BY ELIZABETH WHITTINGTON | APRIL 13, 2012
Yesterday, CURE magazine hosted a Facebook chat on dental health with Dennis M. Abbott, DDS, founder and CEO of Dental Oncology Professionals of North Texas.
We had a good crowd who asked some great questions. You can view the chat in its entirety on our Facebook wall (you can view it here).
We also had some great questions posed before the chat on the Events page. Here are a few of those questions and Dr. Abbott's answers.
Sara asks: I had perfect teeth before cancer. After my diagnosis, chemo and radiation, everything went downhill. I had a tooth shatter and another one is ready to give out, and I have "surface cavities." When I mention to my dentist if these could be chemo and radiation related, my dentist shrugs it off. What do you think?
Dr. Abbott: @Sara...Unfortunately, you're not the only one who has had experiences like this. We have known and understood for some time that some chemotherapeutic agents and head and neck radiation affect salivary flow and thus increase susceptibility to dental decay. I, however, do believe that there is still much we don't know. It is very possible that some chemo agents could contribute to weakening teeth, and it is extremely likely that weak teeth are a long-term effect of radiation where the teeth were in the field. I know that this answer doesn't directly help your teeth, but I truly appreciate you sharing your story because it helps us understand associated risks. This influences research and information we can share with patients in the future.
Kenda asks: I was on Fosamax 5 years ago, was diagnosed with stage 4 breast cancer that spread to the bones and switched to Zometa. Since September, I've been on Xgeva. What are my risks for the jaw problems?
Dr. Abbott: @Kenda...You should know that because of the bisphosphonate therapy you have received/are receiving, you are at a higher risk for bone necrosis than someone who has not taken these meds. The scientific community believes that risk is directly related to dose. "Dose" means the strength of the bisphosphonate, route of administration, and the frequency/duration of treatment. This risk is usually only realized if dental surgery is necessary - like having a tooth pulled. Should you ever require an extraction, please MAKE SURE your dentist or dental oncologist FULLY understands your medical history (especially bisphosphonate therapy).
Kevin asks: Is it common to have sensitive gums after radiation and chemo?
Dr. Abbott: @Kevin...the short answer is yes. Everyone is different and in the world of medicine that adage is especially true. If you are experiencing sensitivity, tell your dentist or dental oncologist. There is much he or she can do to help!!!
Cathy asks: How do you know if your dentist knows how to treat cancer patients? What information do you make sure he/she knows? What questions do you ask?
Dr. Abbott: @Cathy...the first thing to do is ask! Most dentists are not going to lie to you. If they are not comfortable treating you (for whatever reason), they will refer you to someone they trust that can meet your needs. I think some basic questions are: What components of my blood work are most important for you to review prior to dental work? (The answer to this is Absolute Neutrophil Count - ANC - and the Platelets. He or she should be able to discuss what the values should be and what to do - or not do - when these values are not where they should be.) You could also ask what he or she does to manage xerostomia or treat mucositis. These are the most common complications due to cancer therapies. He or she should have a definitive answer for this question.
Jodie asks: What should a parent know about dental issues for their child with cancer? I did my own research and had to find someone who was familiar in with dealing with immunosuppressed children. What are some long-term effects of chemo on our children's teeth? What should we watch for and be aware of?
Dr. Abbott: @Jodie...This is a great question. Parents should know that cancer therapies can wreak havoc in kiddos' mouths just like adults. It is not uncommon for pediatric patients to experience mucositis (mouth sores) and dental decay (especially if their treatment causes severe dry mouth). In addition to dealing with these conditions that are similar to adults, children's have dental developmental issues. Some cancer treatments may affect adult tooth development and/or pediatric teeth (baby/milk teeth) loss. Some kids make it through chemo without much long-term trouble at all. Others experience many, many teeth and oral health problems. Unfortunately, there is no one answer that can apply across the board. I would say that awareness is the best way to handle the issue. Understand that cancer treatments can affect dental health. Have regular dental exams and cleanings. Take fluoride treatments at those visits - and more often if necessary. Fix any dental issues (cavities) as soon as you are aware of them. If you notice a pattern of dental problems, please talk to your dentist or dental oncologist about your concerns.
