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Anno 2018 Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

Luca Vigano1*, Casu Cinzia2, Andrea Oliveira3 and Pierluigi Guerrieri4

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1Department of Radiology, San Paolo Dental Building, University of Milan, Italy
2Private Dental Practice, Cagliari, Italy
3San Paolo Dental Building, University of Milan Italy
4IRCCS Ca Granda Fondation General Hospital University of Milan Italy
*Corresponding Author: Luca Viganò, Department of Radiology, San Paolo Dental Building, University of Milan, Italy.

Received: November 06, 2018; Published: November 29, 2018 Abstract

Background: Oral diseases should be considered potentially associated with systemic diseases. Several systemic diseases, including oncological ones, must be taken into consideration by dentists since they can be intercepted early by the dentists themselves and the repercussions of many systemic diseases and their therapies on oral cavity are widely demonstrated.
Objectives: The purpose of this review is to investigate the relationship between the breast cancer and the changes that can occur at the oral level, both alterations of the oral microbiome and pathological conditions. We also want to investigate how breast cancer therapies can affect patients' oral health.

Materials and Methods: The purpose of this review is to investigate the relationship between the breast cancer and the changes that can occur at the oral level, both alterations of the oral microbiome and pathological conditions. We also want to investigate how breast cancer therapies can affect patients' oral health.
Results: The data seem to suggest a correlation between breast cancer and periodontal disease. The effects of therapy for breast cancer on the oral cavity are remarkable: chemotherapy induces an increased risk of caries, dysgeusia, bone loss and mucositis may appear. There was also an important alteration of the oral microbiome in patients receiving chemotherapy.

Conclusions: From this review the importance of dentists is clear in proposing to patients with breast cancer appropriate therapies and dedicated prevention sessions. Appropriate oral hygiene (both professional and domiciliary), a proper diet and the use of artificial saliva may reduce the risk of developing oral complication resulting from breast cancer.

between breast cancer and diseases of dental interest such as periodontitis.

Keywords: Breast Cancer; Impact; Oral Health Introduction

It is now proven that oral diseases are associated with systemic diseases. The interactions that develop between the oral cavity and the rest of the organism are multiple and very complex. More than 120 medical conditions, some of which are life threatening can be detected and treated in the early stage by dentists [1].

In this traditional review we will investigate in particular the link between breast cancer and oral health and microbiome. One of the most common oral disease is periodontitis which is characterized by chronic infection and inflammation in periodontal tissue leading to destruction of the bone surrounding the teeth. Periodontal disease is initiated by a biofilm of bacteria on the teeth which trigger an immune- inflammatory response in the adjacent host tissues [5].

Several studies have shown a close relationship between chronic inflammatory diseases and the development of tumors [2].

Inflammation is a crucial aspect in chronic conditions, such as in periodontal disease [3], but it is also central for tumors, since in these there is an inflammatory microenvironment [4]. Therefore, inflammation is the starting point for understanding the link

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

On the other hand, it is also important to investigate the influence of breast cancer therapy on oral health. In fact, there are

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Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

45 several repercussions that these treatments can cause in the oral This association also seems to be confirmed by a study by cavity, so it is essential to know them to adopt a correct treatment Freudenheim., et al. [11], in which the risk of breast cancer among plan for post-cancer patients. more than 93,000 postmenopausal women with a history of periodontitis has been increased, especially in former smokers who Prevalence of breast cancer quit in the previous 20 years. But periodontal disease increases the

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Breast cancer is the most common cancer diagnosed among women in the United States, accounting for nearly 1 in 3 cancers. It is also the second leading cause of cancer death among women after lung cancer [6]. Over 200,000 women are diagnosed with breast cancer in the U.S. annually. Breast cancer occurs more frequently in post- menopausal women and the median age at diagnosis is 61 years. The etiology of most breast cancers is unknown. However, some risk factors have been established like gender, age, family history, late menopause, early menarche, ethnicity and genetic risk factors [7].

risk of breast cancer regardless of smoking [12].

Breast cancer is by no doubt a very serious and widespread problem, for this reason it is important to evaluate if there is a correlation between oral pathologies and this type of tumor to have a further defense against this pathology. On the other hand, an important decrease in mortality due to breast cancer has been observed in recent years thanks to the development of new adjuvant therapy and screening programs [8]. This involves the need to control possible reactions of the organism to therapy; in the article we analyze this interaction at the level of the oral cavity.

