Can Immune Checkpoint Inhibitors Cause Oral Complications in Cancer Patients?

If you’re one of the many thousands of cancer patients whose treatment includes immune checkpoint inhibitors (ICIs), you should be aware that you could experience debilitating and painful oral side effects from the very medication that may save your life. But experts at Baptist Health Miami Cancer Institute say there are ways to help eliminate or minimize the problems that may interfere with your ability to eat, swallow, talk or even continue ICI treatment.

It’s a growing issue as ICIs are being increasingly used successfully to treat a variety of cancers, including lung cancer, melanoma, kidney cancer, gynecological cancers, colorectal cancer and triple-negative breast cancer.

Common Oral “Immune checkpoint inhibitors have revolutionized cancer treatment but also introduced immune-related adverse events (irAEs), including oral irAEs,” says Alessandro Villa, DDS, MPH, Ph.D., chief of Oral Medicine, Oral Oncology and Dentistry at Miami Cancer Institute.

Oral Side Effects for Some Cancer Patients on Immune Checkpoint Inhibitors

Common irAEs include xerostomia (dry mouth), hyposalivation (reduced saliva production), dysgeusia (altered taste) and oral mucosal lesions (ulcers, erosions and other lesions). “Oral irAEs impact quality of life, leading to pain, weight loss, dehydration and, in severe cases, the need for feeding tube placement or opioid analgesics,” he says.

Dr. Villa, who is the only cancer center-based board-certified oral medicine specialist in South Florida, is also the first author of “Oral Immune-Related Adverse Events Secondary to Immune Checkpoint Inhibitors: Call to Action.” The paper was published in February in JCO Oncology Practice, a journal of the American Society of Clinical Oncology (ASCO).

“Up to 8 percent of patients on ICIs experience oral immune-related adverse events (irAEs),” Dr. Villa says. “ICIs are a class of cancer immunotherapy drugs that block immune checkpoints, which tumors use to evade immune attack.” When the checkpoints are inhibited, T-cell activity is boosted, allowing the immune system to target and destroy cancer cells more effectively.

Dr. Villa teamed up with Bryan Schneider, M.D., University of Michigan Health System, Douglas Peterson, DMD, Ph.D., School of Dental Medicine at UConn Health, and Christina Lacchetti, MHSc, and Thomas Oliver, B.A., both with ASCO, to develop the Call to Action.

Lowering the Risk of Oral Side Effects During Cancer Treatment

The group has a number of recommendations, including building greater awareness, closely monitoring patients, developing treatment management guidelines and conducting more research to improve care for those on ICIs.

They also want to educate patients on methods to prevent or lower their risk. Among their suggestions to maintain optimal oral health during ICI treatment are:

·      Brushing teeth with a soft toothbrush and fluoride toothpaste twice a day.

·      Using over-the-counter saliva substitutes.

·      Avoiding spicy, acidic or very hot foods.

·      Staying hydrated and chewing sugar-free gum to stimulate saliva.

·      Seeking dental care immediately for any oral pain, ulcers or dryness.

·      Reporting changes in taste or swallowing difficulties early.

At Miami Cancer Institute, Dr. Villa says that oral medicine specialists, collaborating with oncologists, perform routine oral exams before and during ICI therapy, educate patients on symptoms and prevention, provide early intervention to prevent severe complications and manage oral irAEs with appropriate treatment.

The Call to Action paper pushes for more research to both better understand who is at high risk for developing irAEs and to help develop new treatment approaches.

“There is some promising research underway, but we need more studies, particularly in the areas of biomarkers to identify genetic, immunologic and inflammatory markers; AI-based risk-prediction models that analyze patient data; and patient-reported outcome measures,” Dr. Villa says.

Alessandro Villa, DDS, MPH, Ph.D., chief of Oral Medicine, Oral Oncology and Dentistry at Baptist Health Miami Cancer Institute

Dr. Villa is optimistic that as the use of ICIs increases, the number of oral immune-related adverse events can be reduced and better managed. Talk to your doctor about your risk for irAEs if you are taking immune checkpoint inhibitors, and if you are experiencing any oral symptoms, see your dentist or an oral oncologist.

For more information about Miami Cancer Institute’s oral medicine program, click here.