Kevin asks: I am an oral cancer patient who had radiation. My insurance is balking on paying for new fluoride gel prescriptions and new trays, but they will pay for bi-annual treatments in the office. What is your feeling about the sufficiency of that treatment? My dentist says she can find no evidence of radiation damage and my teeth appear to be in great shape.
Dr. Abbott: @Kevin...I totally feel your frustration with insurance companies! I think the thing to look at in your case is the recommendation of your dentist. If she feels like your teeth are in great shape, then fluoride trays may not be necessary. In my opinion, fluoride trays are superior to bi-annual in-office treatments...but again, I must defer to the recommendation of your dentist. She is the one who has the benefit of actually seeing you, in-person. Treatment should always be personalized. Just because fluoride trays are best for one person doesn't mean that they are the only option for you.
Christine asks: What is your dental office's policy on oral cancer screenings? Do you automatically screen your patients?
Dr. Abbott: @Christine...Oral cancer screenings should be a part of EVERY dental office's standard of care. Yes...we automatically screen patients. We also offer an exam with a multi-wavelength diagnostic light for an additional nominal fee ($32), but this is in addition to our standard oral cancer examination.
Linda asks: How do I approach my medical insurance about dental care? I had the root rot on two teeth that were anchors for bridges and had to have them extracted and new bridges built to the tune of $9000. My dental insurance only covers $1000 per year, and my health insurance policy says it has to be due to an accident. How do I approach this with my medical insurance?
Dr. Abbott: @Linda...this is a tough one, because I know you're not going to like my answer. Unfortunately, insurance is a contractual agreement between the company and the insured. Within that contract are many stipulations regarding what will and will not be covered. It has been my experience that insurance companies will not stray from that contract. Most medical policies will only cover dentistry when it is related to an accident. Some will cover extractions in unusual cases. One of these "unusual cases" that is SOMETIMES covered is the need for extractions prior to head and neck radiation. Again, this is on a case-by-case basis and is dependent upon how your policy reads.
Rhonda asks: Should I avoid sugar? Can I use whitening trays? I use fluoride trays, salagen, floss and brush at least four times a day. So far, so good, and I want to keep it that way. Does everyone have teeth problems eventually or is what I'm doing enough for me to continue having no problems?
Dr. Abbott: @Rhonda...let's face it, most people are not going to avoid sugar completely. Carbohydrates that damage teeth come in many forms...white, sticky bread; sports drinks; sweetened green tea; ice cream; etc. While these foods have actual nutritional value, they also cause decay in teeth when left on the tooth surface. Minimizing "cariogenic foods" (foods that cause dental decay) will help. Brushing, or at least rinsing with water, after eating such foods is a great practice. It sounds like you are doing a good job with the brushing and flossing and making sure your dry mouth is kept in check. Continue to keep up the good work! Regarding whitening trays...you should really talk to a dentist or dental oncologist who has the benefit of seeing you in person. He or she would also be the one to answer your question regarding if what you are doing to sufficient. Understand, however, that many, many people do have dental issues related to cancer treatments.
Cathy asks: What are the limitations to dentistry if you are taking a bisphosphonate or the newer Xgeva for your bone health?
Dr. Abbott: @Cathy...patients with a history of bisphosphonate usage should be cautious when undergoing any dental procedure that causes insult to the bone. This most often means extractions (teeth pulling). Bisphosphonates work because they decrease the activity of cells in the bone that remodel the bone matrix. This eliminates the bone's ability to heal after an extraction and causes bisphosphonate-related osteonecrosis (dead bone) which is a very difficult situation to manage. The result is often pain and an increased risk of infection for the patient suffering from osteonecrosis. The risk of a patient developing osteonecrosis seems to be directly related to the dose of the bisphosphonate. Patients taking bisphos via IV (like Zometa, Aredia, Xgeva) are at highest risk.
Dale asks: What should I recommend for patients when they experience a metallic taste after radiation that makes their food taste terrible?
Dr. Abbott: @Dale...this is a great question, and one that we deal with on a pretty regular basis. First, make sure that the patient is not using metal utensils. When my mother-in-law was going through chemotherapy, she would eat with plastic "silverware". For some, that's enough to help. For those who still experience that metal taste, we have had some success with an antioxidant rinse put out by PerioSciences. Email me for more information...email@example.com.
