Dental Considerations for the Breast Cancer Treatment Patient
Are dental professionals prepared to discuss dental care and oral health changes with their patients who are undergoing breast cancer treatment? Are there any dental guidelines in place for seeing patients who have history of breast cancer?
As dental professionals, how much do we really about breast cancer therapies and how comfortable are we in giving them information and educating them in their oral health needs? One study showed that over 70% of dental hygienists were not confident enough in their treatment protocols when it came to treating patients with breast cancer. Only 13% said that they understood the mechanism of action in medications that were prescribed to breast cancer patients. The purposes of this article is to help educate and guide clinicians to a better place of understanding of how to treat our patients with breast cancer pre and post treatment.
There are different guidelines that are in place that are recommended for our breast cancer patients. That starts with an interdisciplinary relationship with the patient’s oncologist. As clinicians, we want to make sure we are in-contact and on the same page with the oncology team to make sure there a cohesive approach to the patient’s overall dental health. Side effects of medications play a major role in patients long-term oral health conditions.
Breast cancer treatments and therapies are recommended and prescribed to patients based on different statuses. Those statuses include their hormone status and menopausal status. Besides major surgery, the systemic treatment pre and post will be dependent on these two factors.
If the patient is in pre-menopausal status, they will most likely be treated with antiestrogen therapy medications along with systemic therapies such as chemo or hormone therapy. Common antiestrogen therapies such as Tamoxifen and hormone therapies also known as Lupron are supposed to reduce and block the estrogen production. The medications don’t allow the receptors to stimulate or signal new tumor growth. This highly reduces the chance of breast cancer re-occurrence.
If the patient is post-menopausal status, their bodies are no longer producing estrogen by the ovaries. However, they will still have the body’s last attempt to make estrogen by means of aromatase enzymes. The enzyme releases small amounts of estrogen. Patients who are post-menopause and going through breast cancer treatment are often prescribed systemic medications such as aromatase inhibitors. Common FDA approved AIs include: Anastrozole, Letrozole, and Exemestane. Often these medications are combined with a bisphosphonate because AI medications put patients at risk for bone density issues.
As dental professionals, we are already familiar with bisphosphonates. Understanding these medications and the mechanism of action makes a big difference in the dental professional’s role in treatment of our patients with breast cancer. We want to be able to see them more frequently – preferably once every three months so that we may monitor, assess, and treat any significant oral health conditions.
Now that we’ve reviewed the medication’s mechanism of action, let’s examine the oral complications and side effects of these medications and their breast cancer treatment. Breast cancer treatments often put a big damper on our patient’s oral heath conditions. The majority of patients will report that they have the following: dry mouth, mucositis, gingivitis, fungal infections, and bacterial infections such as periodontitis. As dental professionals, we need to be on the lookout for these conditions in both our pre and post-menopausal breast cancer patients. Additionally, Tamoxifen has been reported to have the side effect of increased jaw pain due to bruxism and clenching. Patients who have taken AI medications are at risk for bone density changes. As clinicians, we want to look out for breast cancer related metastases that can present in the mandible and maxilla.
Dental guidelines for patients who are undergoing or about to start breast cancer treatment are good to have in place so that we may better communicate and work with our patients before, during, and after their treatments. These guidelines ideally include: medical clearance from the oncology team, neutropenia (white blood cell) count, premedication if recommended by physician (usually due to patient having received chemo through a intravenous port catheter), and updated radiographs to detect any possible developments from previous dental visits as patients who have taken AI’s are at greater risk for bone density changes. Additionally, if patients have had lymph nodes removed from the underarm they are at risk for lymphedema. Therefore, it is important to not take blood pressure readings on that arm but rather on the other arm or with a wrist cuff.
In conclusion, it is important as dental professionals to be educated on dental considerations for our patients who have had or are undergoing breast cancer treatment so that we may provide the best care possible.