The following article was published in Dentistry magazine, 11 January 2002.
HOW TO TREAT PATIENTS WITH MOUTH CANCER Dr Vinod K Joshi looks at the dentist's role after mouth cancer has been diagnosed The accompanying images may be disturbing to some viewers.

In the UK, about 3800 people will be diagnosed and treated for oral, pharyngeal, lip, or salivary gland tumours. Most of these patients will be over 40. The oral status of these cancer patients is no different from that found in the rest of the general population. Often they will have average dentitions in various states of repair with filled teeth, crowns, bridges, some root-filled teeth, varying degrees of periodontal disease, ill-fitting denture prostheses and general hygiene neglect. Reference

Many of these patients will be treated with radiation therapy to the head and neck area. Severe problems in the mouth can occur after radiation therapy for head and neck cancer. A substantial number will suffer clinically significant short and long-term oral adverse effects. Most patients being treated for head and neck cancer (and many patients with other cancers) also experience oral complications from chemotherapy.


Dental assessment
The most significant risk factors of oral complications of cancer therapy (View Table 1) are oral or dental disease that already exists, poor oral care during cancer therapy, and any factor that affects the mouth tissues.

Oral problems that already exist, such as periodontitis, caries, failing restorative work (such as crowns, or fillings), and dentures may increase the risk of infection. Areas where the gums or tissues are irritated can lead to ulceration in the mouth. Pain and discomfort resulting from teeth and gums may make it difficult for a patient to receive all of his or her cancer treatment. Sometimes treatment must be stopped completely. These patients require urgent dental care before and after cancer treatment.

By starting preventive measures before and during early cancer therapy, it is possible for dentists to reduce the occurrence and the problems associated with their patients’ cancer treatment and significantly improve oral physiologic and social functioning. Timely oral care can improve post treatment social adaptation and life quality. The Calman report on cancer care emphasised the need to focus treatment and management regimens on both longevity and quality of life. Reference

Cancer treatment centres have a head and neck cancer team that usually consists of a radiation oncologist, a head and neck surgeon, a hospital dentist and a medical oncologist who evaluate the patient and recommend the most appropriate treatment plan. The clinical guidelines published by the Royal Colleges of Surgeons of England state that a clear pathway of care is necessary to prevent or minimise oral complications. Reference

The clinical guidelines recommends that every relevant oncology protocol include an early pre-treatment oral assessment with a permanent member of the oncology team responsible for arranging the oral assessment and organising oral care, arranging or carrying out any active dental treatment required.


GDP education
Ideally, comprehensive dental care for these patients should be available. However, this is an exception rather than the rule. Many cancer patients receive no proper dental assessment or preventive treatment to minimise or avert the known and common oral complications of radiation therapy due, in part, to the lack of resources and recognised local standards of dental care for cancer patients undergoing head and neck radiation. It is also due to the lack of information provided to general dental practitioners and the lack of interest on the part of general dental practitioners in this aspect of dental care. This results in many teeth being extracted in the interests of expediency with the patient having little choice in the matter. To improve the current situation, a campaign to educate general dental practitioners about the role they could play, in conjunction with the hospital cancer service, in managing to reduce the complications of oral cancer treatment is urgently required.



There is a window of opportunity for dental treatment but the capacity for rapid delivery of dental care can only be achieved if the patient is given priority both within the hospital’s departments and by the patient’s general dental practitioner. The patient’s dentist could help provide oral care to a treatment plan with advice from the consultant in a Restorative Dentistry Oncology Clinic. General dental practitioners need to urgently carry out the advised dental treatment plan for these patients to avoid any delay of cancer treatment. This would help their patients retain teeth, which would otherwise be lost, for improved function and life quality. After the extractions required are completed, urgent care such as placement of restorations, adjustment of prostheses and elimination of oral discomfort should be undertaken by the patient’s dentist. Dental extractions should have a healing time of seven to ten days prior to commencement of radiation therapy. The goal should be to complete all dental care within two weeks of referral of the patient.

Radiation therapy If the preceding procedures have been completed, most patients will not need oral care during the course of their radiation therapy though continuing evaluation and supportive reinforcement for management or amelioration and control of oral problems consequent to cancer treatment such as mucositis (View Table 2), xerostomia (View Table 3), opportunistic infection (View Table 4), nutritional difficulty, will be needed. (The tables appended provide a quick guide to management of these complications.)

