Cancer treatment profoundly impacts oral health, creating unique challenges that require specialized dental care and management. As dental professionals, understanding these complications and their treatment is essential for providing optimal patient care throughout the cancer journey. This blog is educational material presented in the CE monthly webinar by the Distance Learning Office of The Herman Ostrow School in Dentistry of USC.
The Critical Role of Oral Health in Cancer Care
Oral health extends far beyond maintaining teeth and gums—it encompasses the entire orofacial structure’s ability to support essential functions like eating, breathing, and speaking, while preserving patients’ psychological well-being and quality of life. For cancer patients, maintaining oral health becomes even more critical as treatment can significantly compromise these functions.
The first recommendation for all patients is simple yet vital: know what’s normal versus abnormal. Patients should become familiar with how their mouth normally looks and feels, reporting any changes to their healthcare team promptly. Early detection consistently leads to better outcomes.
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Multidisciplinary Approach to Head and Neck Cancer
Effective cancer care requires collaboration among multiple specialists:
- Head and neck surgeons
- Radiation oncologists
- Medical oncologists
- Dental oncologists
- Oral and maxillofacial surgeons
- Oral medicine/orofacial pain specialists
- Dental hygienists
This team approach ensures comprehensive care addressing both cancer treatment and oral health maintenance.
Common Orofacial Complications from Cancer Treatment
Cancer therapy can cause numerous oral complications, including:
- Oral infections (bacterial, viral, fungal)
- Dental caries
- Xerostomia (dry mouth)
- Mucositis
- Neuropathies
- Osteoradionecrosis
- Trismus and myofascial pain
- Increased risk of oral potentially malignant disorders
Pre-Treatment Dental Evaluation
Before Chemotherapy: Complete surgical procedures at least one week before treatment to allow two weeks of healing before the white blood cell nadir, which typically occurs 7-14 days after chemotherapy initiation.
Before Radiotherapy: Allow three weeks of healing time after extractions, as radiation reduces bone remodeling activity and causes progressive fibrosis. For treatments requiring less than three weeks, carefully weigh infection risk versus healing time.
Key Oral Complications and Management
Xerostomia (Dry Mouth)
Saliva performs crucial functions including antimicrobial activity, taste function, and tissue protection. Management includes:
- Systemic treatments: Pilocarpine (5mg three times daily) or cevimeline (30mg three times daily) for at least three months
- Topical agents: Over-the-counter saliva substitutes, mucosal lubricants, and sugar-free gums
- Preventive care: Daily high-fluoride toothpaste application
Mucositis (Figure 1)
Treatment options include:
- Magic mouth rinse (viscous lidocaine, Maalox, and Benadryl in equal parts)
- Topical steroids like clobetasol 0.05% gel or dexamethasone solution
- When prescribing steroids for more than two weeks, consider prophylactic antifungals to prevent candidiasis
Figure 1. Cancer patient under immunotherapy treatment with mucositis.
Pain Management
Pain care requires interdisciplinary approaches with personalized treatment plans. Topical compounds offer targeted relief for localized pain, including NSAIDs, anticonvulsants, tricyclic antidepressants, and NMDA blockers.
Osteoradionecrosis
This serious complication affects patients receiving high-dose radiation (>60Gy) with a 4-15% overall risk. Management includes:
- Adequate nutrition and tobacco/alcohol cessation
- Antibacterial rinses and systemic antibiotics
- Removal of bony sequestrae
- Hyperbaric oxygen therapy in select cases
Infectious Complications
Cancer patients face increased infection risks due to immunocompromised states (Figure 1). Common infections include:
Herpes Simplex Virus: Can present as large, persistent ulcers in immunocompromised patients. Treatment includes acyclovir or famciclovir with prophylactic therapy for recurrent cases.
Varicella Zoster Virus: May affect multiple dermatomes with potential for dissemination. Treatment requires IV acyclovir for severe cases.
Candidiasis: The most prevalent oral opportunistic infection. Treatment ranges from topical antifungals (nystatin, clotrimazole) to systemic options (fluconazole) for resistant cases.
Figure 1. Cancer patient with severe dry mouth, candidal infection intraoral and extraoral.
Oral Potentially Malignant Disorders (OPMDs)
Cancer patients have increased risk for developing oral leukoplakia and other potentially malignant lesions. Recent research shows that 40-46% of leukoplakia cases present with epithelial dysplasia or squamous cell carcinoma. Treatment options may include:
- Watch and wait approach
- Surgical excision or laser ablation
- Immunotherapy with off-label imiquimod 5%
- Immunotherapy
Clinical Recommendations
- Regular monitoring: Schedule dental visits every 4 months for cancer patients
- High-fluoride prevention: Daily application of prescription fluoride gel
- Avoid extractions in areas receiving >50Gy radiation
- Patient education: Teach patients about potential complications and when to seek care
- Maintain excellent oral hygiene throughout treatment
The USC Approach
At USC’s Herman Ostrow School of Dentistry, the OralCare Precancer and Pain Clinic (Figure 2) provides specialized care for cancer patients, combining clinical expertise with ongoing research to improve patient outcomes. This multidisciplinary approach exemplifies the standard of care needed for this vulnerable population.
Figure 2. Photo of one of the cubicles of the OralCare Precancer and Pain Clinic at USC.
Conclusion
Oral health directly impacts overall recovery and quality of life during and after cancer treatment. As dental professionals, staying vigilant, maintaining excellent preventive protocols, and communicating regularly with the healthcare team about any changes or concerns can significantly improve patient outcomes. The key is early intervention, comprehensive care planning, and ongoing monitoring throughout the cancer journey.
Postgraduate Oral Pathology and Radiology Certificate
Learn more about the clinical and didactic skills necessary to evaluate and manage patients with oral diseases by enrolling in Herman Ostrow School of USC’s online, competency-based certificate program in Oral Pathology and Radiology.
