With its new series of educational webinars for oral care professionals, Sunstar connects each month with two experts from different dental specialties to explore home-based oral care from their perspective: the special demands from patients, the specific challenges, and the strategies to overcome those. On June 1st, 2022, the 3rd episode was dedicated to cancer therapy, how it can affect oral health but be supported by oral care. Prof. Carlo Lajolo, MD, DDS, PhD, and Ms. Susan Cotten, BSDH, RDH, OMT, shared their views on the topic.
How is oral health linked to cancer therapies?
Head and neck cancer represent a growing type of cancer in patients, including oral cancer, mainly squamous cell carcinoma, that is treated by major oncology surgery. As a specialist in head and neck cancers, Prof. Lajolo points out how frustrating these cancers are for patients as they affect a part of the body that is used for many different functions: speaking, breathing, tasting, and swallowing. The quality of oral health and quality of life is impaired by the treatment itself but one of the risk factors of oral cancer, alongside smoking and drinking habits, is poor oral hygiene itself.
As a specialist in oral cancer screening, Ms. Cotten emphasizes that early detection is key to the results and the survival of the patient. Hygienists and dentists can play a fundamental role in the early diagnosis. Visual and tactile, extraoral and intraoral evaluation of the oropharynx is gold standard: thoroughly palpating the lymph nodes and glands, assessing any abnormality of the musculature, the thyroid or in the swallowing or persistent hoarseness, followed by an evaluation of the soft palate, the uvula, the palatine tonsils, the posterior third of the tongue – noting any disruption in tongue movement – and finally, the anterior portion of the mouth.
What are the main oral conditions and their associated care?
Salivary glands are often impaired by radiotherapy in the head and neck area, with many side effects. Some of them are severe, life-threatening, like grade-3 and 4 mucositis (1979 WHO classification of oral mucositis), or less severe but still frustrating like hyposalivation and xerostomia. As such, hygienists and dentists can also play a fundamental role in the support of cancer therapy, be it radiotherapy or a combination of radio and chemotherapy.
In the late 80s, Sonis started to hypothesize the pathogenesis of mucositis that can occur during radio or chemotherapy, affecting the mouth but also the digestive
tract. Mucositis affects both the epithelium and the underlying connective tissue, triggering a cascade of inflammatory mediators like TNF-alpha, interferon gamma and many others that cause the formation of potentially extensive ulcers affecting the quality of life of the patient.
Dentists follow the cancer patient before the start of the radiotherapy until the end of it, usually six weeks later, when the daily fractions of the 70 grays are all administered. As such, by working in conjunction with the oncologist, they can proactively address the onset and the severity of the mucositis, by immediately putting the patients on an early regimen of optimal oral hygiene, before oral mucositis even reaches a grade 2 requiring a softer diet, and a fortiori before a grade 4 when the patient must be hospitalized for a parental diet.
Following questions from the audience, Prof. Lajolo answered that patients in later stages of ENT cancer with high radiotherapy doses and adjuvant chemotherapy and those presenting Candida albicans at the beginning of therapy are the 2 most prone categories to an onset of oral mucositis and to a severe form of it. Also, radiotherapists may prescribe bicarbonate solutions as the gold standard to treat oral mucositis. However, in a study he performed, administration of gelX Oral Spray, especially before the onset of mucositis, did also allow its relief.
To learn more about oral mucositis, check out the clinical guidebook developed with Prof. Lajolo here on sunstar.com.
Generally, there is little saliva in these cancer patients, and the quality of saliva also changes during radiotherapy, becoming thicker, and more mucous. Xerostomia not only comes from radio and chemotherapy but also from medications or systemic conditions like diabetes or hypertension that a lot of these patients also suffer from. In clinics, Prof. Lajolo suggests measuring the salivary flow (basal flow and stimulated by citric acid) and further investigating the sensation of xerostomia with questionnaires as sometimes patients can have a normal salivary flow but still feel xerostomia. Often, sugar-free lemon drops or xylitol gums are recommended to stimulate the production of saliva and salivary flow. It is also suggested to not drink sparkling beverages as they can remove mucous and saliva from the mouth. Ms. Cotten adds that there is nothing to totally prevent xerostomia but being proactive, collaborating in a multidisciplinary way, and prescribing salivary substitutes early on is key.
As the salivary flow drops, the physiological clearance of the mouth is altered and deep changes in the microbiota can favor the rise of Candida, an otherwise commensal microorganism of the oral cavity. A swab can be performed to detect colonization by this fungus. There’s no absolute to prohibit this condition from occurring but acting early with drugs or probiotics can reduce its development.
Rampant caries, periodontal diseases, and osteoradionecrosis
Rampant caries typically occur on the apical third of the crown. They are difficult to treat, with poor remaining enamel and dentin structures. Many cancer patients also present a poor periodontal status, many of them being heavy smokers and alcohol abusers. As the patient gets radiotherapy, tooth extraction is a major risk factor oforal osteoradionecrosis of the jaws. The hygienist’s role in treating periodontal disease and caries by using silver diamond fluoride or fluoride trays, and in adjusting the care to the evolution is therefore paramount to keep the teeth in the mouth, delay the need of extraction, and avoid the risk of osteoradionecrosis.
What type of patient management improves oral health compliance in cancer patients?
After the dentist and the hygienist have done a thorough head and neck exam and referred the patient for a biopsy, they should reach out to the patient’s oncology team to let them know they want to be kept abreast of the diagnosis, in order to take care of any needed restorative, periodontal or extraction work. Ms. Cotten even recommends a separate personal appointment to review oral hygiene instructions – brushing with a post-op soft toothbrush, flossing, and using interdental brushes.
Having the patient in for weekly visits or even having a hygienist in cancer facilities would allow adjustments of oral care and improve the quality of life of patients. Prof. Lajolo adds that, as radiotherapy starts two months after the ENT surgery and as patients usually leave the hospital one month after the surgery, there is just one month to provide the oral hygiene instructions and perform periodontal therapy and/or extractions before the cancer treatment begins and this scheduling directly falls into the interdisciplinary care and communication between dentists, hygienists and the oncology team, including doctors and nurses.
Learn more and watch the replay here.