Aggressive cancer therapy places patients at greater risk for oral complications and treatment-related consequences. Unfortunately, prevention and/or treatment of such oral sequelae have become often overlooked priorities of the treatment team. We describe a philosophy of management of the cancer patient that specifically emphasizes the prevention and treatment of oral complications associated with cancer therapy. These concepts and principles are based on treatment protocols and ongoing clinical practices at The University of Texas M.D. Anderson Cancer Center in Houston, Texas.
In 1995, a projected 1.2 million people in the United States (excluding those with skin cancers) will be diagnosed with cancer; most of these individuals will undergo some form of potentially curative chemotherapy, surgery, radiotherapy, or combinations thereof . These therapies can be even more effective when accompanied by supportive care aimed at (1) preventing preexisting or treatment-associated pathologies from compromising treatment outcome and (2) maintaining patients' quality of life.
Almost all patients treated for cancer need some measure of rehabilitation, specifically delivered through a team effort focused on the whole person rather than on a cancer at a specific site. Consequently, the past several decades have seen the evolution of multidisciplinary teams that offer maximal therapy with minimal morbidity and optimal functional recovery. The dental oncologist is an important member of such teams.
In this article, we aim to help practitioners better understand how diverse dental oncology concepts are unified and used in the multidisciplinary treatment of cancer patients. Thus, we will discuss, in terms of a practical approach developed at our institution, general and specific considerations related to minimizing the oral complications of chemotherapy, radiotherapy, and surgery. We will also explore the integration of dental and oral treatment into specific oncologic therapy.
The status of the oral cavity in the cancer patient is no different from that found in the general population: poorly maintained dentition, moderate to advanced periodontal disease, ill-fitting denture prostheses, and related soft-tissue pathologies associated with tobacco and alcohol use and nutritional and/or general hygiene neglect [2,3]. The overall treatment outcome in cancer patients can be influenced by preexisting oral/dental pathologies that could be easily diagnosed with appropriately timed oral examination and minimized or eliminated with the implementation of preventive or treatment measures.
In addition, patients being treated aggressively with anticancer regimens often develop preventable or treatable oral mucosal and dental sequelae that can produce morbid events . This treatment-associated oral morbidity may vary, depending on the interaction of each patient's oral/dental status with the type of malignancy and the combination of therapies used, ie, surgery, radiation, and/or chemotherapy . Also, treatment-limiting toxicities that can lead to possible dose reduction or termination of therapy, such as mucositis, infection, and bleeding, can be minimized, and in some cases eliminated, by means of early evaluation and treatment by a dental oncology team.
Pretreatment Oral Examination
It is most important for the oncologist to ensure that patients who have head and neck surgery and associated radiotherapy or who receive chemotherapy undergo a thorough pretreatment oral examination. Several general types of oral complications are associated with cancer therapy: stomatitis, infection, bleeding, mucositis, pain, loss of function, and xerostomia . Most of these are related to preexisting conditions that cause the complication's initiation, intensification, or persistence. The three sites in the oral cavity that are the focus of these complications and at which preventive or therapeutic measures can be directed are the mucosa, periodontium, and teeth.
At the initial dental oncology visit, a patient undergoes a head and neck evaluation, oral and dental clinical examination, and an intraoral radiologic evaluation. This initial visit is directed at documenting and removing preexisting acute and chronic conditions that could produce obvious complications: dental abscesses, teeth with advanced periodontal disease, dental calculus that could cause gingivitis, partially erupted teeth with the potential for pericoronitis, and soft-tissue tooth trauma. Even if the cancer treatment is nontoxic to the mucosa or nonmyelosuppressive, the potential for oral infection is still present and could develop into a painful condition even under usual circumstances. Thus, with the possibility of cancer progression necessitating prompt and aggressive therapy, evaluation of the oral/dental status and treatment of any pathologies will minimize these predictable complications.
Modification of Oral Care and Hygiene
The patient's oral care and hygiene techniques are modified, if possible, to minimize mucosal and gingival complications that could arise from the specific treatment(s) being given. One major objective is to reduce and control plaque formation on teeth and soft tissue. Plaque is a proteinaceous, adherent, bacteria-laden debris material that can be colonized by normal flora as well as opportunistic pathogens; plaque accumulation can lead to several harmful conditions, such as superinfection of mucositis, gingivitis, periodontal disease, or caries .
Calculus can eventually form from plaque, resulting in the pathologic loss of supporting soft tissue and bone and thus creating a sanctuary for bacteria or sites of gingival bleeding . It must be mentioned that, contrary to popular belief, rinsing with salt or baking soda does not remove the potential septic foci of plaque and calculus; rather, they must be professionally removed.
Removal of Infected Tissue
Oral surgery, definitive or intermediate restorations, and oral prophylaxis may be performed quickly and safely under local dental anesthesia and/or intravenous sedation/general anesthesia to expeditiously remove acutely and chronically infected tissue. However, because communication and teamwork are critical in maximizing therapy, the medical and hematologic status of the patient must be reviewed and discussed with the primary-care physician before such dental treatment is initiated.