How do dentists support oncology teams during cancer treatment?

How Dentists Support Oncology Teams During Cancer Treatment

Dentists are integral members of the multidisciplinary oncology team, providing coordinated oral care assessment before cancer therapy initiation, implementing preventive protocols during treatment, and managing oral complications to reduce treatment-related morbidity and maintain quality of life. 1

Pre-Treatment Dental Assessment and Coordination

Before initiating cancer therapy, comprehensive oral evaluation must be performed to identify and address dental issues that could complicate treatment. 1

Initial Evaluation Components

• Complete oral and head/neck examination with panoramic radiographs and full-mouth intraoral radiographs to assess existing periodontal disease, dental caries, periapical pathology, and oral hygiene status 1
• Risk assessment for caries and periodontal disease based on patient's past dental history, motivation, and compliance 1
• Medically necessary dental extractions should be completed at least 2 weeks before starting radiation therapy or bone-modifying agents (BMAs), considering long-term prognosis of teeth and patient motivation 1

Care Plan Development and Communication

• A dental care plan must be developed and coordinated between the dentist and oncologist to ensure medically necessary procedures are completed before therapy initiation 1
• Dentists should receive the patient's medical diagnosis and complete antiresorptive/angiogenic inhibitor profile from the oncology team 1
• Patients referred from oncologists should be seen by dentists within 2 weeks of referral 1

Prevention of Treatment-Related Complications

Medication-Related Osteonecrosis of the Jaw (MRONJ) Prevention

For patients receiving BMAs at oncologic doses, dentists play a critical role in preventing MRONJ through coordinated care and risk factor modification. 1

• Address modifiable risk factors early: poor oral health, invasive dental procedures, ill-fitting dentures, uncontrolled diabetes, and tobacco use 1
• Elective dentoalveolar surgical procedures (non-medically necessary extractions, alveoloplasties, implants) should NOT be performed during active BMA therapy at oncologic doses, unless reviewed by a dental specialist with MRONJ expertise 1
• If dentoalveolar surgery is required, evaluate patients every 6-8 weeks until complete mucosal coverage occurs, with ongoing communication to the oncologist regarding healing status 1

Osteoradionecrosis (ORN) Prevention for Head and Neck Radiation

Radiation therapy to the head and neck dramatically increases risk of dental caries and osteoradionecrosis due to xerostomia and salivary gland dysfunction. 1

• Patient education (oral and written) regarding oral/dental complications of radiation therapy and need for compliance with preventive protocols 1
• Maintain range of motion exercises for masticatory muscles using tongue blades, gentle stretching, or custom mouth-opening devices to prevent trismus 1
• Implement daily fluoride application protocols to prevent radiation-related caries that can appear within 3 months post-radiation 1

During Active Cancer Treatment

Routine Monitoring Schedule

Follow-up by the dentist should be performed every 6 months once BMA therapy has commenced, with more frequent visits for high-risk patients 1

Ongoing Dental Care Activities

• Conduct complete dental examinations with orthopantomography and intraoral radiographs 1
• Evaluate oral mucosa integrity and perform annual orthopantomography during antiresorptive therapy 1
• Reinforce ongoing education about maintaining good oral hygiene and lifelong commitment to oral care 1
• Manage xerostomia, prevent/treat dental caries, prevent/manage oral candidiasis, and monitor for trismus 1

Basic Oral Care Protocol Support

Dentists guide patients in daily oral hygiene routines to reduce oral tissue injury and associated complications. 1

• Instruct patients to brush teeth and gums four times daily with soft brush and mild fluoride-containing, non-foaming toothpaste 1
• For patients on targeted therapy, recommend saline-containing mouthwashes instead of plain water due to increased microbial burden and infection risk 1
• Alcohol-free mouthwash should be used at least four times daily after brushing 1

Management of Oral Complications

MRONJ Detection and Treatment Coordination

When suspected MRONJ is observed, the dentist or oncologist should refer to a dental specialist for additional treatment management. 1

• Diagnosis requires: (1) current/previous BMA or angiogenic inhibitor treatment, (2) exposed bone or bone probeable through fistula persisting >8 weeks, and (3) no history of jaw radiation or metastatic disease 1
• Initial conservative treatment includes: antimicrobial mouth rinses, antibiotics if indicated, effective oral hygiene, and conservative surgical interventions (e.g., superficial bone spicule removal) 1
• Management should be on an 8-week follow-up schedule with the dental specialist 1

Communication with Oncology Team

Continuous bidirectional communication between dental and oncology teams is essential throughout the cancer treatment continuum. 1

• Dentists send diagnosis and treatment plans to oncologists and coordinate if oral surgery is necessary 1
• Oncologists inform dentists of required dental assessments and provide updates on BMA therapy status 1
• Communication regarding healing status is particularly important when considering future BMA use 1

Common Pitfalls and Barriers

System-Level Challenges

Significant barriers exist in providing coordinated oral care for oncology patients, including minimal correspondence between provider teams and lack of standardized protocols. 2, 3

• Insufficient time for dental care before therapy initiation (61% of dentists report this obstacle) and lack of patient education on oral complications (56%) 2
• Only 50% of dentists feel adequately trained to treat oncology patients, and 46% infrequently follow NIDCR recommendations 2
• Many NCI-designated comprehensive cancer centers (56%) do not have dental departments, resulting in fragmented care delivery 3

Clinical Practice Gaps

Variability in referral patterns and lack of standard protocols compromise optimal oral care delivery. 2, 3

• Dentists report minimal correspondence from oncology teams during referrals, limiting coordinated care 2
• Financial/insurance factors and lack of dental insurance (31%) create barriers to medically necessary oral care 2
• No standard protocols exist at many centers for oral preventive care or supportive services during/after cancer therapy 3