Assessment of Periodontal Status and Periodontal Treatment Requirement in Hospitalized Cancer Patients: A Cross-Sectional Study
Background: Periodontal assessment for 35 cancer hospitalized patients was examined for oral hygiene conditions, periodontal status, and the need for oral care. Further, the study evaluates the necessity of medical personnel to assist in achieving oral health maintenance during their period of hospitalization. Introduction: Cancer patients, usually present with low immunity during their period of hospitalization. Maintenance of oral hygiene is usually neglected, which leads to an increase in plaque and calculus accumulation, thus contributing to the initiation of Periodontal Disease (PD). Materials and Methodology: A cross-sectional study was conducted among 35 cancer hospitalized patients at Kidwai Cancer Institute, Kalaburagi. A hard copy questionnaire comprising 15 questions, based on the condition of oral hygiene and periodontal status with their period of hospitalization was circulated among hospitalized cancer patients based on the inclusion and exclusion criteria. Results: Poor periodontal status was observed in the hospitalized cancer patients with generalized bleeding on probing, with a mean pocket depth of 7.4mm, the percentage of furcation involvement (grade 1: 94.3%, grade 2: 91.4%, grade 3: 100%, grade 4: 31.4%), generalized recession, grade 1 mobility: 94.3%, grade 2 mobility: 97.1%, grade 3 mobility: 71.4%. missing teeth < 10 = 60%, > 10 = 40%. Conclusion: Taking this into consideration, it is very necessary to implement oral health programs in the hospitals and appointment of dental staff/assistants in the wards to provide oral hygiene instructions and educate the patients about the need to keep their oral cavities healthy.
Hospitalized cancer patients, Periodontal assessment, Oral hygiene education, and Motivation
The easy accessibility to advanced technology has contributed to a significant improvement in our knowledge base of cancer biology and therapy.
With the emergence of focused cancer therapy and advances in chemo and radiation therapy, there have been notable advances in the field of cancer treatment. Although many advances have emerged, the primary method of treatment remains chemotherapy, radiotherapy, and surgical excision.
Periodontists and other dental specialties need to be aware of the effects of cancer treatments. Knowledge regarding these cancer therapies will allow dental practitioners to provide these patients with the highest standard of care before, during, and after the patient’s cancer treatment and management.
Periodontal therapy of cancer patients at the time of diagnosis
Cancer treatment has several associated cooccurring conditions like neutropenia, anemia, impaired wound healing, etc. that can complicate periodontal maintenance and treatment. Thus, it is advisable to plan and complete the treatment strategy before the commencement of cancer therapy. In the pre-treatment protocol for chemotherapeutics, periodontal treatment is helpful if conducted before high-dose chemotherapy [1-3]. Oral hygiene instruction is often one of the most important and successful measures to prevent bacterial recolonization and maintenance of disease control. In a recent systematic review by Hong et al., 2017 , there are broadly three levels of dental treatment protocols prior to anti-neoplastic therapy and bone marrow transplants: complete, partial, and minimal. Complete treatment involves the treatment of all dental pathologies prior to cancer treatment or bone marrow transplantation. Partial treatment involves a graded approach to dental pathologies present prior to cancer treatment or bone marrow transplantation with the following criteria; Minimal treatment includes symptomatic treatment or if there are limited time constraints prior to cancer therapy or bone marrow transplantation.
Periodontal therapy of cancer patients undergoing treatment
In neutropenic patients undergoing cancer therapy, periodontal disease or periodontal infections may be intensified. Ulcerated periodontal pocket epithelium may serve as a gateway of entry for the migration of microorganisms into the bloodstream. In addition, the inflamed or infected periodontal tissues may serve as a reservoir of proinflammatory mediators and endotoxins that have systemic effects .
Periodontitis is assessed by bleeding, attachment loss, probing depth, mobility of tooth, gingival erythema, and other etiological factors which include the presence of bacterial plaque and calculus. Periodontal probing should be avoided during neutropenia, meaning that pretreatment evaluation is of absolute importance to coordinate oral care . Even if gingival signs and symptoms of inflammation are not observed; moderate to severe periodontitis in a patient who develops neutropenic fever should be considered a clinically defined infection.
Aim of the Study
To evaluate oral hygiene maintenance by measuring different parameters and periodontal conditions among patients suffering from different carcinomas and determining the preventive measures for dental problems during their period of hospitalization
Materials and Methodology
A hard copy questionnaire comprising 15 questions, based on the condition of oral hygiene and periodontal status with their period of hospitalization was circulated among hospitalized cancer patients.
The participants comprising both sexes were included in the study
Demographic data such as name (optional), age, sex, occupation, place, and address were included.
A total of 50 hospitalized patients admitted to Kidwai Cancer Institute of Kalaburagi district were randomly selected for the study.
Patients admitted for any type of carcinomas.
Participants’ willingness for this survey.
Above 18 years of age.
Pregnant and lactating women.
Below 18 years of age.
