Wouldn’t it be great if no one had to experience cancer and the emotional, physical, and financial turmoil it causes in a person’s life? Sadly, there will continue to be cancer diagnoses and treatments, so as health-care providers, we must understand the possible side effects and collaborate with the medical community to help alleviate poor oral health outcomes as much as possible for this population.
Oral complications from cancer therapies are more common than most people realize and are not limited to treatments that target head and neck cancers. In fact, about 40% of patients who receive chemotherapy, nearly 80% who receive stem cell transplants, and almost all who receive head and neck radiation experience oral complications.1 These could include, but are not limited to, oral mucositis, dry mouth, caries, osteoradionecrosis, periodontal disease, nerve damage, increased bleeding, dry mouth, a change in taste, inflammation, trismus, candida, dysphagia, and pain.2 Some of the side effects will subside, but for many patients, there are long-lasting poor health outcomes. We need to connect with oncologists, educate them about what dental professionals can offer, and start using a noninvasive treatment during active cancer therapies.
Since many people experience cancer treatment oral side effects, it is recommended that they see their dentist at least one month before undergoing treatment to address all oral infections and complete any invasive treatment, at least 14 days before head and neck radiation therapy starts, and seven to 10 days before myelosuppressive chemotherapy begins.3 Even with the best of intentions, this does not always happen, and typically any dental treatment will need to wait until after cancer treatments are completed.
According to Kris Potts, BS, RDH, FAADH, owner of Oral Health Promotion Strategies, prevention or “prehabilitation concepts” as she refers to them, are very important in helping to decrease the oral effects of cancer therapies. Jill Meyer-Lippert, RDH, of Side Effect Support, said, “Many times cancer patients are not advised to go to the dentist before treatment. We need to think about all cancer patients, not just those who are caries prone. Even if we see them before treatment, things change during treatment.”
Susan Cotten, BS, RDH, OMT, and the creator of the Cotten Method of oral cancer screening, suggests, “We should see cancer patients once a week and be proactive. Things happen so fast in the mouth, and we have to stay on top of it.” She recommends having a dental hygienist in every cancer treatment facility. They could look at the status of the mucositis and other sores and apply silver diamine fluoride as needed after a consultation.
Oral side effects from cancer therapies can be painful (especially mucositis) and affect a person’s ability to perform oral hygiene, eat, sleep, drink, talk, and swallow, which affects overall nutrition and health as well as quality of life.4 There is often dentinal hypersensitivity, which can be the result of vomiting after chemotherapy.2 Oral complications increase the risk of treatment delays, may affect dosages of the therapies, and can increase the need to stop treatment altogether, thus influencing treatment outcomes. Salivary glands can also be affected, resulting in a decrease of saliva, which increases the risk for oral infections.
These patients need good nutrition but often cannot tolerate eating, so they may drink “health shakes.” Many health shakes have a high sugar content, and when combined with poor oral hygiene and a reduced salivary flow, they can greatly increase the risk for caries. Patients will likely be doing little if any chewing and subsequently will build up more plaque biofilm than normal. Combined with the sugar, lack of saliva, and poor oral hygiene, this is a recipe for disaster in the mouth.
Even though these patients have oral side effects, we generally do not see them during active cancer treatment and many do not see a dental professional before their cancer treatment begins. According to Potts, patients are most vulnerable to infection when they are in the nadir phase (Latin for lowest point) and their white blood cell count is low. She says this is the time when it is not advised to undergo dental treatment because anything that can initiate bleeding or introduce bacteria is not recommended.
