The Indian Council of Medical Research (ICMR) announced in its projection in 2016, that the total number of new cancer cases is expected to be around 14.5 lakh and the figure is likely to reach nearly 17.3 lakh new cases in 2020. Dental care for these patients during/after chemotherapy and radiotherapy is critical. At Smayate Dental Clinic we specialize in treating dental issues for all types of cancer patients.
DENTAL CARE PRIOR TO CANCER THERAPY – AT INITIAL DIAGNOSIS
- DENTAL CHECKUP – The oral assessment must include a radiographic survey for both patients with teeth and also for patients without teeth.
- PREVENTIVE CARE – The use of an aqueous alcohol free chlorhexidine mouthwash or dental gel will contribute to the treatment of gingival disease in combination with improved oral hygiene practices.
- RESTORATION OF TEETH – Where time permits it is preferable to restore teeth with a permanent restorative material. When time is limited glass ionomer cements make an effective provisional restoration. Sharp teeth or restorations can be particularly uncomfortable during the period of mucositis. They can contribute to soft tissue damage and ulceration. They should be appropriately adjusted.
- CARE FOR DENTURES AND OBTURATORS – Dentures or obturators are uncomfortable during the period of mucositis. The patient may wish not to wear dentures during this time. Those who discontinue the use of their dentures often experience problems with denture stability when they return to them, probably as a result of adaptation loss. Obturators must be worn since wound contraction can occur within hours of removal. They must be examined by a member of the dental team if painful.
- EXTRACTION OF INFECTED TEETH – Patients are particularly at risk of ORN (osteo-radionecrosis) when tooth extractions are undertaken both immediately before and after radiotherapy. Extractions should preferably be undertaken up to three weeks prior to the commencement of treatment. Ten days should be considered a minimum period. Patients about to undergo bone marrow transplantation should have any appropriate teeth removed at the time of the bone marrow harvest. Children should have all primary teeth within three months of exfoliation and those with any risk of pulpal involvement removed. Permanent teeth with a doubtful prognosis should be removed. It should be borne in mind that permanent teeth with non-symptomatic periapical lesions are rarely exacerbated by cancer therapy. Judgement needs to be made on overall prognosis. vi. All teeth in direct association with an intra-oral tumour should be removed. Teeth should be removed with a minimum of trauma and if possible primary closure achieved.
- ORTHODONTIC TREATMENT – Children undergoing orthodontic therapy should have their orthodontic appliance removed and treatment discontinued until one year after completion of cancer therapy.
DENTAL CARE DURING CANCER THERAPY
- MUCOSITIS – The period of mucositis is extremely unpleasant. It usually subsides in 8-10 days. Difflam (benzydamine hydrochloride mouthwash( 15%) reduces the frequency and severity of mucositis and is recommended. A regime of 15ml four to eight times daily starting before radiotherapy and continuing during and for two to three weeks afterwards is recommended. Oral cooling for 30 minutes prior to chemotherapy is recommended where mucositis inducing chemotherapeutic agents are used (e.g. 5- FU).
- ORAL CARE – Normal daily toothbrushing by the patient, along with a use of floss or interdental brushes. If brushing becomes very painful a very soft brush (e.g. TePe Special Care Toothbrush) can be substituted but normal toothbrushing should be resumed at the earliest opportunity.Chlorhexidine is an effective antibacterial and is available in concentrations 0.12-0.2% mouthwash. It is important to use the alcohol free preparations. 10ml should be rinsed round the mouth for 1 minute then spat out, twice daily. Thirty minutes should be allowed between use of chlorhexidine and toothbrushing. The 0.2% concentration may be diluted 1:1 with water if it causes mucosal discomfort.
- DENTURE CARE – Dentures should be rinsed after meals and cleaned at least once daily by brushing with a toothbrush and soaked in chlorhexidine mouthwash overnight. An alternative is dilute sodium hypochlorite solution (Milton‘s diluted 1 in 80) provided there are no metal components. Dentures should not be worn at night.
- CARIOUS PREVENTION – The importance of preventing dental caries cannot be overemphasised. Cariogenic food supplements (e.g. Fortisips, Nutricia) should be monitored. Rinse the mouth after intake of even sugary medication. Adults should use an alcohol free fluoride mouth rinse at least once daily (0.05% NaF, ) at a different time from brushing. In addition they should be prescribed 5,000ppm fluoride toothpaste for use twice daily and fluoride varnish (2.2% fluoride) should be applied twice a year. Children and young adults should have fluoride toothpaste, fluoride varnish ,fissure sealants and fluoride mouthwashes appropriate to age.48
- PREVENTION OFFUNGAL INFECTION – Children and adults receiving bone marrow transplants often receive aciclovir as a prophylaxis if there is a high risk of viral infections. This is usually prescribed by the oncology team. There is increased risk of oral fungal infection in patients receiving chemotherapy and/or radiotherapy. Antifungal medication should be used following detection of oral candida. Topical agents may be preferred to systemic agents due to lower risk of side effects. . Nystatin sugar free oral suspension 100,000 units per ml four times daily for at least 7 days and 48 hours after resolution. Miconazole oral gel 24mg/ml 10ml applied four times daily continued for 48 hours after resolution is an alternative. Systemic agents have more consistent efficacy and fluconazole is recommended for moderate or severe oropharyngeal candidiasis or unresponsive infection. The regime is 50mg capsules or suspension daily for seven to fourteen days. Miconazole and fluconazole are contraindicated in patients taking warfarin or statins. Denture hygiene is very important if there is fungal infection; dentures should be cleaned with a toothbrush and soaked in chlorhexidine mouthwash or dilute sodium hypochlorite. Miconazole oral gel should be applied to the fit surface prior to re-insertion, provided it is not contraindicated.