The questionnaire included in the survey: demographic data (Name, age, sex)
Number of days of patient’s admission in the hospital:
Type of cancer
Head and neck region
Any other organ system
Type of cancer treatment received
Whether the patient is associated with any other systemic diseases?
Mention drug history?
Do you have unsatisfactory diet?
Dental problems faced during hospitalization?
Pain with caries tooth/grossly decayed tooth
Or any other?
If present, have they managed to treat?
Simplest oral hygiene method used by the patient?
Soft tooth brush
Whether they require dental assistance during hospitalization?
Whether any support is provided by the hospital for dental assistance?
Do you know the impact of poor oral health on systemic illness?
How often the patient visited for regular checkup for prevention of oral diseases?
Do you have oral health unit in the hospital?
Is there pain associated with any tooth? If yes mention the tooth number.
All the patients agreed to answer the questionnaire.
Among the 35 participants, the distribution of tumors was as follows: esophageal (n=7), squamous cell carcinoma (n=3), breast (n=5), tongue (n=4), lung (n=5), cervical (n=1), testicle (n=1),
Rectum (n=2), thigh (n=2), gall bladder (n=1), ovary (n=1), gastric region (n=1), abnormal growth in the neck region (n=1), retro molar triangle (n=1).
Periodontitis is directly correlated to the systemic health of individuals and the treatment is now based on patients’ current oral hygiene status and systemic state. Cancer patients are in need of standard periodontal care (chemotherapeutic, radiation surgical) before during, and after cancer therapy. However, hospitalized cancer patients with existing periodontal disease are at increased risk with the consequences of a bacterial challenge to other major organs and loss of teeth, improper diet, and nutrition.
From the analysis conducted in the present survey, 35 patients (M= 17, F= 18), with a mean age of 48.03 years presented with deteriorating periodontal status during their period of hospitalization [Figure 1 and Table 1]. The screening method included the following parameters: bleeding on probing, pocket depth, furcation involvement, tooth mobility, recession, and missing teeth.
Figure 1. Demographic Data (Mean Age).
Table 1: Mean age of the patients.
This present study assessed oral hygiene methods in all the examined patients. The improper brushing habits mentioned above led to plaque retentive areas [Table 2].
Table 2: Bleeding on Probing.
This was associated with food lodgments and increased caries risk. Thus, as a result of, there was bleeding on probing, which was seen in all the 35 patients examined [Figure 2 and Table 3].
Figure 2. Bleeding on Probing.
Table 3: Pocket depth.
Studies conducted by Sjögren et al and Sachdev, M et al have shown an increase in plaque and gingival inflammation as well as an increase in the Bleeding on Probing index even in short periods of hospitalization [6,7].
No intervention was made by the staff in the unit that led to the severity of increased pocket formation, with a mean depth of 7.4mm [Figure 3 and Table 4].
Figure 3. Periodontal Pocket Depth.
Table 4: Grade IV furcation involvement.
One patient presented with pain in relation to the caries-affected tooth and stopped the basic oral hygiene procedures on the involved site, leading to halitosis and accumulation of plaque which was a vicious cycle, which finally led to periodontal disease.
Patients presented with different grades of furcation involvement. [Figure 4 and tables 5-8].
Figure 4. Grades of Furcation Involvement.
Table 5: Grade III furcation involvement.
Table 6: Grade II furcation involvement.
Table 7: Grade I furcation involvement.
Table 8: Recession
Patients also presented with generalized recession [Figure 5, table 9].
Figure 5. Gingival Recession.
Table 9: Grade I mobility.
The existing mobility of the tooth which was at 97.1% is a main indication of bone loss, which is a sign of already existing periodontal disease, which was aggravated after radiation therapy [Figure 6, table 10-12].
Figure 6. Grades of Mobility.
Table 10: Grade II mobility.
Table 11: Grade III mobility.
Table 12: Missing teeth.
This finally led to the loss of the tooth as there was no intervention done at this stage. This led to the overall unsatisfactory diet among the patients admitted to the ward resulting in added nutritional deficiencies.
We had substantial support for the same clinical findings, by a study conducted by Albuquerque et al in which the periodontal parameters were recorded in hospitalized ICU patients, a high dental plaque index and a high prevalence of periodontitis, in moderate and localized chronic form, were observed [Table 13]. Many patients, as a matter of fact, rely on attending staff for care and oral hygiene, which is usually ill-equipped, thus favoring the deterioration of oral conditions.
|Age||Bleeding on Probing||Pocket Depth||Furcation Involvement||Mobility||Recession||Missing Teeth|
|48.03yrs (Mean)||1||7.44mm (Mean)||Grade 1: 94.3%
Grade 2: 91.4%
Grade 3: 100%
Grade 4: 31.4%
|Grade 1: 94.3%
Grade 2: 97.1
Grade 3: 71.4%
Table 13: Overall Summary of the Findings.
