Oral complications occur in virtually all patients receiving radiation for head and neck malignancies, in approximately 80 percent of hematopoietic (blood-forming) stem cell transplant recipients, and in nearly 40 percent of patients receiving chemotherapy. Risk for oral complications can be classified as low or high:
Lower risk: Patients receiving minimally myelosuppressive or nonmyelosuppressive chemotherapy.
Higher risk: Patients receiving stomatotoxic chemotherapy resulting in prolonged myelosuppression, including patients undergoing hematopoietic stem cell transplantation; and patients undergoing head and neck radiation for oral, pharyngeal, and laryngeal cancer.
Some complications occur only during treatment; others, such as xerostomia, may persist for years. Unfortunately, patients with cancer do not always receive oral care until serious complications develop.
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The Role of Pretreatment Oral Care
A thorough oral evaluation by a knowledgeable dentist before cancer treatment begins is important to the success of the regimen. Pretreatment oral care achieves the following:
Reduces the risk and severity of oral complications.
Allows for prompt identification and treatment of existing infections or other problems dental equipment.
Improves the likelihood that the patient will successfully complete planned cancer treatment.
Prevents, eliminates, or reduces oral pain.
Minimizes oral infections that could lead to potentially serious systemic infections.
Prevents or minimizes complications that compromise nutrition.
Prevents or reduces later incidence of bone necrosis.
Preserves or improves oral health dental supplies.
Provides an opportunity for patient education about oral hygiene during cancer therapy.
Improves the quality of life.
Decreases the cost of care.
With a pretreatment oral evaluation, the dental team can identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease that could contribute to oral complications when cancer therapy begins. The evaluation also establishes baseline data for comparing the patient’s status in subsequent examinations.
Before the exam, you will need to obtain the patient’s cancer diagnosis and treatment plan, medical history, and dental history. Open communication with the patient’s oncologist is essential to ensure that each provider has the information necessary to deliver the best possible care.
Ideally, a comprehensive oral evaluation should take place 1 month before cancer treatment starts to allow adequate time for recovery from any required invasive dental procedures Dental Chair. The pretreatment evaluation includes a thorough examination of hard and soft tissues, as well as appropriate radiographs to detect possible sources of infection and pathology. Also take the following steps before cancer treatment begins:
Identify and treat existing infections, carious and other compromised teeth, and tissue injury or trauma.
Stabilize or eliminate potential sites of infection.
Extract teeth in the radiation field that are nonrestorable or may pose a future problem to prevent later extraction-induced osteonecrosis.
Conduct a prosthodontic evaluation if indicated. If a removable prosthesis is worn, make sure that it is clean and well adapted to the tissue. Instruct the patient not to wear the prosthesis during treatment, if possible; or at the least, not to wear it at night.
Perform oral prophylaxis if indicated.
Time oral surgery to allow at least 2 weeks for healing before radiation therapy begins. For patients receiving radiation treatment, this is the best time to consider surgical procedures. Oral surgery should be performed at least 7 to 10 days before the patient receives myelosuppressive chemotherapy. Medical consultation is indicated before invasive procedures.
Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.
Consider extracting highly mobile primary teeth in children, and teeth that are expected to exfoliate during treatment.
Prescribe an individualized oral hygiene regimen to minimize oral complications. Patients undergoing head and neck radiation therapy should be instructed on the use of supplemental fluoride.
Impending Dental Surgery Tools – Advice Needed? for more information.