The Restorative Dentistry Oncology Clinic would provide this care, and any specialist rehabilitative prosthodontic treatment required. A close collaboration between the hospital oncology service and the patient’s dentist in the oral management of cancer patients would be in the patient’s interest.

Follow-up Radiation patients with head and neck cancer are at lifelong risk for oral disease as a result of their treatment. Dental caries (View Table 5) and periodontal disease are common in xerostomic patients and osteoradio-necrosis (View Table 6) is a serious potential sequela to radiation treatment. The possibility of tumour recurrence or persistence is also significant. These patients are therefore scheduled for their follow-up oral care appointments to coincide, wherever possible, with their appointments for review by their oncologist in the Head & Neck clinic.

It is prudent for them to be seen by the dental oncologist at least annually for the first few years. However, for geographic reasons, it may be more convenient for these patients to be seen by their own dentist for any dental care they need. These patients could be seen, when desirable, by the general dental practitioner. By keeping the patient’s dentist informed of the treatment delivered and the means of continuing care upon referral back to the dentist, it would analogous to the manner in which cancer centres seek to involve the primary general medical practitioner into the management of the patient’s medical care plan.

Ideally, head and neck cancer patients should be referred to a well-staffed specialist dental oncology unit for their appropriate care and treatment planning. Other cancer patients with oral complications from their cancer therapy could also be assisted. However, the lack of manpower and funding means that comprehensive total dental care will be unavailable. Until well staffed dental oncology clinics at cancer centres or host hospitals become a reality, the only way to provide an improved service is to involve the patient’s dentist. General dental practitioners should grasp this opportunity and play a bigger role in the oral health care of cancer patients. An educational campaign to facilitate this is urgently required. There is more that dentists can do, besides the early detection of mouth cancer.

TABLE 1: ORAL COMPLICATIONS OF CANCER TREATMENT General nausea and vomiting (early onset) dental demineralisation altered taste (starts about 2nd week) mucositis/stomatitis (starts about 2nd week) xerostomia/salivary gland dysfunction (starts about 3rd week) hypersensitive teeth (early and delayed onset) burning mouth bacterial, viral, or fungal infection (secondary infections) erythema and oedema of skin, facial tissues nutritional compromise, dysphagia altered development in the child patient (delayed onset) difficulty chewing and reduction of chewing power altered speech altered social function Treatment-specific Radiation therapy post-radiation dental caries (delayed onset) muscle trismus/tissue fibrosis (delayed onset) osteoradionecrosis (delayed onset) Chemotherapy neurotoxicity bleeding

TABLE 2: MANAGEMENT OF MUCOSITIS Avoid tobacco and alcohol Gentle oral hygiene Floss your teeth after each meal. Be careful not to cut the gums. Brush your teeth after each meal. Use an ultrasoft, even-bristle brush and a bland toothpaste preferably containing fluoride (e.g. BioXtra Toothpaste, Biotene Toothpaste). Brushing with a sodium bicarbonate - water paste is also helpful, Arm & Hammer Dental Care toothpaste and tooth powder and Sage Mouthpaste dentifrice are bicarbonate based. If a toothbrush is too irritating, cotton-tip swabs (Q-tips) or foam sticks (Sage Ora-Swab or Toothette) can provide some mechanical cleaning. Use a barrier forming mouthwash (e.g. Gelclair, Aloclair). Some commercial rinses containing chlorhexidine have been shown to worsen established radio-mucositis besides altering taste and staining teeth Therefore, their use in treating mucositis is not recommended. The adverse effect is mostly extreme pain due to the alcohol content of these rinses. Rinse with an antiplaque solution two or three times a day when you cannot follow other oral hygiene procedures. A pulsating water device, e.g., Water-Pik, irrigators, will remove loose debris. Use warm water with 1/2 teaspoonful each of salt and baking soda and low pressure to prevent damage to tissue. Use custom made, flexible vinyl trays for self- application of fluoride gel to the teeth for five minutes once a day after brushing. (Stannous fluoride gel 0.4%, put 7 to 10 drops in a custom tray and cover teeth for 5 minutes every day. Gel must not be swallowed.) PTA lozenges (Polymyxin E, Tobramycin and Amphotericin B): This medication should be started two days before therapy and continued during radiation (generally fractioned irradiation with a total dose of 64 Gy or more). It has been proved to reduce duration and degree of mucositis in patients irradiated for oral carcinoma. Sodium bicarbonate mouthwash Rinse with a warm, dilute solution of sodium bicarbonate (baking soda) or salt & bicarbonate (also commercially available as Sage Salt & Soda Rinse) every two hours to bathe the tissues and control oral acidity. Two teaspoons of bicarbonate (or one teaspoon of table salt plus one teaspoon of bicarbonate) per quart solution is recommended. Benadryl elixir - Benzydamine hydrochloride is a nonsteroidal drug with anaesthetic, anti-inflammatory and antimicrobial properties which reduces the severity of radio-mucositis). Topical steroids Orabase or Milk of magnesia or Kaopectate (as a coating gent to protect ulcerated area) Soft and non-irritating foods A bland and liquid diet avoiding alcohol, caffeine or any other irritant such as tobacco products. Food should be lukewarm. Maintain hydration Use humidifier, vaporizer A humidifier in the sleeping area will alleviate or reduce night time oral dryness.