Meanwhile Taichman., et al. [14] conducted a population- based analysis, that examined the prevalence of periodontal diseases along with the self-perceived oral health and patterns of dental care utilization of breast cancer survivors in the United States.

Periodontal disease is characterized by chronic infection and inflammation in periodontal tissue leading to destruction of the bone surrounding the teeth.

Shi., et al. [15] in a Meta-analyisis of Eight studies, with 168,111 individuals, explored the connection between periodontal disease and breast cancer. They showed that periodontal disease did increase susceptibility to breast cancer (RR = 1.18, CI 95%: 1.11– 1.26) with robust results confirmed by sensitivity analysis.

Periodontitis and breast cancer

The interaction between breast cancer and periodontitis has
been widely investigated by several works. In this other systematic review, Corbella., et al. initially examined

In 2011, Söder., et al. conducted a prospective study of 3273 women randomly selected between the ages of 30 and 40 for a period of about 16 years. The study showed that women with experience in periodontitis and with missing molars have a higher risk of developing breast cancer [9].

just under 500 articles to understand the role of periodontitis in cancer development in various sites, including breast cancer. There was an association between periodontal disease and the breast neoplasm (RR = 1.11; CI 95%: 1.00-1.23).

The work of Virtanen., et al. 10 of 2013 examined the association between periodontitis and breast cancer risk by recruiting 286 subjects with periodontal disease in 1985: in 2009, 6.3% of these had cancer. Moreover, it was observed that the risk is greater if the first mandibular molar was missing, compared to the second mandibular molar.

Amodio., et al. [16], unlike the studies previously taken into consideration, conducted a matched case-control study in which they assessed the prevalence of periodontal disease in 48 post- menopausal patients after cancer treatment, compared to 48 controls without cancer. They detected a high prevalence of periodontitis in postmenopausal survivors: 98% in breast cancer survivors and 87% in controls. However, we report that there are limitations in the design of the study as claimed by the authors themselves.

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

Sfreddo., et al. [13] wanted to evaluate the linkage between periodontitis and breast cancer in a sample of adult Brazilian women. They observed that cases had significantly greater clinical attachment loss than controls. Women diagnosed with periodontitis had two to three times higher odds of breast cancer than women without periodontitis. They conclude that a significant association was observed between periodontitis and breast cancer.

They observed in this sample that a history of breast cancer does not significantly impact periodontal health, self-perceived oral health, and dental care utilization.

We report two systematic reviews researched on PubMed by writing the key words 'periodontitis breast cancer'.

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Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

The results found are therefore oriented in two directions: on the one hand, periodontitis, in affected patients, leads to an increased risk of developing breast cancer; on the other hand, in patients suffering from cancer, after the treatment of cancer itself, a greater prevalence of periodontitis has been observed.

46 o Breast conserving surgery: It consists in removing the tumor and normal tissue around it while maintaining the structure of

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A possible explanation is that Periodontal disease is associated with an increased production of reactive oxygen species which cause damage to the host cells and tissues. The byproducts of the oral inflammation enter the bloodstream, which may enhance cellular proliferation and mutagenesis, allowing for the development and spread of cancer [17]. Some studies have also described that some polymorphisms of the TLRs (toll-like receptors) genes are associated with greater susceptibility to periodontitis [18,19], but also to several types of cancer [20,21].

Radiotherapy is a treatment that uses high intensity x-rays to neutralize rapidly proliferating cells, thus strongly affecting the cancer cells. The radiation therapy for breast cancer is usually external with machines specialized in the emission of these rays toward the cancer. Prolonged radiotherapy can lead to the development of important lesions in the oral cavity that must be monitored and treated.

It is opportune to observe how the lowering of the immune defenses, due to the tumor and its treatments, can be a factor favoring the development of periodontal disease, since this has bacterial etiology

Chemotherapy

Vargas-Villafuerte., et al. [22] evaluated the influence of tumor therapy on periodontal therapy: they have seen that patients who receive breast cancer chemotherapy respond less to non-surgical periodontal treatment compared to patients without cancer and therefore require further treatment. As said before, the effects of breast cancer therapy have a huge impact on the patient's oral health; therefore, an evaluation of oral health before, during and at the end of the treatment should be included in the breast cancer management protocols, so as to intercept the initial lesions and favor the patient's adhesion to the treatment.

