Author: Tara Haelle

Complications from oral cancer and the toxic effects of treatment — including demineralization, caries, fibrosis, candidiasis, pain, sensitivity, and aesthetic concerns — can continue long after any evidence of cancer is apparent, experts reported at the World Dental Congress 2019.

One of the major toxic effects is changes in saliva, said Joel Epstein, DMD, director of cancer dentistry at the Cedars Sinai Health System in Los Angeles and director of dental oncology at the City of Hope Comprehensive Cancer Center in Duarte, California.

Another problem area — one that is often ignored — is taste, he told Medscape Medical News.

And toxic effects are common, he added, citing one study that showed that 16% of patients experienced dental toxicity in the year after undergoing radiotherapy. The rates increased to 36% after 3 years, 55% after 5 years, and 74% after 7 years.

For patients undergoing cancer therapy, dentists should look at overall oral hygiene, decay prevention, lip lubrication, dental emergencies, and oral mucosal infections, Epstein told the audience during his presentation on the management of patients with oral cancer, both during and after treatment.

Fortunately, there are a lot of things that dentists can help with, he pointed out. For example, fluoride can be used to promote mineralization and chlorhexidine rinse can be used to reduce cariogenic bacteria.

And photobiomodulation therapy, or low-level laser light therapy, can be used for the prevention of mucositis, which can be particularly painful, he added. Pain related to oral mucositis can be treated with transdermal fentanyl, 2% morphine mouth rinse, and 0.5% doxepin mouth rinse.

Dentists also need to emphasize prevention and monitor survivors for recurrence. “The highest-risk person for cancer,” said Epstein, “is the person who has already had cancer.”

Recognizing Worrisome Lesions
It can be difficult to determine which abnormalities in the mouth are cause for concern, said Mark Lingen, DDS, PhD, from the University of Chicago Pritzker School of Medicine. For example, candidiasis and squamous cell carcinoma can look similar, he pointed out.

Lingen opened the session on oral cancer prevention, early diagnosis, and patient management with an interactive exercise. He showed images of various oral lesions and it did not take long to winnow out the audience members who could correct identify all the worrisome lesions without false positives.

Some of the images were fairly textbook, said attendee Andrew Barnes, a dental hygienist from Santa Rosa, California, but others were a helpful refresher.

“Some of the more subtle stuff, you would look at it and think, ‘that’s nothing’,” Barnes told Medscape Medical News. “You need to be reminded that that might not be nothing.” In contrast, other images might appear concerning but probably aren’t cancerous.

The review of images was particularly helpful, said James Friedman, DDS, a dentist in private practice in Greenbrae, California. “I was one of the first people to sit down because I thought something wasn’t as serious as it turned out to be,” he said.

The use of cytology for the evaluation of suspicious lesions in patients who are resistant to biopsy or who live far from a provider who does biopsies, presented by Takashi Inoue, DDS, from the Tokyo Dental College, was also helpful, Friedman added.

The prevention guidelines, also presented by Lingen, were more familiar to Barnes and Friedman, and are part of conversations they have with their patients everyday about quitting smoking, reducing alcohol use, practicing good oral hygiene, and getting vaccinated against human papillomavirus (HPV), the most common cause of oral cancer.

Although the HPV vaccine has typically been regarded as the province of pediatricians, dental providers have taken an increasingly active role in preventing 70% of the 13,500 new cases of oropharyngeal cancer diagnosed each year in the United States.

“Dentists should be at least as involved as the medical community in advising vaccination for HPV,” said Epstein. “HPV cancers are preventable, but only by immunization, and it’s part of healthcare delivery that dentists should be more involved in.”

Although the prevention of oral cancer is a mainstay of daily dental practice, far fewer dentists feel confident about caring for patients who have oral cancer, said Epstein. In one study of Michigan dentists, for example, 55% of respondents said they did not feel adequately trained to care for patients with oral cancer, and 72% said they were interested in additional education.

The first part of this education is learning how to discuss bad news with patients. Epstein explained that he uses a version of the SPIKES protocol to talk to patients about a new oral cancer diagnosis.

Understanding a patient’s preferences can guide the provider’s approach, Epstein told the audience. “Some want a frank picture, the worst-case scenarios, while others want optimistic views” and a clear picture of all the treatment options from the start.

World Dental Congress (WDC) 2019.