DENTAL CARE FOR PATIENTS UNDERGOING CANCER TREATMENT
If you have been diagnosed with some form of cancer wherein a course of radiation or chemotherapy has been prescribed for you, certain extra precautions and procedures will be needed to prevent or alleviate the oral side effects that occur as the result of these kinds of treatments. While these cancer remedies are intended to attack the targeted malignancy, other systems in your body are almost always negatively affected, particularly your mouth.
Cancer is basically a malfunction of cell reproduction in whichever of your tissues is concerned. These altered cells do not carry out their intended function and eventually your involved organ (and any of your other organs these cells spread to) fails as it becomes composed of mostly inert cells. These cells are characterized by extremely rapid replication and it is such swiftly dividing cells that your chemotherapy aims for. Since chemotherapy works through the bloodstream, it has the potential to have an effect on any part of your body, including your mouth. Radiation therapy is far less discriminating in its action, with just about any of your cells damaged by its use. For this reason it is mostly used on localized tumors where the focus of its beam can be limited to spare surrounding healthy tissue. For this reason radiation therapy usually does not have an effect on your oral cavity unless your cancer is of the head or neck.
The two most serious oral side effects you may experience from these treatments are dry mouth (technically known as xerostomia) and oral ulcers (technically known as hard or soft tissue necrosis). Chemotherapy can also depress your immune response leading to opportunistic infections that can appear in your mouth. These problems may have far reaching consequences that can devastate your mouth if not adequately dealt with.
Saliva safeguards your teeth and gums from oral disease due to its many protective characteristics while aiding in the mechanics of chewing, swallowing, digestion and the sense of taste through its lubricating properties. Calcium in your saliva helps harden your teeth against decay and antibodies contained in your saliva along with its other immune system elements check the bacteria in your mouth responsible for decay and gum disease. If significant xerostomia results from your cancer treatments, rampant decay and severe gum (periodontal) disease can occur with infection to the point where many or all of your teeth can be lost. Secondary infections (be they viral such as herpes or fungal such as thrush or moniliasis) can also occur in your mouth if not suppressed by normal salivary action and adequate immune function, as can bacterial infections. Both chemotherapy and radiation treatments can impair the function of your salivary glands (creating as much as a 93% reduction in the ampount of saliva you produce) and cause you to have acute dry mouth.
Rampant decay at the gumline is a typical result of radiation therapy induced dry mouth.
Both chemotherapy and radiation treatments can also cause you to have ulcers of the mucous membranes in your mouth called soft tissue necrosis. They can also cause a more generalized and less severe inflammation of your mouth called mucositis. The cells of these membranes that line your cheeks, tongue, roof and floor of your mouth are rapidly dividing and thus are negatively effected by your chemotherapy. The ulcers that follow can be extremely painful with a constant burning sensation and intermittent bleeding as the chemotherapy affects those blood cells responsible for clotting. This may cause a loss of appetite that can even lead to malnutrition. These soft tissue effects usually start 2-3 weeks after your cancer treatment begins and resolve 2-3 weeks after it ends.
Since radiation treatment can hurt any cells within the x-ray's beam being used to fight your cancer, your mouth will often suffer ulcers if the tumor is in your head or neck. These ulcers can affect not only your mucous membranes, but your jawbones as well if the radiation damages the blood vessels nourishing them with dead bone tissue showing through the ulcers in the overlying gum tissue. This is called hard tissue necrosis and may not show up until several months after your treatments have been completed as the bone slowly dies from lack of blood supply. The hard tissue necrosis caused by radiation treatments is also known as osteoradionecrosis. Secondary infections can also take hold through any of these ulcerations in your mouth. Radiation treatment of your head and neck can cause trismus (difficulty opening) as well due to exposure of your jaw muscles to the radiation.
If you are scheduled to undergo any such treatment, it is imperative that you have a complete oral examination first so that any dental problems you may have can be corrected before your cancer therapy begins. Any and all decay or fractures will need to be restored. If you have any hopeless or partially erupted teeth, these will need to be extracted. Active gum disease will need to be controlled as well.
Once your oral condition has been stabilized and your cancer regimen has begun, a strict schedule of preventive dental care should be instituted to avert its side effects as much as possible. Cleanings here in our office should be performed every three months to forestall periodontal disease along with fluoride treatments to prevent decay. Dr. McArdle will prescribe an anti-infective rinse for you to use at home that will inhibit the bacteria that contribute to gum disease and a professional strength of fluoride toothpaste to fight decay. You should be using an over-the-counter fluoride rinse at home to augment the effects of the fluoride treatment as well. Depending on the severity of your dry mouth, Dr. McArdle may advise over-the-counter saliva substitutes and oral lubricants (such as Biotene or Salivart, etc.) as well as prescribe salivary stimulants (Salagen or Evoxac) to supplement or enhance your salivary flow. If you experience any of the secondary infections described above, antiviral, antifungal or antibiotic medications will need to be prescribed for you.
Preventing or treating ulcerative conditions that occur during the course of your cancer treatment can be a more difficult task. Some chemotherapy agents have a lesser tendency to cause ulcers than others do and if such agents are appropriate to your situation these can greatly reduce the incidence of ulceration. Short of that, you will experience some ulcers while undergoing chemotherapy and radiotherapy of the head or neck will almost certainly create ulcerative lesions.
The ulcers seen at the tip of this patient's tongue were caused by chemotherapy.
To alleviate the discomfort associated with eating in the presence of ulcers, there are medications (Zilactin or Orabase) you can use that produce a shielding film over them. This can make eating considerably more comfortable and encourages proper nutrient intake. A diet of soft, moist foods as opposed to course one and low sugar intake are helpful in these situations. These ulcers can frequently make your home care (brushing and flossing) extremely uncomfortable and in many instances patients discontinue such manual oral hygiene measures due to the intense irritation present with the ulcerations. If you experience such irritation and cannot continue with your normal home care routine, Dr. McArdle will advise you to use the previously prescribed anti-infective rinses (either Peridex or Therasol) instead. Their use will limit depositing on your teeth and curb bacterial proliferation in your mouth until the ulcers resolve sufficiently to allow resumption of your regular brushing and flossing.
If osteoradionecrosis is anticipated due to the planned dosages of radiation during your cancer treatment (the higher the dose of radiation the more severe the signs and symptoms of its consequences will be) hyperbaric oxygen therapy can be used to reduce your risk of this side effect. Hyperbaric oxygen treatment consists of you being in a special chamber with an elevated oxygen pressure to replenish the oxygen supply to your jawbones that has been diminished due to the radiation's effect on the blood vessels that nourish your bone tissue. This is usually done at a hospital.
THE ILL EFFECTS OF RADIATION AND CHEMICAL CANCER THERAPY IN YOUR MOUTH CAN BE MINIMIZED WITH THE APPROPRIATE DENTAL CARE BEFORE AND DURING YOUR TREATMENT. PLEASE LET DR. MCARDLE KNOW IF YOU WILL BE UNDERGOING SUCH THERAPY SO HE CAN PLAN THE DENTAL CARE MOST SUITABLE FOR YOU.