MD Anderson Cancer Center
Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. [phonetic] And today our guest is Mark Chambers. He is a dentist and he is a Chair in the Section of Oral Oncology here at MD Anderson and we're going to talk about dental care as it relates to cancer care. And Dr. Chambers, first welcome, thank you for coming.
Dr. Chambers: Yes, thank you.
Lisa Garvin: I think a lot of people would say why is a dentist working in a cancer center?
Dr. Chambers: Many people wonder why we are part of a large comprehensive cancer center and interestingly the first 14 faculty of MD Anderson, many years ago in the infancy of this institution there was a stomatologist, a dentist that actually was part of the faculty so we've been part of MD Anderson for many years. And we principally deal with complications that develop from a variety of oncologic treatments, treatments that may be chemotherapy, that may have radiation as part of it, as a combined treatment or radiation itself and or surgical intervention. And so each of those may have a certain oral manifestation that we are involved in enhancing the patients overall quality of life.
Lisa Garvin: And I understand, and this has been an old adage and tell me if this is true, they say your oral health is kind of a precursor or kind of a signal of your overall health.
Dr. Chambers: Sure.
Lisa Garvin: Is that true?
Dr. Chambers: I think so. You know in the United States I would say that over half of the population have varied levels of periodontal challenges and that's most certainly true in our patients here at MD Anderson. And we want to heighten what oral care can do for each of those patients and to reduce complications that may be due to having poor oral health. So you're absolutely correct. We would like to, at the beginning of the digestive tract we believe very confidently that infections and or preexisting challenges in the mouth could lead to consequences after a patient would go through a suppressive type of therapy, for example. And it could lead an individual having pain and or infection and or other challenges that could certainly cause a break in treatment, which we certainly would not like to see, and there could be consequences that need to certainly be considered before a patient starts therapy.
Lisa Garvin: And how important is it to address oral health before treatment, if possible?
Dr. Chambers: Right, if possible, and of course we are a smaller section. We don't have the luxury of having enough staff to see every patient that will be a part of MD Anderson but we believe strongly that examinations of the patients preexisting oral health is important. We believe that having infection removed first and foremost out of the oral cavity will heighten the patient's ability to have better chewing, to have less of a chance to have a sepsis, an infection that could start in the mouth and then become systemic and become very problematic for the treating oncologist. And generally speaking having a better chewing efficiency with better teeth and better gums and better bone in the mouth certainly will make for a much better quality of life.
Lisa Garvin: I understand, if at all possible, if oral surgery is needed they try to schedule it about one to two weeks before active cancer treatment?
Dr. Chambers: Right so what we try to do is we attempt to have an appropriate time of healing. We certainly would like to have the procedure, if it's oral surgery, to be done through coordination through the multidisciplinary team. We will have substantial communication with the treating physician, the oncologist, to determine when is the most appropriate time for such intervention. We would like obviously for most of the oral surgical procedures to be done before oncologic treatment begins so we do not have to be dealing with the challenges of immunosuppression or other wound healing issues. However we don't live in utopia and we do indeed have to manage and schedule these type of interventions when patients are already well underway in a treatment and could be suppressed or could have challenges from hematological blood factor standpoint. So hence it does help us to be able to discuss with a treating physician and their team importance of a healing window and we're so blessed here at MD Anderson here to have such multidisciplinary team that all of us realize that particularly with oral surgery that windows of healing are expected and are needed.
Lisa Garvin: And let's talk about the main treatment modalities for cancer. The surgery maybe not much of an effect on oral health unless it's surgery to the head and neck.
Dr. Chambers: Right.
Lisa Garvin: So if somebody is just having traditional surgery below the neck, would oral health be important?
Dr. Chambers: You know it would be important because of the fact if a person has substantial infection around a root, let's say for example, or in a jaw and they're going to go forward for an orthopedic type of procedure. We certainly do not want to see some type of limb salvage or some type of procedure being performed that could be damaged or challenged because there's oral infection preexisting and that it is the cause of a failure of a rehabilitation or a reconstruction or a tumor oblation. We will typically, if a person is going to go into a surgery that's not in head and neck and they will have tumor removed, if there's going to be any form of a an implant being placed, let's say, or an allograft of some sort, we have seen in our experience that when there's preexisting infection in the mouth, it could worsen the overall outcome of that particular procedure due to again an infection that could lead from the mouth to elsewhere on the body and the person's overall wound healing capacity could be markedly challenged. Now we add to that chemotherapy and or radiation and further the patient's competency in healing is markedly reduced. So I think that overall, even though we principally work in head and neck surgery, elsewhere on the body if there's infection on the oral cavity and the treating physician sees their overall oral examination and their physical exam that the patient has mouth issues, it would behoove them and for the patient to have oral intervention.