It is recommended that fluoride trays be used during and after cancer therapies. Meyer-Lippert explains that patients often have difficulty wearing trays and have a hard time tolerating them because of an increase in their gag reflex, or they have mucositis, which makes it painful to wear the trays. Using SDF as an adjunct can alleviate some of this stress, which is better for healing. If a patient undergoes radiation to the head and neck, hopefully the person will be advised to wear a guard or splint if they have amalgam. The radiation hits the metal, which results in backscatter radiation, which increases the incidence of mucositis and can alter the treatment schedule.5
Even if a cancer patient should not receive traditional dental treatments, we shouldn’t let them suffer with a toothache, sensitive teeth, or mouth sores. If there is infection, either tooth or periodontally related, these patients are at higher risk for poor outcomes and complications while undergoing cancer therapies. Even if custom fluoride trays are recommended, it is likely that the patient will not be able to tolerate these trays once mucositis sets in. If they are in nadir, traditional dental treatments will be out of the question. Fluoride trays depend on patient motivation. Patients may have difficulty wearing them throughout treatment; they may need to take breaks if nausea, tissue tenderness, or ulcerations become an issue.
What can we do?
I propose that we see cancer patients for noninvasive silver diamine fluoride treatment before, during, and after their cancer therapies to help stop the progression of carious lesions, prevent new carious lesions, alleviate sensitivity, and decrease biofilm. Sometimes cancer patients are told not to use a toothbrush or clean interproximally, but new studies dispel this advice. We know what happens when they’re not able to clean—higher numbers of bacteria and biofilm demineralizing the tooth. What about periodontal health if they can’t perform good daily oral hygiene? This leads to perio issues, increased probability of inflammation, infection, abscesses, poor healing due to a compromised immune system, more bacterial growth, and more dental disease. It’s a vicious cycle, and that’s why it’s imperative to adopt Potts’ “prehabilitation concepts.”
Cotten says that not only are patients who have head and neck radiation treatment extremely susceptible to osteoradionecrosis, but they will likely have lifelong side effects from the treatment. She says that these patients will probably have difficulties swallowing and that there can be damage to the epiglottis, which increases the chance of aspiration. I learned from Cotten that patients who have had radiation to the neck have an increased possibility of damage to the baroreceptors in the carotid artery. This can also occur in patients who have had chest radiation, head and neck surgery, and strokes that involve the brainstem nuclei.6
This damage can cause baroreflex failure, which makes it more difficult for these patients to maintain their blood pressure, increasing the incidence of syncope, hypotension, and labile hypertension.6 It is likely that they cannot tolerate being supine, may have limited opening, may not be able to endure water sprayed in their mouth, might be susceptible to choking and aspiration, and could be at high risk for a medical emergency. It is likely that these patients will require short appointments that are not invasive, with treatment plans that may need to be altered and include SDF.
Is SDF for adults?
You may have heard that SDF is only for kids and deciduous teeth that will eventually fall out. SDF can be for anyone, and research is proving that. Even though it does not fix form and function, an arrested lesion is hard and resistant to acids. Because it is noninvasive, SDF could be an option while a patient is still undergoing cancer therapies. (Be sure to consult with the patient’s oncologist.) SDF offers the ability to relieve pain and stress and can be an interim treatment to gain some time until dental restorative treatment can be done.
SDF for patients undergoing active cancer therapies is an innovative treatment, as most of these patients are not seen by dental professionals during treatment. To date, there are no known studies that have been done on SDF for this group. If a patient is receiving head and neck radiation, they might be told to wear a protective guard during the sessions if they have amalgam fillings. This may be true of SDF since silver is one of its ingredients, but to be safe, always consult with the oncologist.
SDF guidelines
It is important to check with your board of dentistry regarding scope of practice for dental hygienists to apply SDF. It is important to show patients color photos of SDF after treatment, explain the benefits and contraindications, and sign a consent form. The application is quick, easy, and noninvasive. But care must be taken if a patient is already suffering from mucositis, and the practitioner must not allow the SDF to touch the affected surfaces.
Great care should be taken when working with SDF as it can easily spread in a patient’s mouth if accidentally bumped during application or handling. If there is mucositis, you can cover the sore with Vaseline and gauze to help prevent the SDF from getting on the lesion. If it does get on the lesion, it will likely result in a burning sensation. Always check with the oncologist before any treatment such as SDF and fluoride varnish.
