Oral cancer is an agonizing experience for its victims - tooth loss, altered taste buds, pain, mental depression, etc. The dental management of these patients represents a complex challenge.
Cathy Hester Seckman, RDH
The oral cancer assessment is a routine part of a prophy for every hygienist. We all can tell a story or two of the suspicious-looking lump or patch in a patient`s mouth that worried us for weeks until the oral surgeon`s report came back negative.
Cancer of the mouth and throat, collectively called oral cancer, accounts for approximately 3 percent of all cancers. Thirty-thousand new cases are reported in the United States every year and 3,000 in Canada.
Some hygienists might spend an entire career and never discover a cancerous lesion. Thankfully, most sores, lumps and red or white patches found in the mouth and throat are benign. But when cancer is discovered, what can the hygienist do to help?
Debbie Manne, a hygienist from St. Louis, Mo., knows exactly what to do. She deals with head and neck cancer issues regularly. She has been a hygienist for 23 years, and her husband, Dr. Marshall Manne, is a periodontist with a special interest in oral pathology, a subject he once taught at the St. Louis Dental School. She is also a registered nurse and last year completed a master`s degree in oncology nursing.
"One of the things we get asked about a lot," Manne said, "is oral complications for people getting chemotherapy, or head and neck radiation." The couple founded Oncology Dental Support Services in 1992 to help provide answers. "We work with dentists, hygienists, oncologists, nurses and patients themselves, doing educational services, any kind of oral symptom management we`re able to provide."
Oral cancer patients, Manne says, are very special people. "Not only do they have cancer coming out of the blue at them, they usually have to deal with altered body image, altered function, no taste, no saliva. There are just a whole lot of complicated issues, pain management, psychosocial problems, oral care. It`s a lifelong battle, for whatever time they have left. And, unfortunately, many times oral cancer has already metastasized before it`s diagnosed."
Not every head and neck cancer patient has someone like Manne to help them understand and cope with lifestyle changes. Some patients struggle on their own, unpleasantly surprised by each new problem that crops up.
A lonely battle
Bertha Smith of Mentor, Ohio*, blames her bout with cancer for the loss of many of her teeth, and she fears the aftereffects may take all of them in the end.
She went to an oral surgeon in the early 1980s, complaining of a lump on the side of her jaw that she associated with her wisdom teeth. The surgeon removed two third molars and a second molar, but the lump remained. She lost other teeth in the next few years, but was always troubled by the same lump. A different oral surgeon, her general dentist, and her physician all told her not to worry about it.
Finally, facing other health problems, Smith went to a new physician who sent her to the Cleveland Clinic in October 1996 for comprehensive testing. When the test results were compiled, they revealed cancer of the right kidney. An otolaryngologist she saw there at the same time tentatively diagnosed a granuloma on the right side of her throat.
"I asked them to do a biopsy on my throat after that," Smith says, "and it came back cancerous, too."
Within the next few weeks she underwent surgery to remove her kidney, and another surgery to excise the tumor on her throat. Then she went home for radiation treatments. "They zapped me 30 times, five times a week for six weeks, then they said I didn`t need anything else because it wouldn`t do me any good. I don`t know if that was because it really wouldn`t do any good or because I`m on Medicare."
Two years post-surgery, Smith lives with the physical and emotional effects of her cancer treatment. A retired nurse with no immediate family, she has had to face her health problems with little help from anyone.
"I get along," she says grudgingly. "I write everything down, every doctor`s visit, every prescription, every diagnosis. I have to look out for myself."
Whenever she leaves the house, Smith carries a plastic bag filled with paper napkins. While she`s talking, she must excuse herself every few minutes, turn aside, cough, and spit into the napkins. "I get this mucous buildup in my throat," she explains. "My saliva glands are gone, but the mucous is always there, for some reason. I have to cough and cough until I can get it out. My throat is always sore because of the coughing, and my voice is always so harsh and raspy."