Lisa Garvin: And let's talk about chemotherapy because there are some chemotherapy's that have marked side effects in the oral cavity such as dry mouth or xerostomia. What are some of the oral side effects we see with certain chemotherapy's?
Dr. Chambers: Right so one of the biggest and most challenging problems that we have with our chemotherapy induced complications is mucusitis. So an individual who becomes immunosuppressed or is on a stomatotoxic style of therapy, which in essence means that the mucosal lining in the mouth and or the digestive tract may be involved once the patient starts to reduce in their overall, let's call it hematological competency, that if their white blood cells and their red blood cells and their platelets start to drop and they become more suppressed and become challenged with wound healing, mucosal barrier injury is very common in numerous oncologic treatments. Mucusitis is a painful ulcerative process that occurs in the mouth or the upper digestive tract and a patient can have problems with bleeding from the mouth, they can have problems with pain upon eating. They may stop eating. They may have increased challenges with increased nausea because of the rampant presentation of ulcers in the mouth. And so mucusitis, we coined the term mucosal barrier injury, because at a certain stage when a person is on a cycle of chemotherapy, which may be a seven day, a 21 day, a 28 day cycle, and their blood counts start to drop and they become much more immunosuppressed and where we see these sites of mucusitis potentially in the mouth, they are very vulnerable for infection, they're vulnerable for all of what I've said already and then in our opinion the quality of life is markedly challenged. We consider that a cluster effect where one problem will enhance another and then eventually patients will end up having more fatigue, much poorer quality of life, may have more pain and so overall one problem may confound another and then eventually the patient is in great suffering.
Lisa Garvin: And let's also talk about radiation therapy and I think this might be an area of specialty for you.
Dr. Chambers: Exactly.
Lisa Garvin: Obviously radiation to the head and neck, what are some of the short and long term effects of that?
Dr. Chambers: Right so acute and chronic complications of chemotherapy and radiation treatment, we will see multiple burdens. Some patients may have varying levels of these challenges but we will say for the most part that most patients with head and neck radiation treatment will have varying levels of dry mouth, particularly if major salivary glands are well within the field of radiation. So dry mouth can become so problematic for our patients with how they will taste food, how they can enjoy alcoholic beverages, how they may end up with acidic beverages, how they can control the environment of foods that will not become problematic for them such as spicy foods or very salty foods. Xerostomia is both an acute and a long term complication and if major salivary glands are well within the field of treatment, many of our patients will suffer for years to come with the dry mouth. Other issues are a poorer blood flow within the path of the treatment. So within the volume of tissue radiated, within that field of radiation a patient may have much less blood flow which can result in the future of having a patient develop bone rot, which we call osteoradionecrosis, which can be very painful. A patient can fracture their jaw, if indeed this would become an uncontrolling dilemma for the patient. Most of our patients who develop infections or who have a motor vehicle accident after a course of radiation treatment may have such an impact in the upper or lower jaws that it could lead them into a fracture, if again infection is present and then they have a blow to the mouth and or they have such profound substance in the jaws that the jaw overall weakens and it could break. So you have xerostomia, you have osteoradionecrosis and then mucusitis is also present in those patients, what I said earlier with chemotherapy. We see radiation induced mucusitis as well and most of the time these conditions are more short term on the mucusitis side of radiation and usually when the patient starts to recover from the effects of radiation they typically will do well. However the xerostomia, the osteoradionecrosis are two chronic complications that we are always faced with and are always reminding the patient of the importance of oral care and keeping their mouth as clean as possible.
Lisa Garvin: Now are there instances where you actually have to do some sort of oral treatment during active cancer treatment?
Dr. Chambers: Right so there is and obviously infection and problems with bone health are two areas that we tend to do more of our intervention while the patient is going through current treatment. Many of our patients, particularly on the bone marrow transplant side, prior to the bone marrow transplant each of our patients will have an oral examination. And we, particularly for those that will go through allogeneic transplants, those that will have donors for their bone marrow transplants, we will do an oral examination on these patients. Our goal is to eradicate infection in the oral cavity prior to the patient becoming substantially immunosuppressed. And so however unfortunately some patients may not have these oral examinations or they'll have a condition that we believe is going to be a minor problem as they go through the course of treatment and it turns out to be a major complication with pain or cellulites, which is a swelling in and around the upper and lower jaws, and we have to do intervention during the course of therapy. Many of those patients it becomes very problematic for us because our hands are many times tied due to the suppressive nature of their other bodies and we're unable to do much intervention so we try to stay as conservative as we can. We try to get the patients on the appropriate antibiotics or antifungals, antivirals and we try to heighten their overall oral health. And one of the problems that we see in the United States and in some other countries that have comprehensive cancer care is the challenge that our patients are having with bisphosphonates, which is a therapy that is given to patients that have bone challenges such as with multiple myeloma or metastatic disease from breast cancer or prostate cancer. And the bones become very weak and easy to fracture. And bisphosphonates are certainly very popular in oncology that have been shown to also have adversity in the oral cavity when there's preexisting infection and the patient starts the bisphosphonate and after two or three cycles of such they could develop a profound problem with pain, with cellulites, swelling, bleeding, that could eventually lead to a bone fracturing. So these are just some examples of what we typically do on a day to day basis within our service.
