Oral Care Before Cancer Treatment

Cancer. The New Oxford American Dictionary defines it as “the disease caused by an 

Cancer. The New Oxford American Dictionary defines it as “the disease caused by an 

uncontrolled division of abnormal cells in a part of the body;” but for the millions of 

people it has touched, cancer is so much more. 

Cancer is a constant unwanted companion that 

opens the door to an unchosen journey and 

demands to be followed.

 

Cancer is a constant 

unwanted companion that 

alters the well-being of those it afflicts. Modern 

treatment regimens given to combat this

disease come with a host of deleterious side 

effects, many of which occur in the mouth. 

 

 

Dentists, dental hygienists and dental auxiliaries 

are in a unique and necessary position to make

a positive impact in the lives of patients battling 

cancer. 

 

Making a difference begins with a desire to help and a willingness to take a risk. It is 

followed by a commitment to learn about the unique oral health care needs of patients 

engaged in the fight of their lives and put into practice skills that can literally provide 

comfort and hope. We, as dental professionals, can and should be a part of a 

comprehensive cancer care team for an ever-growing number of people facing cancer.

 

DENTAL ONCOLOGY 

 

Dental oncology is a focus of dentistry dedicated to meeting the unique dental and oral 

health care needs that arise as a result of cancer therapy. It is an area of oral medicine 

devoted to improving the well-being and quality of life of people battling cancer. Dental 

oncology goes beyond the scope of general dental treatment to include management of 

the soft tissues of the mouth and care for oral side effects specific to cancer therapy. A 

dental professional knowledgeable in dental oncology plays an important role 

throughout cancer treatment by preventing and managing mouth sores, dental needs, 

oral pain and infections. As a member of the patient’s oncology care team, the dental 

professional communicates directly with the medical oncologist, radiation oncologist and 

other team members to provide optimal comprehensive care before, during, and after 

cancer treatments. 

 

Ideally, a patient’s relationship with a dental professional begins as soon as possible 

after receiving the diagnosis of cancer. Most of the present-day treatments for cancer 

involve the administration of cytotoxic drugs, radiation, myelosuppressive treatments or 

some combination thereof. Having a baseline assessment completed before the 

implementation of immunosuppressive therapies allows the dental professional to have 

a pre-treatment reference point to compare oral and systemic health at future visits. 

 

For the newly diagnosed patient with cancer who has not received regular dental and 

oral health care, a prompt visit to the dentist’s office also allows for immediate attention 

to unaddressed periodontal issues and unresolved dental needs before 

immunosuppression begins. During cancer treatments, bacterial components of 

calculus, dental plaque and oral biofilm can easily become vehicles for bacteremia or 

oral infections. Properly addressing these oral health concerns at this pre-treatment 

stage can prevent or significantly reduce the severity of oral issues that could 

complicate or even interrupt the patient’s cancer treatment schedule. 

 

ORAL HEALTH CARE BEFORE CHEMOTHERAPY 

 

Chemotherapy is the treatment of choice for a wide range of cancers. It can be used 

either alone or in combination with other treatment modalities. The goal of 

chemotherapy is to eradicate the rapidly dividing cancerous cells, but unfortunately 

these drugs often cannot differentiate between cancer cells and other types of cells that 

divide rapidly under normal conditions within the body. These cells include bone 

marrow, hair, and the mucosa of the entire gastrointestinal tract, including the mouth.

 

Because chemotherapeutic 

agents are used to combat 

cancers of all types, the dental 

professional is needed to care for 

patients with most kinds of 

cancer, not just malignancies 

relevant to structures within the 

head or neck. 

 

Because chemotherapeutic 

agents are used to combat cancers of all 

types, the dental professional is needed to 

care for patients with most kinds of cancer, 

not just malignancies relevant to structures 

within the head or neck. 

 

Optimally, the patient should see a dental 

professional well enough in advance so that 

all 

dental procedures can be completed one 

week before beginning chemotherapy. At a 

minimum, dental procedures that might 

introduce bacteria into the bloodstream 

should be completed in this timeframe. 

Close communication with the medical 

oncologist is of paramount importance as 

each member of the oncology team needs 

to be aware of the scheduling of all 

care 

related to the patient. Communication 

should include a summary of the present 

 

oral health of the patient, a treatment plan of essential dental care, and an anticipated 

timeline of when that care can be completed. The dental professional should also 

confirm that the medical colleagues on the oncology team understand the nature of 

anticipated oral complications during treatment and be prepared to function as the 

expert able to address those oral health issues.

 

Dental management before chemotherapy should include a thorough baseline dental 

and periodontal assessment with close attentions paid to conditions that could be 

problematic during times of immunosuppression. Preemptive measures should be 

taken to correct or remove any possible sources of oral trauma. These might include 

broken teeth or ill-fitting existing restorations or prostheses. Non-restorable teeth that 

pose an infection risk in the short term should be extracted. This would include any 

tooth affected by severe periodontal disease or deemed to be of endodontic concern. 

