Dental care in patients during cancer treatment

Lesions within the oral Cavity that develop in cancer patients constitute a serious problem both medically, and emotionally. Severe pain that is observed in the patients makes it impossible for them to eat, speak, or use dentures. Very often, escalation of the lesions and reaction to treatment both depend on the original state of the oral cavity before chemo- or radiation therapy.

Dentists who work at the Dental Clinic at St. Wojciech’s Hospital in Poznan know perfectly well, how strict cooperation with an oncologist is and how important it is to start appropriate prophylactic measures that prevent from the development of side-effects within the oral cavity.

If a Patient who is scheduled for cancer treatment, arrives at our Clinic, our dentists recommend that the Patient should take a panoramic x-ray in order to facilitate the decision-making process while preparing the Patient for treatment.

It is of utmost importance that all sources of infection be eliminated: residual roots should be extracted, teeth that in short-term should cause complications (significantly destroyed, with deep caries, at advanced periodontitis stages – bone loss exceeding 5 mm, with periapical lesions).

Careful preparation of the Patient plays an extremely important role in the prophylaxis of complications after chemo- and radiation therapy.

Full-mouth disinfection should be performed approximately 3 weeks before cancer treatment commences. The term full-mouth disinfection denotes the removal of potential infection foci from the oral cavity.

The procedure should include:

• very careful oral examination with radiographic evaluation concerning the teeth and periodontium
• treatment of all caries lesions,
• replacement or adjustment of improper restoration,
• supra- and subgingival scaling,
• treatment of gingivitis and mucositis,
• informing the Patient that there is an absolute necessity to maintain appropriate oral hygiene and to use increased fluoride prophylaxis (fluoridation),
• extraction (pulling out) hopeless, destroyed teeth with poor prognosis (that cannot be treated),
• temporary removal of removable dentures and orthodontic appliances.

Surgical treatment should be performed at least 10-14 days before the planned radiation and/or chemotherapy. It is indicated that the procedures be performed in antibiotic prophylaxis.

Reduction in oral complications during cancer treatment is possible provided that the Patient follows the advice of the Dentist.

Information for the patient:

• careful meticulous tooth brushing, brushing the gums, and the tongue after each meal and before going to sleep using an extra-soft toothbrush and fluoride-containing toothpaste
• continuation of fluoride prophylaxis (individual trays filled with fluoride-containing gel, varnish application),
• very careful interproximal cleaning with dental floss; if bleeding is observed, dental clinician should be contacted immediately and flossing should be stopped,
• drinking small amounts of water frequently, sucking on ice cubes, candy, chewing sugar free and fragrance-free gum,
• rinsing the mouth with clean, previously boiled water or flaxseed infusion, which provides moisture to oral mucosa, professional mouthrinses should be avoided
• lubrication of dried lips with clear Vaseline and abstaining from the use of lipsticks,
• removing orthodontic appliances and braces for the night, or total abstaining from their use
• abstaining from eating spicy and acidic food, total abstinence from drinking alcohol and smoking.

For the whole duration of radiation and/or chemotherapy, contact with the dental clinician is necessary, as the dentist will initiate specialist diagnostics and care if the symptoms are severe.

Cancer treatment is related to a variety of side-effects and to reactions that occur early or at delay and that destroy healthy tissues.

The most frequently observed “dental” complications of radiation therapy include inflammatory lesions within the oral mucosa which are referred to as “mucositis”. Damage to mucous membrane involves pain, erythema, and ulcerations. Mucositis appears within a few days after cancer treatment begins.

The course of complications within oral mucosa can be classified into four phases: inflammatory, epithelial, ulcerative-bacterial, and healing. Other consequences following radiation therapy, which are also called critical, as they influence the quality of life, include:

• opportunistic infection (fungal infection, Herpes),
• radiation caries,
• periodontitis,
• trismus,
• taste disturbances, dysphagia,
• osteoradionecrosis.

Several side-effects of cancer therapy within the oral Cavity do not appear during or directly after treatment, but come to light even a few months after treatment is completed. This complicates and makes rehabilitation longer after treatment of the basic disease is accomplished. This also constitutes an open pathway for infection of the human body.

Thanks to correct, daily oral hygiene it is possible to reduce the increase in duration of side-effects of cancer therapy.

Soft toothbrush, fluoride toothpaste (but without large amounts of detergents, particularly laureth sulphate which irritates mucosa, i.e. the one for children) should be performed twice or three times a day.