TABLE 3: MANAGEMENT OF XEROSTOMIA If the mouth is dry, advise sipping cool water frequently (every ten minutes) all day long. Allowing ice chips to melt in the mouth is comforting. Artificial salivas, e.g., Sage Moist Plus spray, Moi-Stir, Salivart, Xero-Lube, Orex, can be used as frequently as needed to make the mouth moist and slick. A mouth moisturizing gel, i.e. Sage Mouth Moisturizer or OralBalance saliva replacement gel may be helpful when applied to the gums. Keep the lips lubricated with petrolatum or a lanolin- containing lip preparation (e.g. BioXtra moisturising gel). Commercial mouthrinses with alcohol bases, coffee, tea and colas with caffeine should be avoided, as they tend to dry the mouth. Use an alcohol free mouth rinse with added flouride (e.g. BioXtra alcohol free mouth rinse, Biotene mouthwash). Sugarless lemon drops e.g. Saliva Stimulating Tablets (SST) Sorbitol- or Xylitol-based chewing gum (e.g. BioXtra chewing gum) Pilocarpine (Salagen, 5mg. tds)

TABLE 4: MANAGEMENT OF SECONDARY INFECTION Culture Cytologic study Antibiotics Acyclovir Antifungals If a fungal infection develops, antifungal medications can be prescribed. Nystatin pastilles; let one dissolve in the mouth five times a day, or Let a 10 mg clotrimazole (Mycelex) troche dissolve in the mouth five times a day, Swish with Nystatin oral suspension for two minutes timed by a clock. Either spit out or swallow, as directed by your dentist or physician. Diflucan (Fluconazole) tablets 100 mg., 1 tablet per day for 4 days then 1 tablet every 3 days. Ask the patient to mix 1 part of hydrogen peroxide in 6 parts of warm water and add a dash of salt. Instruct to intraorally swish this mixture for 2 to 4 minutes several times a day. This is a good alternative to chlorhexidine.

TABLE 5: MANAGEMENT OF RADIATION CARIES Oral hygiene procedures Topical fluoride gel (e.g. Colgate Gel-Kam) Flouride mouthwash (e.g. Colgate Flouriguard) Frequent dental recall Restore early lesions

TABLE 6: MANAGEMENT OF OSTEORADIONECROSIS Avoid trauma to mucosa Avoid extractions Irrigate with saline, antibiotics Hyperbaric oxygen, tetracycline antibiotics Resection

References

1. Toth BB et al. Minimizing Oral complications of Cancer Treatment. Oncology, 1995; 9, No 9 (September 1995)
   
   
2. Feber T. Management of mucositis in oral irradiation. Clin Oncol (Royal College of Radiologists) 1996; 8:106-11.
   
   
3. Calman, K., Hine, D. A Policy Framework for Commissioning Cancer Services. Dept. of Health, April 1995.
   
   
4. Clinical Guidelines: The Oral Management of Oncology Patients, Faculty of dental Surgery, Royal College of Surgeons of England.

Last modified: Thursday 31 Jan 2002