Numerous studies show the link between cancer and inflammation and their involvement with periodontal disease. The impact of cancer treatment proves to significantly affect one’s health. The aim of this literature review is to determine whether cancer treatment will negatively affect the periodontal condition and oral health.
In total, 28 reviews, including cohort, cross-sectional, case-control, and systematic reviews dated within the past ten years, were carefully examined. The study population consists of individuals with both a periodontal disease and a cancer diagnosis. This review examines the effects of cancer treatments on the periodontium and the recommended preventative dental hygiene strategies as directed by a dental clinician.
Recent studies show the correlation between inflammation-induced pathogens and cancer growth. They also show that there was a significant increase in periodontal pathogens, such as Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, and Aggregatibacter actinomycetemcomitans, found in the oral cavity of patients with periodontal disease. These bacteria aid in the destruction of the periodontium and normal cells, while forming carcinogenic cells in the process.
Certain cancer treatments destroy healthy cells in the oral cavity. Cancer treatments also have undesirable side effects, including oral mucositis, osteoradionecrosis, and xerostomia. These side effects increase the number of pathogens in the mouth and impair bone remodeling.
Numerous studies have shown that performing periodontal treatment to remove harmful pathogens significantly reduces the risks associated with cancer formation. Most patients were stated to be in generally poor dental health prior to cancer treatment. Dental clinicians should stress the importance of prevention and completion of dental treatment to improve the patient’s quality of life.
From this data, we can conclude that the effects of cancer treatment negatively affect the periodontal condition and overall oral health.
Many adults live daily life with undiagnosed and untreated periodontal disease (PD). Meyer et al. reported that periodontal disease is a chronic infection caused by bacteria that creates inflammation of the gingiva and leads to the destruction of the tissues and bone supporting the teeth.1 It is no secret that periodontal disease can aid in the progression of many other systemic diseases.
Specifically, cancer has remained one of the leading causes of death in the world. According to a study completed by Torre in 2012, nearly 300,400 new cancer cases were diagnosed, and an estimated 145,400 deaths occurred from head and neck cancer.2 A wide variety of cancer treatments are available, but the most common include surgery, chemotherapy, radiation, and a combination of surgery and radiation or chemotherapy.3
These cancer treatments have undesirable side effects, and an overall negative effect on a person’s body and health, including oral hygiene.4 Studies show that there is a connection between PD and an increased risk of cancer.5
Inflammation is the constant link between the relationship between periodontal disease and cancer.5 The immune system’s response to these inflammatory indicators is thought to be the main correlation between the two.5
Cancer treatments affect different regions of the body. For example, surgery and radiation therapy are limited to affecting specific parts of the body, while chemotherapy inhibits all cell growth and living cells.4 This means that malignant or toxic cells and healthy cells are all affected together during treatment. Cancer treatments have many other negative effects on the oral cavity including dental caries, xerostomia, and mucositis.3
Numerous studies have shown that periodontal treatment can lower inflammatory indicators and reduce risks associated with cancer within 2to 6 months of treatment completion.5,6
However, studies have also shown that noncompliance is a major issue with patients.3,7 One study stated that 97% of patients needed dental treatment before beginning cancer treatment, but only 81% completed the restorative dental work.7 Stressing the importance of practicing good oral hygiene habits routinely, early detection, and effective treatment is necessary to ensure a better quality of life.4,8
The objective of this literature review is to evaluate the effects of cancer treatment on periodontal health. The research question of this literature review is: For patients undergoing cancer treatment, will cancer treatments worsen periodontal disease and overall oral health?
