Dental Oncology Can Be Key for Cancer Care

May 7, 2016

Dental exams and procedures should occur before treatment begins for patients with head and neck cancer and other malignancies, and post-treatment dental follow-up care should be life-long for cancer survivors.

Dental exams and procedures should occur before treatment begins for patients with head and neck cancer and other malignancies, and post-treatment dental follow-up care should be life-long for cancer survivors, according to two experts who spoke at the Oncology Nursing Society (ONS) 41st Annual Congress in San Antonio, Texas.

“The dental oncologist can play an integral role before, during, and after anti-neoplastic therapies, in order to provide the maximum possibility of functional and aesthetic outcomes,” said Maureen Sullivan, DDS, chief of the department of dentistry, oral oncology, and maxillofacial prosthetics at the Erie County Medical Center in Buffalo, New York.

The goals of dental care are to control, treat, and prevent infection, to control and treat pain, to maintain or recover oral function, and to manage oral complications caused by cancer and cancer treatment.

Dental oncology care can also be life-saving. Dental abscess during cancer treatment can lead to potentially lethal brain infections, noted oncology nurse navigator Colleen Palay, BSN, RN, of the Seidman Cancer Center in Cleveland, Ohio.

Some of the most dramatic acute oral side effects are seen among patients undergoing head and neck radiation. Common examples include mucositis, pain, hypogeusia (a loss of taste perception), dysphagia, and erythema. Concurrent radiation and EGFR inhibitors or tyrosine kinase inhibitors can increase the risk of mucositis, as might hypofractionated radiotherapy, which can interrupt or halt cancer treatment. “Compromised oral mucosa from diabetes, immunosuppression, alcoholism, chronic liver disease, or existing oral infections” can further complicate mucositis, Dr. Sullivan cautioned.

Mucositis is treated for symptom palliation with baking soda rinses, local or systemic analgesics, antifungal medications, and high-fluoride, dry mouth–formulated rinses and toothpaste.

Post-radiotherapy xerostomia (loss of salivary gland function), xerostomia-associated tooth decay, dysphagia, trismus, and infection can impact a patient’s ability to swallow, eat, speak, and wear dentures.

Amifostine can help to protect radiotherapy patients’ salivary glands, but has significant side effects, including hypotension, nausea, and vomiting. “It’s very expensive, and timeliness of administration is crucial,” Dr. Sullivan said.

Xerostomia can be palliated with salivary substitutes and hydration such as pilocarpine or cevimeline.

Xerostomia-induced tooth decay can trigger osteoradionecrosis, usually affecting the mandible, increasing the risk of fracture and extra-oral fistula, Dr. Sullivan warned. Treatment strategies include topical antiseptics like chlorhexidine, antibiotics, and symptom management.

Customized acrylic trays for fluoride treatment can help prevent radiation-associated cavities. Salivary substitutes may also help to normalize oral microbiota and reduce the risk of infection. “Systemic antifungals and antivirals are favored, especially for patients who are noncompliant with oral care regimens,” Dr. Sullivan noted.

Trismus, in which scarring limits a patient’s ability to open her mouth and eat normally, can be prevented through passive stretching procedures immediately after surgery, or the use of dynamic devices to maintain or improve jaw-opening range.

For patients treated with bisphosphonates, bone osteonecrosis of the jaw can also develop, causing painful exposures and purulent lesions of the jaw bone, because bisphosphonates are disproportionately deposited in bone with high turnover rates. “Preventive measures are paramount for the dental and oral health of patients receiving bisphosphonate therapy,” Dr. Sullivan said. “All invasive dental procedures should be performed and all potential risks of infection should be eliminated before beginning bisphosphonate therapy.”

It is important to integrate dental assessments and treatment into cancer care. “Get a dental history,” urged Palay. “How often do they see a dentist? How does the patient describe their oral health and function? Identify untreated dental problems.”

Dental histories should also include a visual inspection of the overall condition and hygiene of the patient’s oral cavity, and questions about how the patient pays for dental care. “You’ll have patients who haven’t been to the dentist in years-and in some cases, decades,” Palay said. If a patient hasn’t seen a dentist in years, “it is probably best to remove teeth,” she cautioned.

The timing of dental care is crucially important, both experts agreed.

“Head and neck cancer patients should absolutely be seen by a dentist prior to surgery,” emphasized Palay. “It’s important to plan ahead wherever possible; dental care should be performed several weeks prior to the initiation of cancer treatment” to allow time for healing before cancer-treatment surgery, chemotherapy, or concurrent chemoradiotherapy.

Postoperative dental care is much more complicated-and complications-prone-than pre-treatment care. “The patient’s going to be upset with you if you don’t tell them to see a dentist before treatment,” Palay advised.