Hormones synthesized by our body can induce a proliferation of the tumor itself. Hormone therapy aims precisely at the inhibition of these processes by acting on the endocrine system. The most used treatments are:

The selection of breast cancer treatments are based on many prognostic and predictive factors including tumor histology, lymph node involvement, tumor hormone receptor content, tumor HER2 status, age, patient preference and others [23]. The choice of the treatment normally depends on two main factors: menopausal status and estrogen receptor status.

Aromatase inhibitor: Used on postmenopausal women which blocks aromatase enzyme from turning androgen into estrogen.

Breast cancer treatment option

All these therapies are fundamental and allow in many cases to greatly increase life expectancy in patients with breast cancer, but they often have important side effects, many of them in the oral cavity. It is therefore the dentist's and dental hygienist's duty to be informed about the possible side effects of these therapies in order to recognize and treat them correctly.

Following PDQ Adult Treatment Editorial Board [24] breast cancer therapies are: Surgery, Radiation therapy, Chemotherapy, Hormone therapy, Targeted therapy.

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

Many breast cancer therapies, exerting a non-specific action on the organism, can lead to the development of oral diseases.

Most of the patients with advanced breast cancer are treated with surgery. The choice in the type of surgery depends on the stage and the spread of the tumor. The main options are:

Surgery

Surgery is a regional treatment only concerning breast, for this reason it has no relationship with possible oral lesions.

the breast.
o Total mastectomy: The removal of the whole breast.

Radiation therapy

Chemotherapy consists of taking drugs that can kill or block cell proliferation. Therapy can be systemic with an oral, intravenous or intramuscular intake or regionally with local injections. Systemic therapy is the most used for breast cancer

Hormone therapy

Ovarian ablation: It is a treatment which stops the production of estrogen by ovaries.
Tamoxifen: It is a drug which blocks the effects of the hormone estrogen in breast tissue, which reduces the growing of breast cancer cells.

Oral disease induced by breast cancer therapy

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Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

Meanwhile Chemotherapy and Radiation therapy are not tissue- specific; these therapies are therefore able to hit the cancer cells, but they also damage normal cells. Oral tissues are particularly susceptible to these therapies. In fact, there are approximately 400,000 cases of treatment-induced damage to the oral cavity [25]. Oral complications that arise with chemotherapy and/or radiation therapy include mucositis; xerostomia; bacterial, fungal, or viral infection; dental caries; dysgeusia; and osteonecrosis [26]. Chemotherapy for breast cancer is certainly more related to these lesions than Radiation therapy which is normally limited to the tumor area.

Oral mucositis is a lesion characterized by inflammation and ulceration of the mucosa with the possibility of pseudomembrane formation [27].

The radiation therapy used for breast cancer can induced only a transient xerostomia, meanwhile the effect of chemotherapy on salivation are more severe. In addition to the changes in clearence, RT and chemotherapy cause significant changes in the oral flora with an increase in cariogenic microorganisms (Streptococcus mutans, Lactobacillus, and Candida species) [35].

Oral mucositis

It is estimated that about 40% of patients treated with standard chemotherapy develope mucositis [28].

It is now known that caries disease is multifactorial and closely related to the quantity and quality of saliva. In fact, saliva has a washing power and a capacity to buffer the acids produced by the cariogenic species of bacteria.

Adamietz., et al [29]. have also reported that mucositis may be seen in nearly every patient when chemotherapy and radiation therapy are used simultaneously.

For this reason, patients undergoing chemotherapy and radiation therapy have a greater risk of caries development.

This entails an increase in hospital admittance, a higher use of parenteral nutrition and very often there is an interruption of therapy that compromises the control of the tumor. Mucositis causes 9% to 19% of chemotherapy and radiation therapy interruption [30].

