Comments and recommendations posted on this website are based on the clinical experience of the dentists/dental clinic at Princess Margaret Cancer Centre. The dental clinic was established in 1984 and since that time, a patient database has recorded the following information:
28,000 cancer patients have been referred to our service for dental care
- ~ 47% of these patients have cancer of the head and neck region referred prior to radiation therapy for dental evaluation
- ~ 30% have hematologic malignancies (leukemia, lymphoma and multiple myeloma) and are referred prior to autologous or allogeneic stem cell transplantation for dental evaluation
- Remaining cancer types are usually referred while in treatment with dental concerns/emergencies
- >1500 new patients seen in 2014
- Continued follow-up on these patients for average of 5 years post treatment to monitor for side effects
- Requirements for patients about to be treated for cancer differ from those that are required by the average patient in a dental practice. While on occasion it may be permissible to observe areas of suspected infection in some patients, this changes when a patient is diagnosed with cancer.
As a guiding principle the primary goals of treatment are: to treat or remove sources or potential sources of infection, to promote scrupulous oral hygiene and to educate the patient in the importance of lifelong preventive dental care. In general, at our institution patients will be prepared for their cancer care by our team. We do this in order to meet and exceed the clinical needs of our medical, radiation, and surgical oncologists. Additionally necessary dental care must be done rapidly so as not to delay cancer treatment.
Patients are followed for a period of time but virtually all of them will return to you, their general dental practitioner for ongoing care. This is a necessity because our clinic sees over 1,500 new patients per year with 12,000 patient visits per year from numerous anatomical cancer site groups. Whilst dental patients with cancer, like all patients require individualized treatment planning and care plans some GENERAL guidelines for oncology patients include:
- Updating the medical history at each dental visit including current cancer treatment, and medications. This may include the presence of central lines and blood counts if the patients have been treated with chemotherapy. Encouraging your patient to assist you by acquiring their blood counts from their oncologist would be beneficial.
- Becoming familiar with chemotherapy drugs or knowing how to access information about them from on-line sources, compendium of pharmaceuticals or texts.
- Arranging more frequent routine dental examinations and cleanings for patients who may require this.
- Exposing more frequent radiographic examinations to look for occult disease. This differs from the non-oncology patient where radiographs should be exposed only after clinical examination.
- Recognizing “dry-mouth caries” that occur after head and neck radiation, some chemotherapy regimens and in the elderly cancer patient; and instituting plans at preventing and treating it.
- Diagnosing problems when they are small and treating them.
- Promoting of the highest level of oral hygiene and self oral care.
- Promoting and enforcing the use of daily neutral pH sodium fluoride gel use in custom fluoride carriers for some patients where it has been prescribed.
- Avoiding extractions, implants and invasive surgical procedures in a selected group of patients such as those receiving head and neck radiation, those with low blood counts and those receiving intravenous bisphosphonates or denosumab.
- Consultation. It is in your patient’s best interests to be knowledgeable about their disease, its treatment and sequelae both medically and dentally. With current advancements in treatment, this is not information that you would be expected to know readily. Once you obtain your patient’s consent to speak with us about their needs, we would be pleased to discuss the generalities and specifics of their dental treatment plan and management.
The Cancer Patient
Cancer is a general term referring to malignant neoplasia. As such, it represents approximately 200 different types and therefore, the therapy is quite variable depending on the type and stage. Below is a table showing the most common types of cancer in males and females with the mortality rates as well as the rates for oral cancer in Ontario.
Most common types & Mortality of Cancer in Ontario
(Canadian Cancer Statistics 2014)
|Type||Male Incidence of cancer||Female Incidence of cancer||Mortality|
The Patient with a History of “Cancer”
There are an estimated 187,600 new cases of cancer that will be diagnosed in 2013 with 75,500 cancer deaths in Canada. The most common cause of death in Canada is cancer accounting for almost 30%. The most common types of cancer are lung, prostate, breast and colorectal accounting for 50% of all new cancers. Forty per cent of cancer deaths are a result of either lung or colorectal carcinoma. You will definitely encounter cancer patients in your practice. By taking a careful history, you should be able to determine whether safe dental care can be provided. Overall, it is your responsibility to manage the dental needs of your patients. This may involve a compromised treatment plan in light of the overall health of your patient.
Note: The total of all deaths in 2011 in Canada was 242,074.
Adapted From: Statistics Canada. Leading Causes of Death in Canada, 2011, CANSIM Table 102:0522
The patient who presents either as a new patient or a long-standing one with a history of any type cancer requires a review of his/her medical history with details about his/her cancer. This is called a review of systems or functional enquiry and gives specific important information that may be relevant for safe dental care. A review of systems provides information on the stability and the severity of the disease. The steps involved in retrieving this information are as follows.
Review of Systems (Functional Enquiry)
- What type of cancer?The type of cancer is important because it dictates treatment and given the stage connotes prognosis. Also, some cancers have a predilection for metastasis to bone including the jaws (e.g prostate and breast) and the dentist may be instrumental in making this diagnosis as they may appear with dental symptoms. Also, these types of malignancies are often treated with intravenous bisphosphonates which have significant dental ramifications. Some cancers (eg melanoma) have an unpredictable course with ongoing therapy a necessity.Percent distribution of estimated cancer deaths by sex, Canada 2014
(Canadian Vital Statistics Death database, Statistics Canada)
- What type of treatment?Generally, surgery, radiation therapy, chemotherapy, bone marrow/peripheral stem cell transplants or any combination of these are the mainstay of treatment. Some cancer therapies have little or no impact on safe dental care while others carry significant risk and morbidity. Surgical resection of a tumor at an anatomic site away from the head and neck has little impact on dental care other than what is listed above. Radiation therapy at an anatomic site away from the head and neck may be regarded similarly. The addition of chemotherapy to the therapeutic regimen may be significant depending on how long ago it was administered. Most chemotherapy is myelosuppressive and may affect blood counts that could impact safe dental care.
- When was it diagnosed and treated?For patients currently undergoing cancer therapy, elective dental care depends on how well the patient is feeling and whether their treatment has affected their blood counts. Consideration should be given to patients who cancel their dental appointments if they are not feeling up to having dental care.Normal blood counts
Males Females Hemoglobin (Hb) 140-180g/L Females 120-160 g/L White Blood cell count (WBC) 4.0-11.0 x 10 -9/L Platelets 150-450 x 10-9/L Neutrophil count (PMN) 2.0-7.5 x 10-9/L
For patients who are currently undergoing cancer therapy and require emergency dental care, most non-invasive procedures may be carried out pending stable blood counts. If this is unknown, consultation with the oncologist is necessary. For patients who have had cancer treatment in the past and are no longer being treated, knowledge of the type of cancer and therapy will help in determining whether invasive procedures are possible. For example, radiation therapy to the head and neck area confers a lifelong contraindication to extractions or implant placement in the field of radiation.
- How often is there follow-up with the oncologist?The frequency of follow-up is a fairly reliable indicator of the stability of the condition. This is applicable to any disease that is being treated. If the follow-up is annually or less, it is more likely that the disease is either in remission or well-controlled. However, if the follow-up is more frequent, ongoing therapy may be contemplated.
In summary, having this information will help you decide whether your dental treatment plan requires alteration or whether you can proceed as normal or whether a compromised treatment plan is more appropriate.