Dentists should be recognized as “key” members of the multidisciplinary cancer-treatment team. A dental-oncology assessment is a thorough evaluation of the hard and soft oral tissues, involving x-rays, and formulation of an oral care and treatment plan. “The dentist needs to know the patient’s diagnosis, expected treatment, hematologic status, past medical history, medications history, need for antibiotic prophylaxis, and whether or not they’re diabetic,” said Palay.

Late dental effects of cancer treatment can significantly impact patients’ function, diet, quality of life, and post-treatment health. Patients should be educated about these, as well as acute dental or oral side-effects of treatment.

Radiation to the jaw during childhood can affect jaw growth, affecting the teeth. Some chemotherapy-related changes can affect tooth root growth, leaving children with smaller and more fragile teeth.

“Children’s side effects are the same as adults but tooth developmental issues and craniofacial abnormalities may occur,” Palay said. That can profoundly affect a child’s self-image, and social interactions. “Studies have shown that children … with malocclusion are likely to be bullied because of their appearance.”

Dental oncology also involves post-treatment reconstruction of oral prosthetics. Patients with extractions for cancer treatment should not get new dentures until about 6 months following treatment.

Patients should be evaluated for denture fit after cancer treatment ends, and should have dental follow-up appointments “at least” every 6 months (ideally, every 3 to 4 months), and continue dental follow-up for life. It’s important that patients be instructed to communicate their cancer and cancer-care histories to community dentists who may not have been part of their cancer care team.

It’s important that prosthetics be evaluated and fluoride-tray treatment be planned-and that a dental team educate the patient how to brush, floss, and do fluoride treatments, Palay noted. Patients should be instructed to brush teeth “up and down” rather than side-to-side, and not to “dig” with their toothbrush. Patients should be told how to use and care for dentures, and advised that foul smells are a red flag that should prompt contact with the dental care team.

If-and only if-patients have been “flossers,” patients should be instructed to use waxed floss but to avoid pick products, Palay said. “If a patient hasn’t been a flosser, this isn’t the time to start, because it can lead to bleeding and infection,” she cautioned.

Too frequently, patients are instructed to seek out dental care themselves, in the community, without enough consideration of likely barriers to access. Not all patients “actually live close to a dentist,” noted Palay.

“In rural locations there are often no dentist offices available, especially for patients on Medicaid,” she said. “Even patients who take very good care of themselves with their general health, may not be willing to go to the dentist.”

Appointments at federally qualified health center free clinics can involve waits of 3 weeks or more, complicating cancer treatment, Palay said. Dental school clinics are an option, as are hospital-based or outpatient dental clinics. Patients with veterans’ benefits can seek dental care through the VA.

Timely access to dental clinics is not the only barrier to care for cancer patients. “Financial and insurance issues are a big cause of frustration for patients and providers,” Palay said. Safety-net dental clinics tend serve low-income or Medicaid patients. “Dental insurance can cap out at $1,000, and they can burn through that pretty quickly.”

Antiquated Medicare reimbursement rules reflect treatment standards from the 1960s, she added. “Head and neck cancer standard-of-care was to evaluate and extract teeth,” she explained. “It doesn’t pay for that same evaluation if you’re not going to pull the teeth, or for preventative dental care, though it does pay for mandibular reconstruction for osteoradionecrosis.”

For leukemia and lymphoma, Medicare pays for mucositis care but not preventative care, she added.

“We pay a lot for dental problems that can be prevented,” she lamented. “Congress is revisiting that and may get the law changed.”

For children and dependents younger than age 20, dental care is considered to be an essential health benefit under the Affordable Care Act, Palay noted. 

It can be easy to overlook other practical barriers to patients’ dental care, Palay said: “Patients who come to us with disabilities, we don’t think of them that much. A fair number of patients roll into our cancer centers [in wheel chairs]. It’s important to monitor them. Are they really able to perform their own oral care now, and will they be able to later? Can they get a wheelchair into a dentist’s room and transfer to the dental chair? Are they able to sit still and hold their head in position for a dental evaluation?”

Approximately 75% of patients with disabilities are enrolled in Medicaid, Palay noted. “Medicaid providers already have a low reimbursement rate for care, so taking a patient with complicated treatment needs and now a cancer, that provider might not be able to accommodate the patient.”

As a result, patients with disability frequently have to travel long distances to dental providers who can meet their needs, Palay said.

After treatment is completed, a patient’s new facial appearance can be very distressing. “Extensive head and neck surgery, it’s sometimes like having a new face, really,” said Palay. “It’s important to consider the psychosocial aspects. Our patients who have had tooth loss due to surgery and cancer treatment can have troubles with employment. People in frontline positions, if they’re missing their teeth, it’s distracting for clients, and those people may be hired for a background position-and be underemployed for their skill sets only because of their appearance.”

Some cancer centers “let the patient take care of it” when it comes to dental care, Palay noted. “But we as nurses need to advocate for our patients to get that care for our patients and help them get through it.”