Lisa Galvin: And you actually said something that begs this question, outside of a comprehensive cancer center setting, how many cancer patients are actually having their oral health checked?
Dr. Chambers: Probably much less than what you see obviously in a multicenter or a comprehensive cancer center. I will say that the training for our general dentists, they definitely get the basics in pathology and in some of the morbidities of cancer treatment but they may have more apprehension on dealing with the newer monoclonal antibodies that are being used today and may not have a really good appreciation of what to do and when the timing to do something. So I will say that for probably over 50% of our what we call dental physicians or general dentists in Texas, let's say for example, will refer to an oral maxillofacial surgeon or into a comprehensive cancer center, when there are oral challenges. However we like to do outreaches, we do several per year, and we try to impress upon our colleagues and gentle dentistry the importance of doing routine examinations, head and neck examinations and oral examinations and what they can certainly do, if there is abnormality or adversity found in the oral cavity, is to get the patient to the correct specialist and or to an otolaryngologist, let's say for example. So we are doing a survey right now to determine just that. And we're actually surveying over 25,000 dentists in Texas to determine their referral patterns when a patient comes in with oral cancer or with breast cancer or testicular cancer, how do they handle the oral health of the patient? And what is their comfort zone in treating such patients? And we're very excited about learning from that particular survey?
Lisa Galvin: So how important is it for cancer survivors to pay attention to their oral health after active treatment has ended?
Dr. Chambers: So that's a very good question because many times obviously our major goal is to cure cancer. And many times that you may after several years and follow up you may then start feeling so good about the cure that some of the side effects and some of the ravishing challenges that have occurred to the body may be less important until one day you find yourself in an infection or in a swelling and you're not real convinced what to do next. So I will tell you that particularly with radiation to the head and neck, once radiation, always radiation challenges and particularly in the long term effects of poor wound healing and also we would say from an oral surgical standpoint we will always want those patients that have head and neck treatment with a course of the radiation to always be astute in understanding that their circulation to the jaws are markedly challenged and could lead them to bone necrosis years after they're cured and years of being no evidence of disease. These patients could still be challenged. Clear on the radiation side is where I would want to focus on on the long term survivorship patient population.
Lisa Galvin: So would they maybe see their dentist three or four times a year as opposed to two times a year as is typical?
Dr. Chambers: Absolutely. We would like to see just having our patients be seen by a general dentist twice a year. And many of our patients are not much unlike many of us who work at MD Anderson, they may see a dentist every once every five years. So we certainly would like to see a dental evaluation being done at least twice annually.
Lisa Galvin: So in closing, Dr. Chambers, is there anything you can say as a take home message to patients who are newly diagnosed or any part along the cancer journey as respect to their oral health?
Dr. Chambers: Right, I appreciate the question too, Lisa. I think that it's important for each patient who are being diagnosed with cancer, no matter where it might be on the body, is that if there's going to be intervention that will suppress their wound healing such as through chemotherapy, I think it would behoove them to have an oral examination by their general dentist, their family practitioner so that they can reduce complications for the future such as a root canal that may be necessary due to an infection on a root tip or something smoldering that's happened for numerous years that up until now really may not have been an issue but now as we suppress the person and their hematological parameters, it may be that this person is in great need of having such tooth examined. So I would say to get their mouths cleaned, to be on a daily regiment to reduce acidity in the mouth. I would say it's important for us to keep our mouths clean and brush our teeth at least twice daily. I feel confident that if there is pain in a tooth, pain in the bone, pain in the mouth somewhere in the upper or lower jaw that they should be evaluated and by either a dental specialist or a general practitioner. So keeping the mouth clean in my opinion can certainly help the patient in the long run as part of other daily care for health of their body.
Lisa Galvin: Great, thank you very much.
Dr. Chambers: Thank you.
Lisa Galvin: If you have questions about anything you've heard today on Cancer Newsline contact ask MD Anderson at 1-877-mda-6789 [background music] or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
© 2013 The University of Texas MD Anderson Cancer Center
1515 Holcombe Blvd, Houston, TX 77030
1-800-392-1611 (USA) 1-713-792-6161