By Thomas Viola, RPh, CCP,
As any health-care professional will tell you, there are moments during interaction with a patient when time seems to stand still. Having served as a pharmacist for over 30 years now, I have had my fair share of these moments.
However, this moment was definitely different. It did not occur with me clad in my white coat behind the security of a prescription counter of a retail pharmacy or safely immersed in the anonymity of a crowd of attending physicians and medical students during rounds at a hospital.
It happened at the conclusion of a continuing education seminar I had presented recently to dentists and hygienists on cancer, its pharmacologic treatment, associated oral complications, and potential dental considerations.
She had been standing in the background for most of the presentation, leaving and returning on cue to facilitate the service of meals, the removal of empty plates, and the filling and refilling of beverage glasses. When the audience had left and the room was mostly empty, she stood before me and said the words that made time stand still.
“I was just diagnosed with breast cancer,” she said softly. “What should I do now?”
Immediately my brain was flooded with a torrent of information, textbooks I had read, images of neoplasms I had seen, articles I had written, and lessons I had taught to students over the years.
At the same time, I was also inundated with emotion, fears of the future for my family members I knew who were at high risk, hopes I had kept and prayers I had said for those I knew who were currently fighting for their lives, and memories of all of my loved ones who were lost to this tragic disease.
In retrospect, I know I could have, and should have, said something that was much more consoling, more supportive, and more hopeful to this wonderful woman who approached me for my advice after listening to me speak all day.
But the first and only words that came out of my mouth at that pivotal moment were simple, perhaps to a fault.
“When is your appointment with your hygienist?” I stammered.
Most, if not all, people know someone who has or had cancer. Unfortunately, many cancer patients and their families are unaware that cancer treatments may affect the oral tissues and that visiting their dental office is an important part of the overall treatment.
Easing oral complications
Cancer treatments, especially chemotherapy, affect dental treatment planning, prioritization, and timing. While chemotherapy is designed to be toxic to cancer cells, unfortunately, it may also be toxic to normal, rapidly dividing cells, such as those of the gastrointestinal tract and hair follicles. As a result, typical adverse effects of chemotherapy include nausea, vomiting, and hair loss.
However, the mouth is also a prime target for the adverse effects of chemotherapy. Normal cells in the lining of the mouth also grow quickly, so chemotherapy may also halt their growth as well. This slows down the ability of oral tissue to repair itself and may lead to an array of oral complications. Necessary dental treatment and proper oral hygiene prior to, during, and after cancer treatments can reduce the incidence and severity of these oral complications.
Why the concern? Oral complications from chemotherapy can seriously compromise patient health and quality of life. These complications can be so severe that patients may tolerate only lower doses of therapy, may have to postpone treatments, or may have to discontinue treatment entirely. Thus, oral complications may affect a patient’s very survival!
We know that preexisting oral disease has long been associated with increased incidence and severity of oral complications in cancer patients. Unfortunately, many cancer patients do not seek care until oral complications develop.
In addition, many cancer patients may have asymptomatic oral pathologies, such as periodontal disease. These pathologies may lead to life-threatening systemic complications as well, especially for patients on chemotherapy who are also, therefore, immunosuppressed.
Managing cancer patients
Thus, evaluation and management of preexisting oral disease before chemotherapy are critical to overall patient care. Communication between the dental team, the oncologist, the medical team, and the patient is essential in preventing and controlling oral complications from cancer treatment.
A pretreatment evaluation by the dental team should focus on identifying existing disease, stabilizing or eliminating potential areas of concern, and extracting teeth that may pose a future problem. It also establishes a baseline for comparing the patient’s oral health status in subsequent examinations.
Ideally, this pretreatment evaluation should be performed at least one month prior to the start of cancer treatment. This allows sufficient time for adequate healing from any required oral treatment. It also provides sufficient time for the dental team to formulate a proper treatment plan for the patient.
If possible, the dental team should see the patient within 24 hours of referral from the oncologist. The referral and follow-up consultation with the oncologist is critical for obtaining necessary information about the patient’s diagnosis, the type of chemotherapy employed, and the planned sequence of treatments so that any necessary dental treatment can be safely scheduled.
Unfortunately, an often somber consideration for the dental team is understanding that any dental treatment plan hinges on the patient’s prognosis and associated cancer treatment. If the goal of the cancer treatment plan is simply palliation, then the goal of the dental treatment plan may be one that simply focuses on esthetics and reducing any pain and discomfort.
However, if the goal of the cancer treatment plan is to eliminate the cancer with chemotherapy, then the goal of the dental treatment plan is to treat any existing oral pathology before chemotherapy, prevent and treat any oral complications that occur during chemotherapy, and maintain good oral health and address any long-term adverse effects after chemotherapy. In addition, the dental hygienist must educate and work with the patient to formulate an oral hygiene treatment plan with a goal of reducing oral complications while ensuring patient compliance.
One of the most serious oral complications of chemotherapy is oral mucositis. Normal oral mucosa cells undergo complete replacement approximately every 10 days. In addition, normal salivary gland function promotes mucosal health through multiple mechanisms. Chemotherapy directly impairs the replication of oral mucosa cells and salivary gland function.
Mucositis emerges approximately two weeks after initiation of chemotherapy and is usually severe. It often requires medical intervention, including the interruption of chemotherapy. Oral mucositis may be complicated by infection of opportunistic bacterial, fungal, and viral pathogens, especially if the patient is immunocompromised. Treatment of these secondary infections may be complicated by potential drug interactions with chemotherapy drugs.