Inflammation and Cancer
Periodontal disease is an irreversible disease that affects the supporting structures and tissues of the oral cavity.1,4, 9-13 Common characteristics associated with periodontal disease include increased bleeding, worsening of periodontal pocket depths, bone loss, tooth mobility, gingival recession, and inflammation.9-12 Together they destroy the gingiva, ligaments, and bone that make up the oral cavity.1, 4, 6, 9-12 Ultimately, if left untreated, periodontal disease leads to tooth loss.10-12
The formation of periodontal pathogens begins with a shift from gram-positive bacteria to gram-negative organisms.1 The most commonly found pathogens in a patient with periodontal disease include Porphyromonas gingivalis, Treponema denticola, Tannerella forsythia, and Aggregatibacter actinomycetemcomitans.1, 11-14 Although many of these harmful organisms can be found in the mouth of a healthy person, they are typically recorded at lower levels, causing little to no damage.1 As the bacteria begin to colonize and become more aggressive, it initiates an inflammatory response, which triggers the destruction and breakdown of the periodontium.1,11 The immune system’s response to inflammation plays a major role in the correlation to cancer formation.1,5
Meyer et al. explain that the connection between cancer and inflammation has been acknowledged in countless publications dating back to over a century ago.1 These studies have shown that the inflammatory markers resulting from periodontal disease are the main link to cancer.1, 5-6, 9-10 From this, we have learned that the chronic inflammation produced by harmful periodontal organisms is what initiates the destruction of normal cells and formation of carcinogens.1
Furthermore, Sun et al. state, “Chronic exposure to inflammatory mediators, including neutrophils, monocytes, macrophages, or cytokine metabolites, has been suggested to increase cell proliferation and mutagenesis, thereby leading to cancer.”14 With regards to the present information, it is clear that the development of cancer suppresses the immune system’s response and sets off a chain reaction aiding in the formation of increased harmful pathogens throughout the body.5
Effects of Cancer Treatments
The type of cancer treatments administered varies from person to person depending on the size and location.4 Chemotherapy uses drugs to kill cancer cells and can be administered to a patient in many ways including oral or intravenous delivery.4 Radiation therapy uses radiation in high or low doses to target and damage the actual DNA of cancer cells.15,16 The dosage is subjective to location, size, and how aggressive the treating physician is trying to be with respect to the patient’s wants or needs as well.4 Surgery simply aids in removing the cancer site from the body.
Together these treatments are said to help kill, shrink, slow the growth, and prevent the reproduction of cancer cells but they can also help ease the symptoms cancer patients are subjected to.16 However, some therapies not only aid in destroying cancer cells but destroy healthy cells in the process as well.4,16
Prior to the initial start of cancer treatment, one study verified that 95% of patients were already diagnosed with periodontal disease.15 In this regard, cancer therapies have many negative effects on the body but can aid in the progression of PD as well.4, 15-16 In a study conducted by Vera‐Llonch et al., it was confirmed that oral mucositis occurred in 83% of patients as a side effect from chemotherapy or radiation treatment.17
Oral mucositis refers to painful mouth sores caused by the formation of ulcerative lesions as a direct result of cancer treatment.17 Not only does this cause extreme discomfort to patients, but it also creates a doorway for the entry of periodontal pathogens.17
Additionally, patients with head and neck cancer treated with radiation therapy often develop osteoradionecrosis of the jaw.7,15 Osteoradionecrosis results in the destruction of bone and bone repairing abilities, is very hard to treat, and often leads to loss of clinical attachment of the gingiva and tooth loss.7,15
Similarly, cancer treatment affects the blood vessels surrounding the teeth, which leads to the widening of the periodontal ligaments, increasing the chances of impairing bone remodeling.16
Radioactive iodine is another type of cancer treatment, specifically for thyroid cancer, that uses oral iodine to emit radiation and destroy cancer cells.18 One study reported, 44% of patients experienced dry mouth after radioiodine treatment, which luckily is easily treatable.18
There are many other side effects from cancer treatments to the oral cavity as well, including xerostomia, dental caries, and infections.3, 19-20 Damage to the salivary gland is a common symptom from radiation treatment. Lack of salivary flow disturbs pH buffering of the mouth and increases the chance of dental caries and infection-causing bacteria to form.3,21 We know that dry mouth can lead to dental caries but forget that it can lead to swallowing and eating problems as well.21 Due to this circumstance, many cancer patients have food remaining in the oral cavity for hours, which increases the formation of dental caries.2
Many of these symptoms from cancer treatment create noncompliance in patients in regard to the necessary home care and periodontal treatment that needs to be completed.7
Receiving the proper dental diagnosis and treatment prior to cancer treatment can help reduce the progression of periodontal disease and one’s risk of cancer.14,22 Many studies stated that patients typically reported to dental offices while already in poor oral health and that a cancer diagnosis did not change an individual’s hygiene habits.3,7
Simply put, stressing the importance of improving the quality of life is necessary for change.4,8 Reducing inflammation-causing pathogens in the oral cavity will slow the development and progression of tumors.23 This can be done by scaling subgingivally on a patient with periodontitis every 3-4 months or when allowed by the treating physician.14 Application of fluoride varnish at each visit can decrease caries formation as well.3
Prevention is key when it comes to treating patients. In this regard, it is the duty of dental clinicians to provide patients with the necessary tools to practice good oral hygiene daily.8
One study confirmed that poor oral hygiene specifically increases an individual’s risk of cancer.24,25 It is extremely important that patients are given detailed oral hygiene instructions in regard to brushing after meals, flossing daily, using prescription mouth rinse as directed, and completing any necessary dental treatment.
