San Antonio, TX—Proper attention to dental care for patients with head and neck cancer can mean the difference between a good functional outcome and a poor one, according to a dental oncologist and nurse who described dental oncology at the Oncology Nursing Society 41st Annual Congress.
The topic was discussed by Maureen Sullivan, DDS, Chief of the Department of Dentistry, Oral Oncology & Maxillofacial Prosthetics at Erie County Medical Center in Buffalo, NY, and Colleen Palay, BSN, RN, an oncology nurse navigator at University Hospitals Seidman Cancer Center in Cleveland, OH.
The discipline of dental oncology encompasses general dentistry, oral medicine, oral pathology, and maxillofacial prosthetics for patients with cancer.
"It is critical to have a dentist involved at the time of diagnosis," Dr Sullivan said. "The dental oncologist can play an integral role before, during, and after antineoplastic treatments, and offers the best chance of functional as well as esthetic outcomes."
The role nurses play is also critical, said Ms Palay. "They educate patients and their families, and they are in a position to advocate for the patient to obtain the necessary care," she said. "Getting the patients to see a dentist before treatment is something that will help with the side effects due to the cancer and the treatment, and will improve quality of life long term."
"We need to treat our dentists as members of the multidisciplinary team," she emphasized. With nurses, dentists, and surgeons collaborating, she said, "we can help prevent things such as crowning a tooth only to have the surgeon extract it."
Optimal timing can be a challenge, especially when the dental oncologist is not on site at the treating facility, Ms Palay said.
The challenge for nurses is to find a dentist at the time of diagnosis. "You call dentists. Take cookies to the dental school. See what you can make happen," she said.
Ideally, patients are evaluated for dentition upon a diagnosis of head and neck cancer. The dental oncologist then communicates to the surgeon his or her recommendations for optimal oral and prosthetic rehabilitation.
The evaluation includes a comprehensive clinical and radiographic assessment of the patient's oral and dental status and existing prosthetics (dentures, etc). At this time, patients should also be educated about acute and late-stage adverse effects of upcoming treatments, and should be taught proper dental hygiene.
Importantly, all dental pathosis is evaluated for and eliminated at the time of surgery and before chemoradiation. Management of dental problems is much more difficult after treatment, which creates its own set of problems, Dr Sullivan emphasized.
"With the patient asleep [during biopsy], we can get aggressive dentistry done in a hurry so there is sufficient healing prior to resection and chemotherapy and radiation," she said, noting that she extracts all "hopeless teeth" at that time. Upfront, there is also better access to the oral cavity.
Common Secondary Effects of Radiotherapy
The adverse effects of radiotherapy are well known to nurses. Dr Sullivan offered her recommendations for management.
Mucositis occurs as a result of permanent damage to DNA, and there is still no effective means of treatment or prevention. Patients can try baking soda rinses, systemic analgesics and local anesthetics, antifungal medications, and fluoride rinses and toothpaste (dry mouth formula).
"The most important thing we do in our center is anticipate mucositis, and give virtually all patients a PEG [percutaneous endoscopic gastrostomy tube]," she said. "And we babysit these patients, and see them through radiotherapy. We alert the head and neck nurses if they are not doing well."
Xerostomia is lifelong, but with intensity-modulated radiotherapy some saliva can return, though it will not be quite normal. Amifostine, a salivary gland protectant, has shown modest benefit but is expensive, has adverse effects, and must be given 20 minutes prior to radiotherapy. For hyposalivation, she recommended salivary substitutes, regular hydration, and systemic sialagogues, which include pilocarpine and cevimeline.
Dry mouth creates a highly cariogenic oral environment, which is another reason Dr Sullivan emphasized "dealing with teeth before and not after treatment."
She creates customized acrylic trays that are filled with prescription fluoride and worn by the patient 5 minutes a day, and advises patients to brush with PreviDent 5000 Plus toothpaste for 12 months. "It's worth its weight in gold," she commented.
In patients with complex crowns and bridges or difficult dentition, and in those receiving high-dose chemotherapy, clinicians should "look beyond the surface for opportunistic infections." For infection prevention, mucin-based salivary substitutes may help restore normal oral flora but systemic antifungals and antivirals are favored, especially for patients who do not adhere to oral care regimens.
"I encourage you to investigate these, but I tell my patients there is no substitute for a toothbrush," Dr Sullivan said.
Scar contracture and fibrosis causing limited oral opening—or trismus—greatly restrict dental care. Prevention involves range-of-motion therapy after surgery and use of dynamic devices.
Osteoradionecrosis is a dreaded, often disfiguring adverse effect of radiation that involves delayed healing of the jawbone and sometimes fracture and extraoral fistulae. The primary approach is preventive, including the elimination of existing infection. For treatment, conservative measures are often sufficient: palliation, antibiotics, meticulous oral hygiene, and removal of necrotic bone with simple surgery. With neck dissection, however, more extreme measures such as hyperbaric oxygen therapy, removal of teeth, and more radical treatment of necrosis followed by reconstruction may be required, Dr Sullivan indicated.
Advocating for Patients
As a nurse navigator, Ms Palay deals daily with patients needing dental care, and she shared her observations.
The nurse's role, she said, is also to align the patient with the dentist, ideally several weeks before beginning treatment. This can be challenging, she acknowledged. It may even be difficult to locate dentists willing to see these patients, who often cannot pay for services. Unfortunately, insurance coverage for dental care is usually inadequate, she pointed out.
A quick initial evaluation, however, is something nurses can handle (ie, assessing dentition and function and getting the patient's dental history). After surgery, nurses teach and reinforce good dental hygiene, including brushing, flossing, and the use of fluoride and mouthwashes. She would not recommend, for the first-time flosser, to start this practice immediately after treatment, when the mucosa is fragile. She suggested that patients delay getting dentures for 6 months after treatment.
Nurses should also be aware of the psychosocial distress that patients can experience posttreatment, if their appearance has been altered. "Social interactions, at least initially, can be distressing," Ms Palay said.
Palay C, Sullivan M. Dental oncology. Presented at: Oncology Nursing Society 41st Annual Congress; April 28-May 1, 2016; San Antonio, TX.