- PALLIATIVE MANAGEMENT – Other palliative management recommended is 2% lidocaine mouthwash used prior to eating . The following should be avoided:
- Hard food, spicy food, strongly flavoured toothpaste: these traumatise the tissues
- Alcohol (especially spirits), tobacco: these exacerbate xerostomia
- Fizzy drinks, acidic fruit and fruit drinks: these contribute to erosion and sensitivity, especially in the dry mouth where there is reduced saliva buffering. Dental treatment should be avoided during the period of cancer therapy because the mouth may be very sore and there is risk of systemic infection during the period of mucositis. If the patient is having chemotherapy the suppressive effect on the bone marrow may cause low platelets, low white cells and anaemia. Therefore special care needs to be taken and timing of interventive dental treatment should be agreed with the haematologists or the oncology team. Pulp treatment of primary teeth during the course of chemotherapy is contra-indicated. Extractions are always contraindicated after radiotherapy to the head and neck area, careful patient pre-treatment assessment and planning should avoid the need.
DENTAL TREATMENT AFTER CANCER THERAPY
Patients on maintenance chemotherapy should have a “complete blood count “done within the 24-48 hour period prior to any proposed dental treatment that might result in bleeding/bacteraemia. The results of such blood tests should be discussed with the patient‘s medical team and appropriate precautions taken.
Patients who have received radiation therapy to the head and neck region are at increased risk of progressive, uncontrolled periodontal tissue breakdown and/or ORN (osteoradionecrosis ). This is likely due to reduced repair capacity of the periodontium following direct irradiation with progressive widening of the periodontal ligament, destruction of the lamina dura and progressive loss of attachment having been reported. Furthermore, the risk of periodontal infection is increased because of radiation induced hyposalivation, the concomitant increased plaque accumulation, and the shift in oral microflora. In the few instances of cyclosporin induced gingival hyperplasia, oral hygiene instructions, supra and subgingival scaling, polishing, and gingival curettage should be carried out in the first instance with this having been found to reduce the need for gingivectomy. Herpes labialis can be a chronic problem. Topical aciclovir (5% cream applied five times daily for five to ten days, starting at first sign of attack) is effective.
Restorations should be simple, functional and provide acceptable aesthetics. Where appropriate, a restorative material with fluoride release should be used. In those patients who have xerostomia related to radiation therapy, cervical caries is problematic and particularly so in those patients who fail to comply with preventive measures. Conservative restorative management of cavitated lesions is to be recommended in the first instance. Full/partial coverage crowns should be provided only when the patient can demonstrate good oral hygiene; caries can quickly progress around the margins of full/partial coverage crowns with the potential for eventual ‗carious amputation‘ of the crown. Should a full coverage restoration be warranted, the margins should be subgingival.
Routine restorative treatment must be delayed until the patient is in remission. Where possible, dental extractions should be avoided in irradiated patients due to the risk of ORN (Osteoo Radio Necrosis). Cancer patients who have received bisphosphonate therapy are also at increased risk of osteonecrosis. Coamoxiclav / amoxicillin (metronidazole in those allergic to penicillins) are generally the drugs of choiceas a prophylactic antibiotic.
Alcohol free 0.2% chlorhexidine gluconate mouthwash is also recommended prior to extractions and the use of low-adrenaline/adrenaline free local anaesthesia may also reduce the risk of ORN and as such their use is recommended. Patients are at particular risk of ORN when:
- The total radiation dose exceeded 60Gy.
- The dose fraction was large with a high number of fractions.
- There is local trauma as the result of a tooth extraction (especially mandibular extractions), uncontrolled periodontal disease or an ill-fitting prosthesis.
- The person is immunodeficient.
- The person is malnourished.
Where there is a high risk of ORN and where it is clinically feasible, serious consideration to root canal therapy and restoration/crown amputation should be made.
Dentures should be avoided wherever possible. Appliances will contribute to plaque retention and oral disease, particularly when there is xerostomia. When dentures are essential to ensure good function following cancer treatment, their construction will aid the ability to chew solid food and, by extrapolation, promote social adaptation and weight gain.
Osteointegrated implants are a useful adjunct to fixed or removable prosthesis provision to improve prosthesis stability.