Author: Jennifer Byrne

When planning their next steps after a cancer diagnosis, most patients don’t put a trip to the dentist at the top of their to-do list.

“When patients are diagnosed with cancer, they just want to put out the fire; they want to address the cancer,” Dalal Alhajji, DMD, MSD, clinical instructor of oral and maxillofacial pathology, radiology and medicine at NYU College of Dentistry, said in an interview with Healio. “That’s when I say, ‘the reason you need to see a dentist is, we want to put out another potential fire — one you might not know about yet.”

Alhajji and her colleagues at NYU College of Dentistry are part of a small but growing movement among oral health professionals seeking to close the gap between medical and dental care for patients with cancer. They see dentists as a vital component of any multidisciplinary oncology care team, offering infection treatment, protection of teeth during head and neck radiation treatments, and quality-of-life care for issues such as dry mouth and mouth sores.

“I’ve been lucky — the oncologists I work with have been great about referring patients to me because they see the impact it has,” Alhajji said. “They see the value of having a dentist on the cancer care team.”

Addressing preventable issues
There are several reasons for a patient with cancer to see a dentist prior to initiating cancer treatment, but patients with head and neck cancers and those slated to undergo bone marrow transplantation especially need a dental examination.

“When patients undergo transplantation, they tend to be immunosuppressed for a while,” Alhaji said. “The duration of immunosuppression is going to be dependent on whether the transplant is from their own body or from a donor. As a dentist, I must keep these things in mind when I’m doing a dental evaluation. So, in anticipation of my patients being immunosuppressed, I have to predict which teeth are going to be problematic. If any tooth is infected, it must be addressed before treatment begins.”

Alhajji said infected teeth can be difficult — if not impossible — to treat once transplantation and immunosuppression has begun.

“If the tooth flares up during the process, it will be very difficult for dentists to intervene, causing patients to be in pain for a very, very long time,” Alhajji said. “So, now we have a patient who is trying to fight cancer but is suddenly dealing with this acute, severe oral pain that could have been prevented. That’s just not the outcome I want patients with cancer to have.”

Addressing these preventable issues prior to the start of cancer care is now a regular component of multidisciplinary care at NYU Langone’s Perlmutter Cancer Center. As part of this treatment approach, oncologists at Perlmutter collaborate with dentists at NYU College of Dentistry to ensure that dental exams are given before the start of treatment.

“One of the items on patients’ checklist before they start treatment is dental,” Alhajji said. “For many of the oncologists I work with, if their patients don’t get a dental clearance, they don’t proceed with the cancer care. That’s a vision I have for all hematologists and oncologists and, more importantly, our patients.”

Pretreatment dental care also addresses potential adverse events of treatment. For example, patients with head and neck cancer may experience severe adverse effects that could cause them issues eating and communicating for the rest of their lives.

“Radiation therapy not only attacks the tumor, but also attacks adjacent structures, such as the salivary glands,” she said. “All of us have millions and millions of minor salivary glands in the head and neck area, and these glands contribute to producing saliva. If that is impaired, then we’re more likely going to get cavities, because saliva has a protective capacity. I’ve seen patients with a mouth full of cavities after cancer treatment, rendering the teeth nonrestorable. In short, they can’t chew their food anymore.”

‘I just don’t want to see this’

Alhajji began to promote the idea of having dentists on the cancer care team after seeing some patients after their cancer treatment.

“I call them ‘after-the-fact’ patients,” Alhajji said. “Early on in my career, I would see patients who would come to me after starting cancer treatment, or after recovery. They didn’t look very good; it was dreadful. I thought, ‘I just don’t want to see this anymore. How can I change this?’”

Alhajji proposed the idea to the oncologists at NYU, and they enthusiastically incorporated it into their oncology care approach, she said.

Although oncologists have been able to observe the direct impact and benefit of the dental examinations, patients sometimes need convincing, Alhajji said.

“Sometimes they get frustrated, and I say, ‘It takes a village. This is not a one-and-done deal,’” she said. “‘This is part of the process, and I will help you navigate it.’ And after talking to them and educating them on what can potentially happen, they’re so grateful.”

As part of her counseling of patients with cancer, Alhajji answers their questions about changes they should make to their dental regimens going forward. For example, immunosuppressed patients need to be aware their platelet counts are going to drop, causing them to bleed more often. The counterintuitive advice she has to give for this scenario makes her cringe a bit, she admitted.

“I tell them not to floss,” Alhajji said. “I even tell them that I feel really uncomfortable saying this, but by the same token, I don’t want them to have prolonged bleeding.”

Alhajji mentioned another bit of advice that’s frustrating but necessary for her to give to these patients.

“I tell them that as long as they are immunosuppressed, they should use an ultrasoft toothbrush,” she said. “I really have to take into consideration the patient as a whole, and everything else that’s going on in their body.”

Where appropriate, she also recommends that patients speak with their dentist about having custom mouth guards made to minimize incidence of mucositis.

Alhajji’s hope is that dentistry will become part of the standard of care for cancer treatment, but in the meantime, she offered some advice for oncologists whose patients might be vulnerable to dental issues.

“I always encourage my oncologists to reach out to a dentist, and even find a ‘go-to’ dentist,” she said. “Even if the dentist you contact doesn’t know what to do, chances are they are going to know someone in the dental community who does. You have to find your dentist or team of dentists. It’s hard because there are so many cancer appointments after a diagnosis, but the dentist appointments could be just as important to protect patients from having lifelong eating and communications issues after the cancer is cured.”