The time period between the diagnosis of cancer and commencement of treatment is usually very short, so it is vitally important that the patient receives immediate and appropriate support from the dental team.
The oral cavity is a site where complications frequently develop either as the direct result of the malignancy or as an unwanted side effect of the treatment. The recommendations must be seen as a contribution to total patient care and as such, should always be implemented in conjunction with care priorities agreed with the oncology team. 78% of patients experience severe difficulties in mastication (chewing) following major head and neck surgery with implications for normal social adaptation, so time must be made available during the pre treatment phase for a dental assessment and realistic oral hygiene instruction.
The Dental Hygienist can provide simple preventive advice to the patient and at the same time emphasise its value in maintaining oral comfort during therapy. This must be tailored to the patients personal situation and needs so that a high standard of oral care is encouraged and achieved. Smoking cessation is recommended during radiotherapy as smoking exacerbates inflammation of the oral soft tissues.
The effects of radiation to the oral cavity are extremely distressing to the patient. They will invariable be prone to impaired nutritional status and the malnourished patient is more inclined to suffer infections, vitamin and mineral deficiencies, poor wound healing, malaise and lethargy.
Along with the assistance of the dietician, detailed oral hygiene instruction and dietary advice can be provided. A high calorific intake occurs during radiotherapy. This usually translates into an increased and frequent consumption of refined carbohydrates and in turn encourages the incidence of dental caries (tooth decay). To combat this, those patients receiving radiotherapy need to use a daily fluoride mouthwash to prevent dental caries and promote enamel remineralisation.
Radiation also can cause the death of the rapidly dividing epithelial cells and the integrity of the mucosal epithelium is lost after the first 12 days of treatment. Normal daily tooth brushing by the patient is reinforced and if necessary a soft, baby's brush can be used. Oral hygiene practices are supplemented with the use of a chlorohexidine gluconate mouthwash or gel. It is also necessary to avoid strong toothpastes, hard, spicy and acidic foods, alcohol and tobacco, fizzy drinks and sweets as these may traumatise and irritate the gums.
A further effect of radiotherapy, depending on dosage, is the reduction or cessation of saliva production. This affects swallowing, chewing and speaking. The mouth becomes vulnerable to infections and the tastebuds are damaged leading to loss of taste.
Water soluble lubricating gels can moisten the lips without the dehydrating effects of glycerol and paraffin based products.
Every effort is made to reduce the effect of xerostomia (dry mouth). The symptoms of xerostomia can be helped by:
1. Frequent sips of water/milk or other sugar free non acidic drinks.
2. Saliva substitutes that lubricate the oral cavity
3. Sugar free chewing gum stimulates saliva production.
4. Ripe bananas are good lubricant but watch high sugar content on teeth.
The remaining saliva can become thick and viscous. This in turn reduces the buffering action of saliva needed to maintain a neutral pH in the oral cavity. With acidic conditions, there is an increase of decay and gum causing organisms. If gingival (gum) disease is diagnosed the gums will bleed easily on tooth brushing and the patient may suffer from halitosis (bad breath). Again the use of a chlohexidine mouth rinse along with gentle debridements by the dental hygienist will help the patient.
The patient is counselled about denture wear during therapy. Usually they are encouraged to take them out as this helps to maintain oral comfort.
Oral care cannot prevent radiation damage, but it is vital in preventing additional infections that can cause further damage and pain. Following treatment, as taste returns, patients often seek comfort in sweet foods and drinks. Diet counselling along with a three month oral hygiene review is arranged to monitor and advise the patient.
When presented with a diagnosis of cancer, a patient will be unlikely to consider the oral implications as a high priority. However, it is important that the patient and carer are counselled about oral care procedures, diet and the oral implications of the proposed treatment to reduce and define potential oral complications.
Rachel Pointer
Dental Hygienist
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