Her worst problems have been with eating. She has lost more than half her teeth, and virtually all of her salivary gland function. "It hurts to swallow because my throat is always sore and my mouth is so dry. And I don`t have enough teeth to chew with, anyway. Most of my food is bland and very soft. I eat a lot of scrambled eggs and creamed cereal. I`m lucky I can still taste it. I guess the radiation didn`t hurt my taste buds. What I usually do is take a bite of food, then a spoonful of yogurt. The yogurt helps the food slide down, then I can take another bite."
Smith worries that her teeth won`t hold up to the strain. "I don`t know how long I can hang onto these teeth. They say that after the radiation your teeth are never the same. Some of them are loose, now, and I worry about cavities because I don`t have any saliva." Her home-care routine includes brushing and flossing after every meal.
A permanent case of dry mouth
Dr. Terrence Wiak, a dentist in Whiting, Ind., is also more familiar with head and neck cancer than most people. He was diagnosed with a squamous cell carcinoma of the right tonsil in July 1995, and underwent surgery, chemotherapy and head and neck radiation.
"It was a pretty rare thing," Dr. Wiak says. "My surgeon at Northwestern Hospital in Chicago only sees about five a year. Mine started with a lump on my neck that I noticed while shaving. I thought I had a swollen lymph node, but three or four weeks later it was still there, and getting bigger. I saw a maxillofacial surgeon, who put me on antibiotics, but it still didn`t go down. A week later I had an endoscopy and biopsy. It showed a Stage II carcinoma on my right tonsil."
Surgery was scheduled a week later. In the nine-hour procedure, a flap was laid exposing the right side of his mandible. The right tonsil, the cancerous tumor and all the lymph nodes on the right side of his head and neck were excised.
Because the surgery was so invasive, it left Dr. Wiak with permanent problems. The inferior alveolar nerve was cut, and the right side of his tongue is permanently numb. His speech is slightly slurred as a result. He also has damage to the brachial plexus nerve, and lives with numbness in his neck, head and right hand. But he shrugs off those problems as minor. "It`s just a natural sequelae of the surgery."
Radiation and chemotherapy began within a few days, and those brought worse problems.
"Oh, that was a son-of-a-gun. It`s hard to even remember that now, because you put things like that out of your mind to keep your sanity. I had chemo every day for three weeks, and at the same time I had 36 radiation treatments, sometimes twice a day."
Dr. Wiak dropped from 200 pounds to 135. He had a feeding tube for four months. And when it was all over with, he was left with the typical consequences of head and neck radiation. "The dry mouth is the worst, because it never goes away. All my saliva glands are gone, and I probably only have 25 percent of my taste buds left. I drink about two gallons of water every day, and I use a lot of products to help me along." His favorites are Oral Balance mouthwash and Biotene toothpaste and chewing gum, all made by LaClede. "I`ve tried a lot of products, and these are ones I`ve found help quite a bit."
Because he is a dentist, Dr. Wiak is very aware of the need for strict attention to oral hygiene. "I brush constantly. In fact, I try not to eat anything unless I can brush immediately. I use a neutral fluoride in a custom tray for 15 minutes every morning and every night. It hasn`t been bad because I`m so scrupulous. I`ve had three or four places with enamel breakdown, but I stay on top of the situation."
The doctors, Dr. Wiak says, tell him there`s a good chance he is cured. "The first two years are the most critical, and after that there`s a 90 percent cure rate. This whole thing was a real shock, because I never smoked or chewed tobacco. I never drank, except socially on the weekends, and there`s no history of cancer in my family. It was a trying experience, a long ordeal, and I`m very happy to be alive. It was so good to get back to work and be able to get around again."
Dr. Wiak, who has practiced general dentistry for 27 years, works part-time now with two associates and three hygienists. "Because of my limitations with numbness, I can`t do root canals and extractions, so I stick with basic operative and crown and bridge."
After his own experience, he is more vigilant than ever with oral cancer screenings. He has discovered two cases of cancer in his own patients, one the same type as his.
Dr. Wiak knew exactly what to do after his diagnosis; Bertha Smith did not, nor do most oral cancer patients. That`s where a health professional like Manne can help.