The overall summary of the findings has been depicted in [Table 14]. The patient’s oral health maintenance was guided mainly by their attenders rather than a skilled and knowledgeable assistant and this affected their oral health as there was no proper protocol for following basic oral hygiene as noticed in our study.
|Finger brushing||11 patients|
|Switch from tooth brushing to finger brushing||02 patients|
Table 14: Oral Hygiene Habits of the Patients Examined.
No protocol was carried out for the treatment of periodontal diseases before the commencement of oncological therapy; patients treated by the oral surgery department were kept under observation post-surgically and were told to continue periodontal treatment. In the rest of the patients, the debilitating conditions overruled the present periodontal disease, and hence immediate periodontal treatment was not provided.
Oncological patients should start dental treatments before the beginning of cancer therapy; professional oral hygiene, the extraction of compromised teeth, and restorations of teeth with wide caries are recommended. At bedtime, it is advisable to use an electric toothbrush and floss (or, in the case of mucosal lesions, a soft toothbrush or sponges soaked in 0.20% chlorhexidine mouthwash).
Soutome et al concluded that chemotherapy is an independent risk factor related to the worsening of periodontal disease .
Limitation of This Study
This survey has a sample size of 50 subjects, but only 35 patients were examined as the rest of the patients were reluctant to participate in this study, as these patients were suffering from major illnesses and could not be assessed clinically. This survey was conducted over a period of 1 week and no further follow-up was done to assess the clinical conditions of the patients at later stages of cancer therapy.
These results mainly indicate how important it is to follow basic oral hygiene procedures among hospitalized patients and the ill effects it may cause if not followed properly. Taking this into consideration, it is very necessary to implement oral health programs in the hospitals and appointment of dental staff/assistants in the wards to provide oral hygiene instructions and educate the patients about the need to keep their oral cavities healthy.
Trial registration: not applicable
Ethics: Ethical approval of the study was obtained from the ethical committee of HKE.SN Institute of Dental Science and Research, Kalaburagi.
Data availability: Kidwai institute on oncology, Kalaburagi.
Consent for publication: not applicable
Conflict of Interest: Nil
Dr. Ramesh Choudhary, MDS, Professor, Shri Sidhartha dental college, Tumkur, PHD, Branemark Institute of Implantology, Sweden.
- Borowski B, Benhamou E, Pico JL, et al. Prevention of oral mucositis in patients treated with high-dose chemotherapy and bone marrow transplantation: a randomised controlled trial comparing two protocols of dental care. Eur J Cancer 1994; 30:93-7.
- Peterson DE. Pretreatment strategies for infection prevention in chemotherapy patients. J Natl Cancer Inst Monographs 1990; 9:61-71.
- Greenberg MS, Cohen SG, McKitrick JC, et al. The oral flora as a source of septicemia in patients with acute leukemia. Oral Surg Oral Med Oral Pathol 1982; 53:32-6.
- Hong CH, Hu S, Haverman T, et al. A systematic review of dental disease management in cancer patients. Support Care Cancer 2018; 26:155-74.
- Raber-Durlacher JE, Epstein JB, Raber J, et al. Periodontal infection in cancer patients treated with high-dose chemotherapy. Support Care Cancer 2002; 10:466-73.
- Sjögren P. Hospitalisation associated with a deterioration in oral health. Evid Based Dent 2011; 12:48.
- Sachdev M, Ready D, Brealey D, et al. Changes in dental plaque following hospitalisation in a critical care unit: An observational study. Crit Care 2013; 17:1-7.
- Albuquerque BN, Araújo MM, Silva TA, et al. Periodontal condition and immunological aspects of individuals hospitalized in the intensive care unit. Braz Dent J 2018; 29:301-8.
- Devi S, Singh N. Dental care during and after radiotherapy in head and neck cancer. Natl J Maxillofac Surg 2014; 5:117.
- Horst JA, Tanzer JM, Milgrom PM. Fluorides and other preventive strategies for tooth decay. Dent Clin 2018; 62:207-34.
- Soutome S, Otsuru M, Kawashita Y, et al. Effect of cancer treatment on the worsening of periodontal disease and dental caries: A preliminary, retrospective study. Oral Health Prev Dent 2021; 19:399-404.
2Department of Oncology, Kidwai Institute of Cancer Hospital, Gulbarga, India
3Department of Oral surgery, Kidwai Institute of Cancer Hospital, Gulbarga, India
Citation: Bindu S Patil, Apoorva DG, Gururaj Deshpande, Veerbhadra, Assessment of Periodontal Status and Periodontal Treatment Requirement in Hospitalized Cancer Patients: A Cross-Sectional Study, J Res Med Dent Sci, 2023, 11(10):1-6.
Received: 26-Sep-2023, Manuscript No. jrmds-23-115004; Accepted: 28-Sep-2023, Pre QC No. jrmds-23-115004; Editor assigned: 28-Sep-2023, Pre QC No. jrmds-23-115004; Reviewed: 11-Oct-2023, QC No. jrmds-23-115004; Revised: 16-Oct-2023, Manuscript No. jrmds-23-115004; Published: 23-Oct-2023