Toothbrush can be soaked in chlorhexidine solution (ATTENTION! The one that does not contain alcohol). After brushing, saline is best used for rinsing (or homemade salt solution – ¼ teaspoon for 250 ml water). Also during the day, it is advisable to rinse the mouth with saline or baking soda solution. These procedures do not irritate tissues, improve blood circulation and nutrition. They make it possible to moisturize the tissues, inhibit the accumulation of food residue, and enable the patient to rinse and dilute thick (due to therapy) mucous that covers oral mucosa. It is forbidden to use ready-made mouthrinses that contain alcohol. Also, hydrogen peroxide is not indicated for daily hygiene. Such solutions may irritate mucosa and intensify the feeling of dryness.

Solutions that contain chlorhexidine should be used carefully, also periodically and under the supervision of a clinician. Under no circumstances can they replace tooth brushing for a longer period of time. Out of all herbs, chamomile is safe.

Flossing should be performed once daily, and is best performed with waxed floss. Bleeding from papilla should motivate to make a break in cleaning for two or a few days (whereas other spaces should be cleaned).

It is important to use fluoride varnishes with high fluoride content. Such contact fluoride should be performed once daily. It reduces the very destructive radiation caries. Using nutritious cream on chapped lips is indicated. Lipsticks containing Vaseline and petroleum should be avoided, as they have dehydrating properties.

Removable prosthodontic restoration – if possible – should not be used for the duration of treatment. In other cases, they should be removed overnight and soaked in disinfecting solutions.

In most cases, various mouthrinses are used to alleviate mucositis. Saline and baking soda solution used every 30 minutes is effective. A 1:4 hydrogen peroxide is effective in treating erosions and ulcerations for the removal of necrotic tissues that remain on the surface. Daily use of such mouthrinses is deleterious. Pain reduction can be achieved by using local anaesthetic gels (Lidocaine, Benzocaine).

Caries risk, mainly due to impaired functioning of salivary glands, should motivate the patient to reduce sugar intake or replace them with aspartame, acesulfame, sorbitol or xylitol. Consumption of foods with spicy, irritating spices should be limited, as should be the consumption of very hot foods. Warm or tepid food is preferred, and mild taste, with minimal amounts of spices.

Fruit juices should be avoided, particularly made of fresh fruit, both due to their sharp taste, and the risk of enamel erosion. The Patient should limit drinking coffee, tea, and foods that increase thirst (dry cookies, salty biscuits, crisps). Thirst should be quenched by drinking mineral water and mild herbal teas.

During therapy, it is absolutely forbidden to drink alcohol and smoke. They aggravate oral lesions, and block appetite, which leads to vitamin deficits (B1, B6, B12, C).

Changes in white blood cell count that accompany cancer treatment, along with diminished protective saliva properties, predispose the patient to fungal infection. The easiest way of preventing such infections includes frequent mouth rinsing with baking soda solution (¼ teaspoon per 250ml of warm water).

0.12% chlorhexidine solution is effective at preventing infections. The mouth rinse should not contain alcohol. It should be used 30 minutes before and 30 minutes after other hygiene-prophylaxis procedures. Chlorhexidine is not effective in the presence of nystatin or toothpaste. It controls the development of bacterial plaque, fights inflammation and the results of impaired functioning of salivary glands. Patients should be very careful while using them. Such solutions may influence microorganisms, which, due to the coexistence of immune system deficits, may destroy the oral ecosystem and delay the healing of pathology within oral mucosa.

If salivary glands are not completely destroyed (particularly due to radiation therapy over the course of head and neck malignant lesions), an increase in salivary flow can be achieved both by mechanical and gustatory stimulation.

For daily stimulation of salivary glands, one can use various kinds of sugar free chewing gum and tablets. Stimulating salivary glands at home can be achieved at home also by sucking on lemon zest, dried plums, frozen pineapple or cucumber slices (cold relieves tingling which is observed in Patients with dry mucosa).

If, however, salivary glands have been destroyed, alleviation of the results of xerostomia can be achieved by the use of products, gels, mouthrinses, and saliva substitutes that are ready made, available at the chemist’s, or made at home.

The easiest way is frequent rinsing the oral Cavity with saline, warm flaxseed or mallow infusion, as well as covering oral mucosa with aqueous vitamin A solution. They provide relief and Temporary feeling of moisturising of mucosa, and plant fluids protect oral mucosa.

Preparations that substitute saliva (the so-called artificial saliva) relieve the feeling of dryness but, at the same time, contain additional substances that are present in natural saliva. That is how they make up for the deficit of these substances.