Periodontal Treatment in Cancer Patients: an Interdisciplinary Approach
- 106 Downloads
Purpose of Review
Dental care is an essential component in the comprehensive treatment for a cancer patient. As such, a review of the literature was completed to determine the relationships between periodontal and dental care in the cancer patient and provide strategic suggestions.
Periodontal treatment must be personalized depending on the patient’s current oral health status, systemic status, and progress in treatment. Oral mucositis, periodontal status, and osteonecrosis of the jaw (ONJ) remain periodontal concerns in providing dental care to the cancer patient. Risk factors for development of ONJ include root amputation (OR = 6.64), extraction of a single tooth (OR = 3.7), severe tooth mobility (OR = 3.60), and unclosed wound (OR = 2.51).
Preventive maintenance, oral hygiene instruction, use of fluoride and chlorhexidine are all important therapeutic strategies. If extractions are required in patients who have received bone-modifying drug infusions, flap management and primary wound closure are needed to reduce the risk of complications.
KeywordsPeriodontics Patient care management Neoplasms
Direct funding was provided by the NIH/NCI PO1-CA093900, the NIH/NCI Tumor Microenvironment Network U54-CA163124 and supplement, Department of Defense W81XWH-14-1-0403, and NIH/NIDCR DE027551 (NJD).
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.• Tsuji K, Shibuya Y, Akashi M, Furudoi S, Yakushijin K, Kawamoto S, et al. Prospective study of dental intervention for hematopoietic malignancy. J Dent Res. 2015;94(2):289–296. These authors completed a prospective study of dental intervention for patients with hematopoietic malignancy, reporting that patients who completed the partial pre-cancer therapy protocol had significantly lower incidence of systemic (15.8 vs. 37.4%) and dental complications (2.9 vs. 34.0%) compared to patients who did not complete any pre-cancer dental therapy. https://doi.org/10.1177/0022034514561768.CrossRefPubMedPubMedCentralGoogle Scholar
- 2.Toljanic JA, Bedard JF, Larson RA, Fox JP. A prospective pilot study to evaluate a new dental assessment and treatment paradigm for patients scheduled to undergo intensive chemotherapy for cancer. Cancer. 1999;85(8):1843–8. https://doi.org/10.1002/(SICI)1097-0142(19990415)85:8<1843::AID-CNCR26>3.0.CO;2-R.CrossRefPubMedGoogle Scholar
- 3.Schuurhuis JM, Stokman MA, Roodenburg JL, Reintsema H, Langendijk JA, Vissink A, et al. Efficacy of routine pre-radiation dental screening and dental follow-up in head and neck oncology patients on intermediate and late radiation effects. A retrospective evaluation. Radiother Oncol. 2011;101(3):403–9. https://doi.org/10.1016/j.radonc.2011.09.018.CrossRefPubMedGoogle Scholar
- 4.Borowski B, Benhamou E, Pico J, Laplanche A, Margainaud J, Hayat M. Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: a randomised controlled trial comparing two protocols of dental care. Eur J Cancer B Oral Oncol. 1994;30(2):93–7. https://doi.org/10.1016/0964-1955(94)90059-0.CrossRefGoogle Scholar
- 5.Peterson D. Pretreatment strategies for infection prevention in chemotherapy patients. NCI monographs: a publication of the National Cancer Institute. 1989;9:61–71.Google Scholar
- 7.Hong CH, Hu S, Haverman T, Stokman M, Napeñas JJ, Bos-den Braber J et al. A systematic review of dental disease management in cancer patients. Support Care Cancer. 2018;26(1):155–174.Google Scholar
- 9.• Vozza I, Caldarazzo V, Polimeni A, Ottolenghi L. Periodontal disease and cancer patients undergoing chemotherapy. Int Dent J. 2015;65(1):45–48. These authors reported the prevalence of periodontal disease in a population with malignant solid tumors submitted to chemotherapy was 35.2% at the time of their cancer diagnosis, and periodontal treatment was effective in reducing plaque index, bleeding on probing, pocket depth, and maintaining attachment loss as these patients underwent chemotherapy. https://doi.org/10.1111/idj.12133.CrossRefPubMedGoogle Scholar
- 10.Philipone E, Yoon AJ. Oral soft tissue manifestations of hematologic abnormalities and diseases. Oral Pathology in the Pediatric Patient. Springer. 2017. p 129–34.Google Scholar
- 13.Bressan V, Stevanin S, Bianchi M, Aleo G, Bagnasco A, Sasso L. The effects of swallowing disorders, dysgeusia, oral mucositis and xerostomia on nutritional status, oral intake and weight loss in head and neck cancer patients: a systematic review. Cancer Treat Rev. 2016;45:105–19. https://doi.org/10.1016/j.ctrv.2016.03.006.CrossRefPubMedGoogle Scholar
- 17.• Hasegawa T, Kawakita A, Ueda N, Funahara R, Tachibana A, Kobayashi M et al. A multicenter retrospective study of the risk factors associated with medication-related osteonecrosis of the jaw after tooth extraction in patients receiving oral bisphosphonate therapy: can primary wound closure and a drug holiday really prevent MRONJ? Osteoporos Int. 2017:1–9. These authors completed a non-randomized, multi-centered retrospective study including 1175 patients, to determine the significant risk factors for ONJ in patients taking oral bisphosphonates. Overall, the study reported a 1.7% frequency of post-extraction ONJ in patients taking oral bisphosphonates. The study determined that concurrent disease status (i.e., cancer and diabetes) was not significant. However, local treatment factors including root amputation (OR = 6.64), extraction of a single tooth (OR = 3.7), severe tooth mobility (OR = 3.60), and unclosed wound (OR = 2.51) significantly contributed risk to the development of ONJ. Google Scholar