SDF is not a cure for dental caries, but it can offer an option to help cancer patients while they’re actively going through cancer treatment when they otherwise could not receive dental care. It is also a great tool during the COVID-19 pandemic because it can be applied without creating any aerosols. We are at a crossroads with dental and medical interprofessional collaboration and need to move forward to take the best care of our patients and allow for the best health outcomes possible, and this includes having a dental hygienist in every medical facility.
Using SDF in nondental facilities can be a method to use teledentistry, which can increase access to care for patients undergoing active cancer therapies. We know that cancer is not going away anytime soon, and many patients suffer from oral side effects from treatment. We need to start thinking differently about dental care and cancer patients. Now we have more options in our toolbox with the addition of SDF.
How to learn more
For more information on oral cancer, oral effects from cancer treatments, prevention, prehabilitation, speaking schedules, or to ask one of them to speak at your next event, contact Susan Cotten, Jill Meyer-Lippert, or Kris Potts.
Susan Cotten, BS, RDH, OMT, owner, Oral Cancer Consulting
- Facebook: facebook.com/SusanCottenRDH
- Instagram: @scottenrdh
- oralcancerconsulting.com; [email protected]
Jill Meyer-Lippert, RDH, founder, Side Effect Support; Community relations manager, Custom Dental Solutions
Kris Potts, BS, RDH, FAADH, owner, Oral Health Promotion Strategies; oral-systemic health advocate
Author’s note: I like using Elevate Oral Care’s Advantage Arrest SDF and FluoriMax varnish. FluoriMax is 2.5% sodium fluoride versus the 5% most other varnishes contain, and it’s not made from tree sap. For more information, visit elevateoralcare.com/site/images/FMVA020819.pdf. For videos and research on SDF, visit elevateoralcare.com/Landing-Pages/silverbulletinv9. If you have never applied SDF or want to learn more about the procedure, contraindications, benefits, and risks, contact Elevate Oral Care and schedule a lunch and learn.
References
1. Dental and oral complications of cancer treatment facts. Leukemia and Lymphoma Society. Revised September 2016. https://www.lls.org/sites/default/files/National/USA/Pdf/Publications/FS29_Dental_and_Oral_Fact_Sheet_FINAL_9.2016.pdf
2. Oral complications of chemotherapy and head/neck radiation. National Cancer Institute. https://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat/oral-complications-hp-pdq
3. Oncology pocket guide to oral health. September 2009. National Institutes of Health National Institute of Dental and Craniofacial Research. https://www.nidcr.nih.gov/sites/default/files/2017-09/oncology-guide-oral-health.pdf
4. Chemotherapy. 2016. College of Dental Hygienists of Ontario. https://www.cdho.org/Advisories/CDHO_Factsheet_Chemotherapy.pdf
5. Katsura K, Utsunomiya S, Abe E, et al. A study on a dental device for the prevention of mucosal dose enhancement caused by backscatter radiation from dental alloy during external beam radiotherapy. J Radiat Res. 2016;57(6):709–713. https://doi.org/10.1093/jrr/rrw092
6. Aung T, Fan W, Krishnamurthy M. Recurrent syncope, orthostatic hypotension and volatile hypertension: think outside the box. J Comm Hosp Internal Med Perspec. 2013;3(2). https://doi.org/10.3402/jchimp.v3i2.20741
KYLE ISAACS, BHS, RDHEP, is an expanded practice dental hygienist (EPDH) at the Benton County Oregon Health Services building, where she provides dental hygiene care. Isaacs writes a monthly column for the county newsletter about different oral health topics for a nondental audience. She has gone into long-term care facilities, schools, and medical offices to provide preventive services, but these outreach mobile clinics have been put on hold during the pandemic. Isaacs is a speaker and can be reached at [email protected].