Dysgeusia is an alteration or reduction of the sense of taste. Dysgeusia or taste disorder is a common complaint among cancer patients undergoing chemotherapy. Pathophysiological mechanisms of dysgeusia during chemotherapy are explained by factors such as neurological damage in cranial nerves (VII, IX, and X) and taste buds and mucosal damage [36].

Oral mucositis is a result of two major mechanisms: direct toxicity on the mucosa and myelosuppression due to the treatment 28 In fact, despite the pathogenesis of mucositis is not completely known it’s thought to have two possible mechanisms related to cancer therapies: direct and indirect [31].

According to Ishikawa., et al. 43,8% of the patient included in the study undergoing cancer chemotherapy experienced dysgeusia [37].

Oral mucosa cells are in rapid turnover, for this reason they are susceptible to effect of cytotoxic therapy like chemotherapy and radiation therapy.

Another study from Imai., et al. Dysgeusia developed in 38.8% (14/38) of chemotherapy patients [38].

Direct mucositis

Breast cancer therapies deeply influence bone metabolism. This can lead to the development of bone loss or structural changes like modification to the BMD (bone mineral density).

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

This mucositis is caused by myelosuppression caused by therapy, which leads to the invasion of bacterial and fungal species due to neutropenia. Chemotherapy in particular also changes the oral microbial flora, the epithelial maturation and composition of saliva, all factors that cause the development of these lesions [32].

Indirect mucositis

47 Xerostomia and dental caries. Salivary glands are very susceptible to irradiation and chemotherapy. According to Epstein., et al. [33] after 1 week of RT both stimulated and resting saliva productions are decreased by 36.67% and 47.9%. Even low doses like 20 Gy can result in changes in the amount of saliva and its

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consistency [34].
The effect on salivary glands also depends on tumor location

and technique.

Dysgeusia

Bone alterations

Hormone therapy is the most related to these bone lesions. As stated by Juozaitytè., et al. Tamoxifen increases bone density in

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Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

post-menopausal patients but cause bone loss in premenopausal women [39].

48 Breast cancer therapy also has different effects on the oral

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According to Reid., et al. in postmenopausal women, the use of aromatase inhibitors increases bone turnover and induces bone loss at an average rate of 1-3% per year leading to an increase in fracture incidence compared to that seen during tamoxifen use [40].

cavity that the dentists must know.

Taichman., et al. also indicated a secondary effect of tamoxifen and aromatase inhibitors on oral mucosa like gingival inflammation, gingival bleeding, and burning sensations [41].

Close professional hygiene sessions can reduce the risk of developing periodontitis as the use of artificial saliva and a diet low in fermentable sugars reduces the risk of caries.

However, chemotherapy and ovarian ablation cause the highest levels of bone loss. For this reason, osteoporotic treatment should be associated with these therapies [39].

For oral mucositis, well-structured trials are needed to define the standard treatment in order to reduce pain and increase the quality of life of the patient [28].

The changes in bone density must therefore be taken into consideration also in the case of implant and bone-rigeneration dentistry by dentits.

For dysgeusia caused by cancer therapy has not yet been established a standard therapy, more studies are needed also in this field [43].

Napenas., et al [42]. determined the profile of the oral bacterial flora in an outpatient cancer population before and after chemotherapy using molecular techniques.

As regards periodontitis, most of the authors who have investigated the correlation with breast cancer have also said that better conducted studies would be needed, with comparable and standardized protocols and with more accurate sampling methods. This requirement is also motivated by the fact that the ODDs obtained in the various studies show a correlation, which although statistically significant, is weak.

The impact of cancer chemotherapy on the oral bacterial flora

They recruited 9 newly diagnosed breast cancer patients scheduled for induction chemotherapy. All were seen immediately before chemotherapy, and 7 to 14 days later.

Patients undergoing hormone therapy have the risk of developing bone loss; the dentist must know this possibility and keep the situation monitored by assessing the possible need for anti-osteoporosis therapy [39].

They found species not previously identified in chemotherapy patients. From pre- and post- chemotherapy samples, 41 species were detected, with a predominance of Gemella haemolysans and Streptococcus mitis.

Chemotherapy modifies the oral microbiome of the patient: an assessment of the cariogenic species through appropriate instrumental tests can be performed periodically to investigate these bacteria early before the sign of caries can appear.

Their results suggest a shift to a more complex oral bacterial profile in patients undergoing cancer chemotherapy.