- 18.Van Poznak CH, Temin S, Yee GC, Janjan NA, Barlow WE, Biermann JS, et al. American Society of Clinical Oncology executive summary of the clinical practice guideline update on the role of bone-modifying agents in metastatic breast cancer. J Clin Oncol. 2011;29(9):1221–7. https://doi.org/10.1200/JCO.2010.32.5209.CrossRefPubMedGoogle Scholar
- 20.Vale CL, Burdett S, Rydzewska LH, Albiges L, Clarke NW, Fisher D, et al. Addition of docetaxel or bisphosphonates to standard of care in men with localised or metastatic, hormone-sensitive prostate cancer: a systematic review and meta-analyses of aggregate data. Lancet Oncol. 2016;17(2):243–56. https://doi.org/10.1016/S1470-2045(15)00489-1.CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, Lacombe L, et al. Long-term efficacy of zoledronic acid for the prevention of skeletal complications in patients with metastatic hormone-refractory prostate cancer. J Natl Cancer Inst. 2004;96(11):879–82. https://doi.org/10.1093/jnci/djh141.CrossRefPubMedGoogle Scholar
- 22.Fizazi K, Carducci M, Smith M, Damião R, Brown J, Karsh L, et al. Denosumab versus zoledronic acid for treatment of bone metastases in men with castration-resistant prostate cancer: a randomised, double-blind study. Lancet. 2011;377(9768):813–22. https://doi.org/10.1016/S0140-6736(10)62344-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 23.• Vehmanen L, Suojanen J, Kontio R, Utriainen T, Blomqvist C. High frequency of osteonecrosis of the jaw among denosumab-treated prostate cancer patients. Acta Oncol. 2017;56(1):104–106. These authors completed a case series with 254 men with castrate-resistant prostate cancer and treated with zolendronic acid, denosumab, or both, who also received dental extractions by oral and maxillofacial surgeons. In total, 29 out of 254 men (11.4%) developed ONJ. Of the patients who developed ONJ, 2 received only zolendronic acid, 9 received only denosumab, and 18 received both zolendronic acid and denosumab. Seventeen of the 29 ONJ cases had chronic disability of the jaw or jaw necrosis that continued until the death of the patient. https://doi.org/10.1080/0284186X.2016.1262548.CrossRefPubMedGoogle Scholar
- 26.• Owosho AA, Tsai CJ, Lee RS, Freymiller H, Kadempour A, Varthis S, et al. The prevalence and risk factors associated with osteoradionecrosis of the jaw in oral and oropharyngeal cancer patients treated with intensity-modulated radiation therapy (IMRT): the Memorial Sloan Kettering Cancer Center experience. Oral Oncol. 2017;64:44–51. These authors completed a case-control study at the Memorial Sloan Kettering Cancer Center. The authors determined the prevalence of ORN to be 4.3% during a median follow-up time of 52.5 months. Furthermore, the authors stated that patients treated for oropharyngeal cancer were prone to develop ORN earlier compared to patients with oral cavity cancer. In addition, these authors reported that poor periodontal status, history of alcohol use, and radiation dose were significant risk factors. https://doi.org/10.1016/j.oraloncology.2016.11.015.CrossRefPubMedGoogle Scholar
- 28.• Dieleman F, Phan T, van den Hoogen F, Kaanders J, Merkx M. The efficacy of hyperbaric oxygen therapy related to the clinical stage of osteoradionecrosis of the mandible. Int J Oral Maxillofac Surg. 2017;46(4):428–433. These authors completed a retrospective study and reported that the cause of ORN was most commonly extractions after radiation therapy (22%) or prosthetics (22%) followed by periodontal disease (11%) and tumor-related surgery (11%). Interestingly, treatment with hyperbaric oxygen is only significantly effective for lower stages of ORN, while higher stages of ORN still require segmental resection of the affected structure. https://doi.org/10.1016/j.ijom.2016.12.004.CrossRefPubMedGoogle Scholar
- 29.Burstein HJ, Prestrud AA, Seidenfeld J, Anderson H, Buchholz TA, Davidson NE, et al. American Society of Clinical Oncology clinical practice guideline: update on adjuvant endocrine therapy for women with hormone receptor–positive breast cancer. J Clin Oncol. 2010;28(23):3784–96. https://doi.org/10.1200/JCO.2009.26.3756.CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Eastell R, Adams JE, Coleman RE, Howell A, Hannon RA, Cuzick J, et al. Effect of anastrozole on bone mineral density: 5-year results from the anastrozole, tamoxifen, alone or in combination trial 18233230. J Clin Oncol. 2008;26(7):1051–7. https://doi.org/10.1200/JCO.2007.11.0726.CrossRefPubMedGoogle Scholar
- 31.Taichman LS, Van Poznak CH, Inglehart MR. Self-reported oral health and quality of life of postmenopausal breast cancer survivors on aromatase inhibitors and women without cancer diagnoses: a longitudinal analysis. Support Care Cancer. 2016;24(11):4815–24. https://doi.org/10.1007/s00520-016-3336-6.CrossRefPubMedPubMedCentralGoogle Scholar
- 32.NIDCR. Cancer Treatment and Oral Health. 2017. https://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/