Partially-erupted third molars should be evaluated and be extracted if they are at risk for 

for pericornitis. A thorough dental prophylaxis including scaling and root planing must 

be completed. Decreasing the existing intraoral bacterial load is one of the best 

preventive services that can be performed for the patient scheduled to undergo 

chemotherapy. Carious lesions and tooth-born fractures should be restored. Resin 

modified glass ionomer is a good restorative material choice for these patients as 

xerostomia is anticipated during cancer treatment. Any orthodontic bands and wires 

should be removed and orthodontic treatment postponed until cancer treatment is 

completed. Oral hygiene instructions should be reviewed, even for regular dental 

patients. Educating about possible or anticipated oral issues and reassuring the patient 

and the family they are not alone in this battle builds confidence and strengthens the 

dental professional/patient relationship. 

 

ORAL HEALTH BEFORE HEAD AND NECK RADIATION THERAPY 

 

Radiation therapy is routinely used to treat tumors in the head or neck, often in 

combination with chemotherapy or immunotherapy. Head and neck radiation, unlike 

radiotherapy in other parts of the body, creates issues of particular concern for the 

dental professional. Patients undergoing head and neck radiation therapy often 

experience permanent life-changing side effects from their cancer treatment. 

Understanding these complications at the pre-treatment assessment positions the 

dental professional to be of the most service. 

 

The pre-treatment assessment appointment for the patient undergoing head and neck 

radiation begins with a full-mouth series of radiographs. A clinical examination including 

complete periodontal charting must be combined with the radiographic evaluation to 

assess periodontal condition, to diagnose periapical pathology and to identify teeth 

requiring immediate attention. All possible sources of intraoral trauma must be 

 

resolved. Because trauma to irradiated bone poses a risk for osteoradionecrosis, the 

dental professional must evaluate the current condition of the teeth and periodontium 

and anticipate the patient’s ability to maintain meticulous oral hygiene for the remainder 

of his or her life, often in challenging intraoral conditions. All non-restorable teeth 

should be extracted. Those teeth with moderate to severe periodontal disease and 

partially-erupted third molars within the anticipated field of radiation should also be 

removed. Other teeth in the planned field of radiation should be evaluated in light of the 

patient’s current hygiene status and dental history, the presence of high-risk deleterious 

habits or co-morbidities (e.g. smoking and diabetes mellitus), the patient’s commitment 

to regular professional dental visits, and the risk of osteoradionecrosis. Any decision by 

the patient to refuse to comply with the dental professional’s recommendation should be 

well-documented in the patient’s chart. All remaining teeth must be thoroughly cleaned. 

Dental impressions should be taken from which fluoride trays can be fabricated for the 

patient’s at-home use. The dental professional should counsel the patient and his or 

her family concerning the anticipated complications of head and neck radiation therapy 

and the life-long changes that must be made in oral health care. 

 

Communication between the dental professional and radiation oncologist is extremely 

important. The dentist should understand the anticipated scheduling of radiation 

treatments and must know the amount of radiation planned for each of the jaws. 

Similarly, the radiation oncologist should be aware of all necessary dental treatment and 

the anticipated timeline to complete it. The timing of dental surgery is of utmost 

importance: at least 14 days should be available for healing following any surgery 

before radiation therapy commences. The dental professional should understand that 

tumors of the head and neck are often times fast moving and require expeditious 

treatment. Every effort should be made to accommodate head and neck patients for 

treatment as soon as possible. There are times, however, when the nature of the tumor 

may be such that radiation therapy must be initiated immediately and not allow 

adequate time for dental work to be completed. In these cases, dental care should be 

postponed until the completion of radiotherapy and the patient has sufficiently 

recovered. Dental care should be avoided while the patient is undergoing radiation 

therapy, but should be completed as soon after radiotherapy as possible since bone 

changes associated with radiation worsen over time. 

 

ORAL HEALTH BEFORE BISPHOSPHONATE THERAPY 

 

Bisphosphonate therapy is used extensively in patients with metastatic bone disease. 

These drugs, which include Zometa®(zoledronic acid) and Aredia®(pamidronate), are 

administered intravenously through a portacath. They fall into a unique class of drugs 

that are characterized by their affinity for bone and the ability to inhibit bone resorption 

through decreased osteoclastic activity. Because they limit bone turnover, these drugs 

have been implicated in osteonecrosis following dental surgery subsequent to 

bisphosphonate therapy. Drug potency and accumulation seem to be important factors 

in assessing whether or not a patient is at risk for developing bisphosphonate-related 

osteonecrosis of the jaw. 

 

If non-restorable teeth exist in a patient who will be undergoing bisphosphonate therapy, 

they should be removed at least 14 days before the introduction of the drug, if possible. 

Partially-erupted third molars and teeth with moderate to severe periodontal disease 

should be considered for extraction. Precautions similar to those for patients 

undergoing head and neck radiation should be considered in evaluating teeth for 

possible extraction as the half-life bisphosphonates can exceed ten years. All dental 

professionals should be aware that a history of bisphosphonate disclosed in a medical 

history should be carefully considered and evaluated to assess the risk for 

bisphosphonate-related osteonecrosis of the jaw.