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Beyond the Diagnosis

Joel Epstein, DMD, MSD, FRCD(C), FDS RCS(E), talks about the dental health implications of treatment for oral cancer and other related cancers.

Q. Once oral cancer is diagnosed and treatment begins, does the oral health care professional still play an important role?

A. Yes, and not just in patients undergoing treatment for oral cancer. Earlier in the year, I attended a meeting of the Multinational Association for Supportive Care in Cancer where the need for a definition of supportive care in the cancer patient, including those with oral cancer, was discussed. We all agreed that supportive care is a requirement when providing excellent cancer care. It enhances the ability of patients to tolerate the acute complications of cancer therapy and impacts the survivorship issues that follow cancer treatment. Oral health care is an important part of supportive care. Oral health care providers should be involved from the time of early detection to diagnosis to post-treatment care. Early detection is necessary for various forms of oral cancer, the most common being squamous cell carcinoma, but early detection in the dental office is also possible for other cancers involving orofacial structures including leukemia, lymphoma, salivary gland malignancy, and metastatic disease to the jaws.

Q. How can oral health care providers help patients with oral and other cancers?

A. Oral health care providers have a role in preparing individuals for cancer therapy. If the patient has head and neck cancer or a cancer where the therapies will cause profound white blood cell suppression, the patient is at risk for oral complications that may have a major impact on quality of life. The oral cavity is a common site of periodontal, dental, and mucosal infection that can adversely affect the patient with cancer. Oral health care providers need to prevent complications that may be difficult or impossible to treat and costly to manage during or following cancer therapy, such as an infection that takes a patient to an intensive care unit where he or she must be tube fed. Managing these risks from the start allows patients to receive the excellent cancer care necessary for positive outcomes.

Q. What type of problems related to the oral cavity may occur in this population?

A. Oral mucositis or oral infections commonly occur during cancer treatment. Cancer patients report in surveys that oral complications are the most severe and debilitating complications they experience during the therapy. Oral infections are common during immuno-suppression or radiation therapy, including fungal infections like candida. Recognition and diagnosis may be complicated by ongoing mucositis. Reactivation of various viral infections, like herpes, is also part of the acute spectrum.

Q. Are there long-term oral health issues in patients who have finished their cancer treatment?

A. Once patients recover from the acute side effects of cancer therapy and have either tumor control or cure, oral health care providers need to manage the long-term oral complications of cancer and its therapies. These include the longterm radiation effects on soft tissue and bone that prevent ease of surgical management and may lead to necrosis of the jaw and cause salivary gland damage, ie, dry mouth. The consequences of radiation exposure include increased risk of caries; periodontal diseases, mucosal infections; limitation in function including jaw and tongue movement; dysphagia; taste alterations; and soft tissue and bone necrosis. The role of the oral health care provider is critical because the diseases that develop due to dry mouth progress very rapidly. Oral health providers also have a role in the detection of recurrent new oral manifestations of cancer. Dental rehabilitation may be required, especially following oral and head and neck cancers, and can include crowns and bridges, implants, and oral and facial prosthetics.

Q. Are oral health care providers aware of this important role?

A. Many physicians, dentists, and dental hygienists are not aware of the broad implications of the treatment for oral, head, and neck cancers. Patients may not report oral complications to their oncologist, and therefore oral conditions may be under-reported and under-treated. Effective communication between the medical and dental worlds is critical. Each group brings an important and necessary perspective and we need to approach treatment as a team for the best interest of our patients.

From Dimensions of Dental Hygiene. September 2008; 6(9):38.

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