Cancer patients deal with many complications from cancer treatments. Advising individuals on how to care for the mouth during this time is extremely beneficial.4 Recommending saliva substitutes (lozenges, sprays, gels) to patients with xerostomia can aid in saliva production, but also soothe the mouth.3,19
Remind periodontal patients who are undergoing cancer treatment to avoid alcohol-containing mouth rinses and whitening toothpastes because it will irritate the mouth.19,25 When eating, advise patients to avoid spicy or acid foods or beverages, avoid sugar, and to stay well hydrated with water.19
Cancer has remained one of the leading causes of death worldwide for quite some time. Depending on the stage and location of the cancer, most forms are treatable. There are many downfalls to cancer treatment. These include the risk of treatment not working, the undesirable side effects or the chance it may return over time are all possibilities. Cancer treatment also presents an individual with a high probability to negatively affect the PD condition. Recent studies confirm that there is a direct correlation between cancer and the inflammation that causes periodontal disease.
With regard to the present information, it is understood that the formation of pathogens can lead to periodontal disease. In turn, these pathogens can aid in the formation and growth of different types of cancer.
When a patient with periodontal disease is being treated for cancer, the oral cavity is constantly being subjected to many changes, including the formation of harmful pathogens, the destruction of healthy cells, and an endless list of harmful side effects.
Some of these are short-term, while others can cause long-term damage with many complications. It is a dental clinician’s duty to give recommendations to a patient on how to care for the mouth during this challenging time.
The aforementioned studies draw to the conclusion that cancer treatment does, in fact, worsen a patient’s periodontal disease and overall oral health. Communicating with patients early on to complete any necessary treatment prior to cancer treatment is a major role the clinician needs to play. A thorough explanation of how the mouth will be affected by cancer treatment and how to care for it will allow more comfort to the patient. Stress the importance of practicing good oral hygiene habits daily and routine dental cleanings to ensure a better quality of life.
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- Meyer M.S., Joshipura K., Giovannucci E., et al. A review of the relationship between tooth loss, periodontal disease, and cancer. CCC [Internet]. 2008 Nov [cited 2019 Oct 4];19(9):895–907. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723958/pdf/nihms108365.pdf.
- Bressan V., Stevanin S., Bianchi M., et al. The effects of swallowing disorders, dysgeusia, oral mucositis and xerostomia on nutritional status, oral intake and weight loss in head and neck cancer patients: A systematic review. Cancer Treat Rev [Internet]. 2016 Apr [cited 2019 Oct 4];45:105–19. Retrieved from: https://ezproxyfh.fhda.edu:2097/science/article/pii/S0305737216000396?via=ihub.
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- Hwang I-M., Sun L-M., Lin C-L., et al. Periodontal disease with treatment reduces subsequent cancer risks. QJM [Internet]. 2014 Apr 10 [cited 2019 Oct 4];107(10):805–12. Retrieved from: https://academic.oup.com/qjmed/article/107/10/805/2890460.