Another consideration is that, during mucositis, normally occurring oral organisms as well as opportunistic pathogens may easily spread systemically. This may result in potentially life-threatening septic infection, especially, again, if the patient is immunocompromised.
When uncomplicated by infection, mucositis typically heals within two to four weeks after cessation of chemotherapy. Meticulous oral hygiene is essential. Oral rinses with chlorhexidine and atraumatic mechanical plaque removal, including brushing and flossing, are usually recommended. Management of oral mucositis via topical approaches includes the use of bland rinses (saline and/or sodium bicarbonate solutions), mucosal coating agents (antacid solutions), water-soluble lubricating agents for xerostomia (artificial saliva).
Systemic antibacterials, such as amoxicillin, are often used to treat bacterial infections, if they emerge. Unfortunately, the use of antibacterials may create a favorable environment for fungal infection. Topical oral antifungal agents, such as nystatin, are often employed but may have limited efficacy. Systemic agents, such as fluconazole, should be used for persistent fungal infections (especially if the patient is immunocompromised).
In addition to bacterial and fungal infections, patients receiving chemotherapy and radiation are at risk for viral infections, including herpes simplex virus and varicella-zoster virus. Since these infections are often the result of reactivation of an existing virus, prophylaxis with antiviral medications may reduce the incidence of infection.
If topical anesthetics such as lidocaine are not sufficient for pain relief, systemic analgesics are employed. Opioid analgesics are typically used in patients receiving chemotherapy since nonsteroidal anti-inflammatory drugs (NSAIDs) may affect platelet aggregation and directly damage gastric mucosa.
Xerostomia may occur in patients receiving chemotherapy due to suppression of salivary function, but it is almost always not permanent, so treatment is usually palliative. However, xerostomia results in increased salivary viscosity, impaired lubrication of oral tissues, decreased buffering capacity and salivary pH, and difficulty in maintaining oral hygiene, thus increasing the risk for dental caries and erosion. In addition, xerostomia interferes with basic oral functions, such as chewing, swallowing, and speech and, thus, has a significant impact on a patient’s quality of life.
The risk of dental caries is ever present due to the loss of salivary antimicrobial proteins and mineralizing components. In addition, dry mucosa is more prone to bleeding and trauma. Meticulous oral hygiene must be maintained and xerostomia should be managed with saliva substitutes. Caries resistance can be enhanced with the use of topical fluorides, chlorhexidine rinses and remineralizing agents, which are high in calcium phosphate and fluoride. Rinsing with a solution of salt and baking soda four to six times a day will assist in cleaning and lubricating the oral tissues and buffering the oral environment.
Certain chemotherapeutic agents can cause neurotoxicity. This may result in deep, throbbing oral pain that, unfortunately, is also consistent with acute dental pathology. If neurotoxicity is the diagnosis, it typically resolves within a week of discontinuing the chemotherapy.
Pain causes increased morbidity, reduced performance status, increased anxiety and depression, and diminished quality of life. Management of oral pain is particularly challenging because eating, speech, swallowing, and other motor functions of the head and neck and oropharynx are constant pain triggers.
Pain management usually involves the use of opioid analgesics. Dental hypersensitivity may also be an issue for some patients. Topical fluoride and desensitizing toothpastes may alleviate the discomfort.
Although rarely serious, oral bleeds may be a concern for patients who are receiving chemotherapy. Unfortunately, it is common for these patients to be told to avoid the use toothbrushes and dental floss when their platelet counts are low. Lack of routine oral hygiene may increase the risk of plaque accumulation and, thus, the risk of local and systemic infection. Foam toothbrushes, which are often recommended in this situation, do not effectively clean teeth or remove plaque.
While not as severe, other oral complications, such as dysgeusia and dysphagia, may be equally devastating for cancer patients because these complications affect eating and communication, the most basic of human activities. Dysgeusia can be quite problematic for patients who are receiving chemotherapy. Patients may experience unpleasant taste due to direct neurotoxicity to taste buds, xerostomia, and infection. This symptom in general is reversible in patients receiving chemotherapy, and taste sensation returns to normal in the ensuing months. Dysphagia is also common in cancer patients and can predispose them to aspiration and potentially life-threatening pulmonary complications.
Dysgeusia and dysphagia may lead to unfavorable dietary changes and decreased oral intake, which may result in dehydration, malnutrition, delayed wound healing, and decreased resistance to infection. Xerostomia and hyposalivation contribute to these issues. Difficulties with speaking, eating and drinking put patients in social isolation and significantly decrease their quality of life. Patients can become withdrawn and depressed as a result of the difficulties they encounter living with these oral complications.
After those initial words in the meeting room, I finally found the ones I had been searching for. The words I should have said and the words I’m sure my new friend wanted to hear me say. We spoke for over an hour and I made sure I answered every one of her questions in detail. I wanted to give her as much information and as much hope and support as I could.
As we finished our conversation, we shook hands. I looked in her eyes and I saw the fear I had seen so many times before in the eyes of my patients, their families, and my own loved ones. And, for that moment, once again, time stood still. RDH
Thomas Viola, RPh, CCP, is a board-certified pharmacist who also serves the professions of dentistry as a clinical educator, professional speaker, and published author in the areas of pharmacology and local anesthesia. Tom is a member of the faculty of 10 dental professional degree programs and is well-known for his regular contributions to several dental professional journals. Tom has presented hundreds of continuing education courses, nationally and internationally, and has earned his reputation as the go-to specialist for making pharmacology practical and useful for all members of the dental team.