also experience dentinal hypersensitivity because of decreased salivary flow, low salivary pH, and neuropathic pain.^1,20 Clinicians should focus on early identification of risk factors, symptoms, and clinical signs that may suggest referral for more specialized expert care.

Managing oral complications remains important upon completion of cancer treatment. Periodontal maintenance and effective oral self-care are key. Patients who can tolerate power toothbrushes should use them. Keeping the mouth and lips lubricated is helpful. Patients should be encouraged to eat healthy diets and to avoid tobacco and alcohol use.

Patients previously treated for oral and head and neck cancer and upper aerodigestive cancers are at higher than normal risk of recurrent or new cancers. Individuals who were young when they underwent HSCT, those who received total body irradiation or chemotherapy, and patients who had GVHD are at higher than normal risk of secondary malignancies. In light of these risks, oral health professionals need to be especially diligent when screening these patients for oral cancer.

CONCLUSION

An aging population and increasing numbers of cancer diagnoses necessitate greater professional attention to improving the oral health of patients with cancer. For head and neck cancers, as well as cancers whose treatment includes immunosuppression or interferes with the protective capabilities of normal salivary flow and the oral mucosa, protocols that consider oral health at every treatment stage and post-treatment maintenance are critical. Oral health professionals should always be members of relevant cancer teams because they can make beneficial contributions to both treatment and disease management outcomes.

REFERENCES

1. Epstein JB, Thariat J, Bensadoun RJ, et al. Oral complications of cancer and cancer therapy: from cancer treatment to survivorship. CA Cancer J Clin. 2012;62:400–422.
2. Ganzer H, Epstein JB, Touger-Secker R. Nutrition management of the cancer patient. In: Nutrition and Oral Medicine. Touger-Decker R, Mobley C, Epstein JB, eds. New York: Human Press, Springer; 2014:235–253.
3. Epstein JB, Güneri P, Barasch A. Appropriate and necessary oral care forpeople with cancer: guidance to obtain the right oral and dental care at theright time. Support Care Cancer. 2014;22:1981–1988.
4. Elad S, Raber-Durlacher JE, Brennan MT, et al. Basic oral care for hematology-oncology patients and hematopoietic stem cell transplantation recipients: a position paper from the joint task force of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology and the European Society for Blood and Marrow Transplantation. Support Care Cancer. 2015;23:223–236.
5. Rankin K, Jones D, Redding S et al. Oral health in cancer therapy: a guide for health care professionals. Available at: doep.org/images/OHCT_III_FINAL.pdf Accessed October 19, 2015.
6. Schubert MM, Peterson DE. Oral complications of hema-topoietic cell transplantation. In: Appelbaum RF, Forman SJ, Negrin RS, Blume KG, eds. Thomas’ Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, United Kingdom: Wiley-Blackwell; 2009:1589–1607.
7. Lalla RV, Brennan MT, Schubert MM. Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, Marrioti AJ, Neidle EA, eds. Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis: Mosby-Elsevier; 2011:782–798.
8. Joshi V.K. Dental treatment planning and management for the mouth cancer patient. Oral Oncol. 2010;46:475–479.
9. Jackson LK, Johnson DB, Sosman JA, Murphy BA, Epstein JB. Oral health in oncology: impact of immunotherapy. Support Care Cancer. 2015;23:1–3.
10. Hong CH, daFonseca M. Considerations in the pediatric population with cancer. Dent Clin N Am. 2008;52:155–181.
11. Keefe DM, Schubert MM, Elting LS, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007;109:820–831.
12. Hong CH, Napeñas JJ, Hodgson BD, et al. A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer. 2010;18:1007–1021.
13. Lalla RV, Latortue MC, Hong CH, et al. A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer. 2010;18:985–992.
14. Worthington HV, Clarkson JE, Khalid T, Meyer S, McCabe M. Interventions for treating oral candidiasis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2010;7:CD001972
15. Gøtzche PC, Johansen HK. Nystatin prophylaxis and treatment in severely immunocompromised patients. Cochrane Database Syst Rev. 2002;2:CD002033.
16. Reusser P. Management of viral infections in immunocompromised cancer patients. Swiss Med Wkly. 2002;132:374–378.
17. Arduino PG, Porter SR. Oral and perioral herpes simplex virus type 1 (HSV-1) infection: review of its management. Oral Diseases. 2006;12:254–270.
18. Nieuw Amerongen AV, Veerman EC. Current therapies for xerostomia and salivary gland hypofunction associated with cancer therapies. Support Care Cancer. 2003;11:226–231.
19. Trushkowsky RD. Xerostomia management. Dimensions of Dental Hygiene. 2014;12(3):34–39.
20. Saunders DP, Epstein JB, Elad SA, et al. Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients. Support Care Cancer. 2013;21:3191–3207.

From Dimensions of Dental Hygiene. November 2015;13(11):41–43.