Dentist should be aware of these disorders resulting from the therapy of breast cancer, to inform patients about the alterations they might have.

The carcinoma of the breast, although it affects a district other than the mouth, causes several problems at the oral level. Some of these acting in a direct way, for example through a lowering of the immune system: the risk of developing periodontal disease increases.

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

Conclusions

From this review, the importance of the dentist is clear in proposing to patients with breast cancer appropriate therapies and dedicated prevention sessions.

Bibliography

1. Singh HSS. “Oral and systemic health. Dent. Horizons Essentials oral Heal. 1st ed. Hyderabad Paras Med. Publications (2011): 259-73.

page5image47227904

Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

2. Landskron., et al. “Chronic Inflammation and Cytokines in the Tumor Microenvironment”. Journal of Immunology Research 2014 (2014): 1-19.

49 17. Saini R. “Vitamins and periodontitis”. Journal of Pharmacy and

page6image47317376

3. Airila-Månsson., et al. “Influence of combinations of bacteria on the levels of prostaglandin E2, interleukin- 1beta, and granulocyte elastase in gingival crevicular fluid and on the severity of periodontal disease”. Journal of Periodontology 77 (2006): 1025-1031.

18. Yang., et al. “Cytokine and chemokine modification by Toll-like receptor polymorphisms is associated with nasopharyngeal carcinoma”. Cancer Science 103 (2012): 653-638.

4. Hanahan D and Weinberg RA. “Hallmarks of Cancer: The Next Generation”. Cell 144 (2011): 646-674.

19. Sahingur., et al. “Single nucleotide polymorphisms of pattern recognition receptors and chronic periodontitis”. Journal of Periodontal Research 46 (2011): 184- 192.

5. Virtanen., et al. “Chronic Periodontal Disease: A Proxy of Increased Cancer Risk”. 47 (2013): 1127-1133.

20. Junjie., et al. “The association between Toll-like receptor 2 single-nucleotide polymorphisms and hepatocellular carcinoma susceptibility”. BMC Cancer 12 (2012): 57.

6. DeSantis C., et al. “Breast cancer statistics, 2013”. CA: A Cancer Journal for Clinicians 64 (2014): 52-62.

21. Bergmann., et al. “Toll-like receptor 4 single-nucleotide polymorphisms Asp299Gly and Thr399Ile in head and neck squamous cell carcinomas”. Journal of Translational Medicine 9 (2011): 139.

7. Taichman L., et al. “Periodontal health, perceived oral health, and dental care utilization of breast cancer survivors”. Journal of Public Health Dentistry 75 (2015): 148-156.

22. Vargas-Villafuerte., et al. “Preliminary Results of Non-Surgical Periodontal Treatment in Patients with Breast Cancer Undergoing Chemotherapy”. Journal of Periodontology 87 (2016): 1268-1277.

8. Berry DA. et al. “Effect of Screening and Adjuvant Therapy on Mortality from Breast Cancer”. The New England Journal of Medicine 353 (2005): 1784-1792.

23. Carlson., et al. “NCCN Task Force Report: breast cancer in the older woman”. Journal of the National Comprehensive Cancer Network 6 (2008): S1-25.

9. Söder B. et al. “Periodontal disease may associate with breast cancer”. Breast Cancer Research and Treatment 127 (2011): 497-502.

24. PDQ Adult Treatment Editorial Board, P. A. T. E. Breast Cancer Treatment. (PDQ®): Patient Version. PDQ Cancer Information Summaries. National Cancer Institute. (US), (2002).

10. Virtanen., et al. “Chronic Periodontal Disease: A Proxy of Increased Cancer Risk”. International Journal of Cancer Research 47 (2013): 2051-2784.

25. Dose AM. “The symptom experience of mucositis, stomatitis, and xerostomia”. Seminars in Oncology Nursing 11 (1995): 248-255.

11. Freudenheim., et al. “Periodontal disease and breast cancer: Prospective cohort study of postmenopausal women.

26. Naidu MUR. et al. “Chemotherapy-induced and/or radiation therapy-induced oral mucositis--complicating the treatment of cancer”. Neoplasia 6 (2004): 423-431.