A patient who sits down with the Mannes for oral care advice might be a referral from an oncologist or dentist, or might be someone whose cancer was first discovered in Dr. Manne`s periodontal practice. The office once diagnosed two cases of oral cancer in a single month.
"One of the things I point out when I`m speaking to nursing and hygiene students," Manne says, "is to be very careful with the oral assessment. Sometimes the cancer can be pretty awful, but sometimes it doesn`t look like much of anything."
The first thing Manne does with a new patient is take a comprehensive health history. "I find out what they know, and what they`re willing to tell me. It`s been my experience that a lot of times a cancer patient doesn`t want to talk about it. Others can give you chapter and verse. Then I contact their physicians. I like to find out what patients have been told about what to expect. Based on the information I get from their oncologist and radiologist, I do a lot of one-on-one teaching with the patient in small increments. I might see them weekly. It depends on their symptoms and problems."
According to Manne, typical problems for cancer patients include xerostomia and mucositis. Severe inflammation of the mucosal lining can happen within one or two weeks of starting radiation. It`s characterized by a reddened, inflamed mouth that can progress into multiple sores or blisters. The inflammation can be extremely painful, can be present throughout the entire mouth, and can last for the entire course of radiation. A patient can also be troubled by reactivation of oral herpes, if they`ve had that in the past, and oral candidiasis.
"Those are things," Manne says, "that come up with radiation because the patients have nothing left to keep it in check. We can also see flare-ups with periodontitis and abscessed teeth, because the patients don`t have the immune system to fight it. When you get that on top of a very dry, sore, mouth, it can be unbearable. And it`s not something you can get to go away."
Treatments for these conditions are palliative. Manne sometimes uses what she calls a "cocktail" mouthwash made up of ingredients like lidocaine, benadryl and milk of magnesia. The patient rinses with one or two tablespoons of the mixture 30 minutes before eating.
Other things that may help are alcohol-free mouthwashes, ice chips, artificial saliva sprays or rinses, warm salt water, baking soda and water, sugarless mints or a clear lubricating jelly.
"I tell my patients to use anything that helps. Whatever they prefer is fine with me. I tell them to avoid alcohol and tobacco and to use a lot of gravy and sauces to coat their food and make it easier to swallow. And they should always drink lots and lots of water."
Loss of taste-bud function can become a serious problem because patients are tempted to sugar their food heavily in order to taste it.
One of the most serious complications for head and neck cancer patients is the risk of osteoradionecrosis after radiation. A mandible, for instance, that is in the direct path of radiation can lose its blood supply and the ability to repair itself. Any trauma, such as a denture sore or an abscessed tooth, that occurs too soon after radiation can spread quickly to the damaged bone.
"The bone has no capacity to fight it," Manne explains, "because it`s basically dead. There`s no way for that bone to regenerate, and the infection literally eats through the bone so the patient can have a spontaneous jaw fracture. It`s very difficult to manage." Treatment for osteoradionecrosis can be incredibly complex, and may include sessions in a hyperbaric oxygen chamber at two atmospheres of pressure for two hours at a time.
Because of the risk for osteoradionecrosis, oncology surgeons suggest any questionable tooth be extracted before radiation begins. Full mouth extractions were recommended in the past, but no longer. Patients with dentures or partials should be asked to do without them for six months after radiation so the traumatized tissue and bone can heal with no load on it.
Long-range follow-up care for oral cancer patients should be comprehensive, Manne states. "Be a very good observer, because a lot of times cancers will come back. These patients have to be watched very closely because they will have dental and oral problems forever."
Every patient who has had head-and-neck radiation should be fitted with a custom fluoride tray and instructed to use it once a day for five minutes. Manne prefers neutral sodium fluoride because it won`t etch porcelain and won`t add any acidity to the mouth.
Survivors of mouth and throat cancer face a lifelong battle to maintain their oral health. They should be encouraged to participate in their own care. They need our help, understanding and support to do that.
*The name and place of residence have been changed to respect the person`s wish for confidentiality.
Cathy Seckman, RDH,is based in Calcutta, Ohio. She recently returned to work as a dental hygienist after working several years as a newspaper journalist.