Linda asks: I would like to ask Dr. Abbott what recommendations he has for general preparation for chemotherapy? In my case, mitomycin and 5FU, especially regarding sore gums/mouth ulcers.
Dr. Abbott: @Linda...the first thing I would say is make sure your mouth is clean before starting chemo. I know this sounds basic, but we have seen a correlation between oral hygiene status and the severity of mid-chemo or post-chemo complications. Have a baseline visit with your dentist or dental oncologist before starting chemo. Have a thorough dental cleaning. Make sure your dentist or dental oncologist knows what kind of treatment you're about to undergo. Understand that dry mouth is a big problem. Keep your mouth moistened and talk to your dentist or dental oncologist about salivary substitutes or stimulants, if necessary. Some of my patients have sworn by popsicles. (Please make sure they're sugarless!) They have used them during infusions - and there is some research to warrant ice therapy may have some benefit. (The same could be true for eating ice chips.) If problems do arise, treat them early. Again, let your oncology team know. There are some great prescriptions out there that can help!
Lauren asks: I have had 8 rounds of Hyper C-Vad and several rounds of CHOP for mantle cell lymphoma, and then a stem cell/bone marrow transplant. My dental work was put on hold for about 2 years, and when I did resume I had 6 cavities after many years of not having any. Since then I have had only 2. Will this continue to be an issue and is there anything I should be doing as a preventive measure?
Dr. Abbott: @Lauren...it's hard for me to say whether or not this will continue to be an issue. It sounds like, however, you are NOT on a downward spiraling roller coaster - and that is a GREAT thing! Continue to pay close attention to your oral health. Make sure your dentist or dental oncologist knows and understands your previous treatment. Six cavities in two years of not going to the dentist (especially given all that went on during those two years) is not too bad. Stay on top of your oral health. Get professional dental cleanings on a regular basis (which may be as often as every three months!). Use fluoride and/or treatments for dry mouth as recommended by your dentist or dental oncologist.
Kathy asks: I postponed my routine dental appointment until a few weeks after my last chemotherapy (taxotere and carboplatin). I believe they will be doing xrays this time. Is it really necessary to have xrays taken every year? I am leery of any procedures that might increase chances of cancer recurrence.
Dr. Abbott: @Kathy...this is a very timely question given the news that broke yesterday. First, let me say that the study that was in the news yesterday is suggestive and offers no hard evidence. Even Dr. Otis Brawley, the American Cancer Society's chief medical officer said that we can't draw definitive conclusions from that study. Now...I think you can ask your dentist or dental oncologist if they are using digital x-rays (which use 90% LESS radiation than conventional films). It is VERY important to see what's going on below the surface...and dental x-rays are the only way to do that. We must make certain that there is not decay on the root surfaces of the teeth or between teeth. These areas are highly susceptible in patients who have had dry mouth (and chemo). Also decay in these areas moves very quickly, making early intervention paramount in the success of treating the tooth.
Kathy asks: My white blood cell count is still a little low. Is it possible to get an infection from routine cleaning?
Dr. Abbott: @Kathy...the short answer is YES. Your dentist or dental oncologist should know your white cell counts and plan accordingly. During a dental cleaning, the bacteria that is being removed from your teeth has a chance to enter the bloodstream (since some amount of bleeding usually occurs with a dental cleaning). Your dentist or dental oncologist should know if antibiotics are necessary before the cleaning or if the dental cleaning should be delayed until the white count has recovered.
Christine asks: If someone has a chronic low white blood cell count, is getting maintenance therapy every 6 months, and has dental issues where there may be surgical intervention and the dentist is reluctant to perform the surgeries because of this, what can the person do if it becomes an ongoing issue that is causing them infection due to dental issue??
Dr. Abbott: @Christine...an ongoing infection is never a good thing, be it dental or otherwise. The dental issue should be addressed. The dentist should consult with an infectious disease doc and collaborate to find a window of opportunity for treatment to be completed. Communication between all healthcare providers on your team is of paramount importance...especially in a case like this. Your docs need to develop a plan and timeline to rectify the dental issue - especially if the dental issue is the source of the infection. If the dentist continues to be reluctant, find someone who better understands the systemic health risk of a chronic dental infection in an immunocompromised patient.
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