12. Nwizu NN. et al. “Periodontal Disease and Incident Cancer Risk among Postmenopausal Women: Results from the Women’s Health Initiative Observational Cohort”. Cancer Epidemiology, Biomarkers and Prevention 26 (2017): 1255-1265.

27. Biron P. et al. “Research controversies in management of oral mucositis. Support”. Care Cancer 8 (2000): 68-71.

13. Sfreddo CS., et al. “Periodontitis and breast cancer: A case- control study”. Community Dentistry and Oral Epidemiology 45 (2017): 545-551.

28. Volpato., et al. “Radiation therapy and chemotherapy-induced oral mucositis”. Brazilian Journal of Otorhinolaryngology73 (2007): 562-568.

14. Taichman., et al. “Periodontal health, perceived oral health, and dental care utilization of breast cancer survivors”. Journal of Public Health Dentistry 75 (2015): 148-156.

29. Adamietz., et al. “Prophylaxis with povidone-iodine against induction of oral mucositis by radio chemotherapy”. Support Care Cancer 6 (1998): 373-377.

15. Shi., et al. “Periodontal disease and susceptibility to breast cancer: A meta-analysis of observational studies”. Journal of Clinical Periodontology (2018).

30. Trotti A. et al. “Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: a systematic literature review”. Radiotherapy Oncology 66 (2003): 253- 262.

16. Amódio., et al. “Oral health after breast cancer treatment in postmenopausal women”. Clinics 69 (2014): 706-708.

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.

Bioallied Sciences 3 (2011): 170.

page6image47189952

Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review

31. Naidu., et al. “Chemotherapy-induced and/or radiation therapy-induced oral mucositis--complicating the treatment of cancer”. Neoplasia 6 (2004): 423-431.

50 43. Rubenstein EB. et al. “Clinical practice guidelines for the prevention and treatment of cancer therapy-induced oral and

page7image47901184

32. Taichman., et al. “Oral Health-Related Complications of Breast Cancer Treatment: Assessing Dental Hygienists’ Knowledge and Professional Practice”. JDH 89 (2015): 22-37.

gastrointestinal mucositis”. Cancer 100 (2004): 2026-2046. Volume 1 Issue 12 December 2018

33. Epstein., et al. “The relationships among fluoride, cariogenic oral flora, and salivary flow rate during radiation therapy”. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology 86 (1998): 286-292.

© All rights are reserved by Luca Viganò., et al.

34. Gupta N. et al. “Radiation-induced dental caries, prevention and treatment - A systematic review”. National Journal of Maxillofacial Surgery 6 (2015): 160-166.

35. Kielbassa., et al. “Radiation-related damage to dentition”. Lancet Oncology 7 (2006): 326-335.

36. Comeau., et al. “Taste and smell dysfunction in patients receiving chemotherapy: a review of current knowledge”. Support Care Cancer 9 (2001): 575-580.

37. Ishikawa., et al. “Incidence of dysgeusia associated with chemotherapy for cancer”. Gan To Kagaku Ryoho 40 (2013): 1049-1054.

38. Imai., et al. “Preliminary estimation of the prevalence of chemotherapy-induced dysgeusia in Japanese patients with cancer”. BMC Palliative Care 12 (2013): 38.

39. Juozaitytė E. et al. “Guidelines for diagnostics and treatment of aromatase inhibitor-induced bone loss in women with breast cancer: A consensus of Lithuanian medical oncologists, radiation oncologists, endocrinologists, and family medicine physicians”. Medicina (B. Aires) 50 (2014): 197-203.

40. Reid DM. et al. “Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group”. Cancer Treatment Reviews 34 (2008): S3-18.

41. Taichman LS. et al. “Periodontal Health in Women with Early- Stage Postmenopausal Breast Cancer Newly on Aromatase Inhibitors: A Pilot Study”. Journal of Periodontology 86 (2015): 906-916.

42. Napenas JJ. et al. “Molecular methodology to assess the impact of cancer chemotherapy on the oral bacterial flora: a pilot study”. Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology 109 (2010): 554-560.

Citation: Luca Viganò., et al. “Breast Cancer and its Treatment: Impact on Oral Health. A Traditional Review”. Acta Scientific Microbiology 1.12 (2018): 44-50.