One of the most rewarding aspects of my job is the contact I have with people. We are a personalised practice, building relationships with patients over the years. We are in a privileged position of trust, providing ongoing care for people. A well functioning mouth and a nice smile is so important to someone’s overall wellbeing. If a patient has a dental emergency, we will do everything we possibly can to help because of a relationship that hopefully both parties value.
The importance of the patient/dentist relationship has been put more in focus for me in the past six months or so, as we have been able to help a few valued patients as they battle one of the biggest medical emergencies of all – cancer. A dentist can help out significantly.
A 26 year old just starting his career was faced with a diagnosis of testicular cancer. He had surgery and was about to embark on chemotherapy, so we reinforced his hygiene and preventive protocol. He pointed out a lump on his gum, which had the appearance of a pyogenic granuloma, or “pregnancy tumour” something we do not see too often in a male! They are benign swellings we see sometimes in pregnancy.
I called our excellent Oral and Maxillo Facial Surgeon in the building next door. He kindly saw him straight away, and then fitted him into his surgical list for the next day. Pathology confirmed it was a metastatic tumour. The patient was able to move on to his chemotherapy, without any delay.
Another long standing 67 year old patient has been undergoing treatment for inoperable throat cancer. Simultaneous chemo and radiotherapy of the head and neck is said to be the most unpleasant and challenging medical treatment someone can have. The radiation destroys saliva glands and blood vessels around the teeth, and causes massive ulceration of the mucosa in the mouth and down the throat, inside and out. The jaw and neck stiffens up due to scarring and exercises are necessary to stop the jaw from seizing up.
A feeding tube inserted directly into the stomach is necessary, at least for the short term, when it becomes too unpleasant to eat. If this is not enough, the chemo makes you feel ill, nauseous and listless – not exactly feeling motivated to brush and floss properly. All you want to do is lie still and eat soothing things like ice cream and chocolate.
All this provides a “perfect storm” for dental issues as:
- Saliva is protective of teeth. It buffers acids, washing away debris, contains antibodies, and lubricates the mouth and throat so that more nutritious foods can be eaten. In its absence, we have seen rampant decay simply “take off.”
- Oral hygiene is a real effort. It is painful to brush and floss the tender ulcerated gums.
- If extraction of teeth is the only option to get out of pain because the decay is so bad, a patient can, as a result, get a condition called osteoradionecrosis. This occurs because the blood vessels, which normally enable injuries in the mouth to heal, have been destroyed by radiotherapy treatment. The extraction site does not heal and the bone gets infected. Patients then have to sit in a hyperbaric chamber (with the footy players!!!) for days/weeks to promote healing.
- Soft, sweet comfort foods like ice cream, chocolate and acidic fruits like strawberries, become favourite foods. Big Nooooo No!
- Usually it all happens in a hurry, as the doctors want to start radiotherapy treatment as soon as possible. A patient’s dental history, the condition of individual teeth, oral hygiene history, motivation, quality of support from family or friends – should all be carefully assessed. Only then can an appropriate Treatment Plan for preventing trouble be arrived at.
I knew this patient and his mouth particularly well . His compliance and motivation with regular check ups and oral hygiene were excellent. I also knew him to be strong-willed, motivated and positive – just the kind of person who would fare the best when confronted with this sort of challenge.
The cancer specialist sent me a map showing exactly which teeth would be irradiated. After analysis, I decided, in his case, that no teeth needed to be removed first. A team approach is important when managing the treatment phase.
It was also important to work out which products or techniques were realistically going to be used. None of them are any good if they are going to be left in a drawer! Radiation or chemo can alter taste sensation, so that products that used to taste ok (i.e. certain toothpastes), can become unpalatable and a suitable replacement needs to be found. Flossing with fingers may become impossible and we have to train the patient to use a flossing gadget. Daily germ-killing is important to prevent secondary infection of ulcers and radiation burns. Fluoride is important to make teeth more resistant to decay. Lubricating agents are important for comfort and eating. There are acid buffering agents, and remineralising agents also available. An Oxyjet machine, which propels solutions in between and around teeth, can be particularly useful. It can be loaded with a warm solution of bicarbonate of soda to neutralise acids. It is easy and convenient to use, even if you are feeling ill.
This patient felt the best, had the least pain medication, fewest ulcers or complications out of any in the cancer ward who were undergoing the same treatment. He had a minimum of discomfort and rode it out with maximum dignity.
Survival is the priority, but quality of life is so important.