- Michaud D.S., Liu Y., Meyer M., et al. Periodontal disease, tooth loss, and cancer risk in male health professionals: a prospective cohort study. Lancet Oncol [Internet]. 2008 Jun [cited 2019 Oct 4];9(6):550–8. Retrieved from: https://ezproxyfh.fhda.edu:2097/science/article/pii/S1470204508701062.
- Niewald M., Fleckenstein J., Mang K., et al. Dental status, dental rehabilitation procedures, demographic and oncological data as potential risk factors for infected osteoradionecrosis of the lower jaw after radiotherapy for oral neoplasms: a retrospective evaluation. Radiat Oncol [Internet]. 2013 [cited 2019 Oct 5];8(227):1–12. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3851528/pdf/1748-717X-8-227.pdf.
- Yan R., Chen X., Gong X., et al. The association of tooth loss, toothbrushing, and quality of life among cancer survivors. Cancer Med [Internet]. 2018 Dec [cited 2019 Oct 5];7(12):6374–84. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6308113/.
- Tezal M., Sullivan M.A., Hyland A., et al. Chronic periodontitis and the incidence of head and neck squamous cell carcinoma. Cancer Epidemiol Biomarkers Prev [Internet]. 2009 Sep [cited 2020 Jan];108(9):2406–12. Retrieved from: https://cebp.aacrjournals.org/content/18/9/2406.long.
- Javed F., Warnakulasuriyab S. Is there a relationship between periodontal disease and oral cancer? A systematic review of currently available evidence. Crit Rev Oncol Hemat [Internet]. 2016 Jan [cited 2020 Jan];97:197–205. Retrieved from: https://ezproxyfh.fhda.edu:2097/science/article/pii/S1040842815300330.
- Lobáo W.J.M., Decarvalho R.C.C., Leite S.A.M., et al. Relationship between periodontal outcomes and serum biomarkers changes after non-surgical periodontal therapy. An Acad Bras Cienc [Internet]. 2019 [cited 2020 Jan];91(2):1–10. Retrieved from: http://www.scielo.br/pdf/aabc/v91n2/0001-3765-aabc-91-02-e20170652.pdf.
- Wen B.W., Tsai C.S., Lin C.L., et al. Cancer risk among gingivitis and periodontitis patients: A nationwide cohort study. QJM [Internet]. 2013 Dec 26 [cited 2020 Jan];107(4):283–90. Retrieved from: https://academic.oup.com/qjmed/article/107/4/283/1675040.
- Vargas-Villafuerte K.R., Dantas F.T., Messora M.R., et al. Preliminary results of non‐surgical periodontal treatment in patients with breast cancer undergoing chemotherapy. J Periodontol [Internet]. 2016 Nov [cited 2020 Jan];87(113):1268–77. Retrieved from: https://ezproxyfh.fhda.edu:2265/doi/full/10.1902/jop.2016.160101.
- Sun J., Zhou M., Salazar C.R., et al. Chronic periodontal disease, periodontal pathogen colonization, and increased risk of precancerous gastric lesions. J Periodontol [Internet]. 2017 Nov [cited 2020 Jan];88(11):1124–34. Retrieved from: https://ezproxyfh.fhda.edu:2265/doi/full/10.1902/jop.2017.160829.
- Schuurhuis J.M., Stokman M.A., Witjes M.J.H., et al. Patients with advanced periodontal disease before intensity-modulated radiation therapy are prone to develop bone healing problems: a 2-year prospective follow-up study. Support Care Cancer [Internet]. 2017 Oct 31 [cited 2020 Jan];26:1133–42. Retrieved from: https://ezproxyfh.fhda.edu:2063/pmc/articles/PMC5847027/pdf/520_2017_Article_3934.pdf.
- Ammajan R., Joseph R., Rajeev R., et al. Assessment of periodontal changes in patients undergoing radiotherapy for head and neck malignancy: A hospital-based study. J Can Res Ther [Internet]. 2013 [cited 2020 Jan];9(4):630–7. Retrieved from: http://www.cancerjournal.net/article.asp?issn=0973-1482;year=2013;volume=9;issue=4;spage=630;epage=637;aulast=Ammajan.
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