More than one third of patients undergoing treatment for cancer develop oral side effects, such as painful mouth sores and dry mouth. At times, these effects may be severe enough to have an impact on a patient’s quality of life, or to even interrupt treatment and affect outcome. But the risk of these complications can be minimized, according to Joel B. Epstein, DMD, MSD, Director of Oral Medicine, Division of Otolaryngology and Head and Neck Surgery at City of Hope National Medical Center, Duarte, Calif.
The painful mouth sores and dry mouth often associated with chemotherapy and radiation “not only make eating and speaking difficult,” says Dr. Epstein, but also put patients at higher risk for dental disease, especially tooth decay. Chemotherapy may result in short-term side effects until the oral tissues and bone marrow function recover, and radiation therapy used in the head and neck area “has the potential to cause lifelong effects... contributing to oral health problems.”
When it comes to minimizing oral complications, prevention based on a team approach to treatment is best, says Dr. Epstein, who was at one time the president of the American Board of Oral Medicine. “Oral side effects often result when a person’s mouth is not healthy prior to cancer treatment. Ensuring dental and oral health should take place as the cancer treatment is being planned and as soon as possible before it starts, so there is adequate recovery time from any necessary dental procedures."
“Options that include dental surgery should be limited during and after cancer therapy, and are best planned with the oncologist and conducted prior to cancer therapy in a manner that promotes rapid healing,” Epstein explains. He says the first step to protecting the patient’s oral health during cancer treatment is a complete dental examination to plan treatment “with a team of experienced healthcare providers who have an understanding of both cancer therapy and oral health.”
Healthcare providers should also give detailed instructions to patients on caring for their teeth while undergoing treatment, and on recognizing signs of oral complications. For patients at high risk for tooth decay, custom-made mouth trays can be used to apply high-potency fluoride gel. An antibacterial rinse can be recommended prior to cancer treatment to reduce bacterial contamination of the mouth.
“If dry mouth does develop, salivary stimulation medications or a saliva substitute may be recommended to help prevent tooth decay,” says Dr. Epstein. These medications or substitutes allow the patient to eat more comfortably, lessening the likelihood of compromised nutrition.
Patients should be advised to brush their teeth gently twice daily, with a very soft brush and fluoride toothpaste, and to floss between the teeth. “In addition to any prescribed rinses," Epstein continues, "a weak solution of salt and baking soda (one quarter teaspoon of each in a quart of warm water) may be soothing for a sore mouth.” Patients should be advised to avoid mouth rinses that contain alcohol, which may be drying and cause stinging.
Dr. Epstein says it is essential to keep the mouth moist, so patients should be encouraged to drink plenty of water. Patients may also find it helpful to dissolve ice chips in their mouths. Gum that contains xylitol, which actively prevents tooth decay, can also be used to promote salivation. (My childhood dentist must be spinning in his grave at the suggestion that any chewing gum be used under any circumstances.)
Finally, says Dr. Epstein, good nutrition is important to support healing tissue and to maintain health status. And of course, alcohol consumption and tobacco use should be eliminated or at least reduced.
All of Dr. Epstein’s recommendations make sense to me. But to what extent are they implemented in the real world? How common is collaboration between medical oncologists and non-physician oral health providers regarding treatment plans? Has passage of the Affordable Care Act had any impact in this regard? How do you help your patients deal with the oral complications of cancer treatment?
- Epstein, JB. Oral health during cancer treatment: Proper dental care can prevent severe side effects. Dear Doctor, 2012;Vol. 6, Issue 2: 28-29.