Cancer Patient Dental Evaluation
Pre-Cancer Surgery and Pre-Phosphonate Dental Evaluation
If you have been diagnosed with an oral or pharyngeal cancer, radiation may be part of your treatment. If you have severe osteoporosis or a cancer that is metastatic or a bone disease you may be put on a bone metabolism altering drug of the class bisphosphonates.
In either of these cases action should be taken in advance. Both radiation and bisphosphonates can cause tooth bearing bone disease.
In the case of radiation: the radiation causes loss of blood flow to the bone and surrounding tissues and loss of some salivary production. The loss of blood flow causes the bone to not heal well and in severe cases can cause a disease calledosteoradionecrosis (ORN). ORN causes further bone death and one can loose their entire jawbone to it. The lack of saliva is a serious problem. Saliva is a protectant to teeth and soft tissues of the mouth and important in swallowing. Loss of salivary production will result in significantly increased caries susceptibility and poor healing of oral wounds and difficultly swallowing.
Bisphosphonates alter the way bone heals itself by inhibiting osteoclast action. Bisphosphonates inhibition of osteoclasts causes the bone’s density to increase and cancers or diseases’ effect on bone can be halted. That is why they are used in severe osteoporosis, bone diseases and cancers. The list includes the following;
- (Actonel) Risedronate – osteoclast inhibitor
- (Fosamax) Alendronate – osteoclast inhibitor
- (Didronel) Etidronate – osteoclast inhibitor
- (Hectorol) Doxercalciferol – PTH inhibitor
- (Skelid) Tiludronate – osteoclast inhibitor
- (Aredia) Pamidronate – osteoclast inhibitor
- (Zometa) Zoledronic acid – osteoclast inhibitor
- (Forteo) Teriparatide – calcium absorption – note; Forteo is in this class of drugs as a calcium metabolism affecting drug but it doesn’t affect bone cell and it probably okay
If the bone becomes exposed as in the case of an extracted tooth or an injury to the gums or if a tooth becomes abscessed, the bone will not be able to heal. Loss of large portions of the jaw can result. To prevent these untoward consequences of radiation therapy and bisphosphonate use, evaluation by a dental professional is imperative. Appropriate dental treatments should occur prior to radiation or bisphosphonate induction. In the case of surgical procedures such as extractions, they should ideally be done 6 weeks prior to induction of radiation or bisphosphonate treatment.
The evaluation by your dental specialist should look for caries and periodontal disease. Any tooth that has a questionable prognosis should be extracted early. Extractions in the future could cause non-healing sites that could result in bone loss. In the case of radiation therapy, the loss of salivary flow will require fluoride trays to be made for daily use at home. Frequent visits to your dentist (on a quarterly basis) will be necessary to ensure proper oral health. If extractions are necessary in the future for patients who have had radiation in the area of the tooth to be extracted and the level is 6,000 rads or greater then extractions must be accomplished using a hyperbaric oxygen therapy protocol. The protocol requires 20 “dives” with 100% oxygen for 60 minutes at 2.4 atmospheres pressure prior to the procedure followed by 10 “dives” after. The “dives” are done at one of the regional hyperbaric oxygen (HBO) chambers.