FACT SHEET: Prostate Cancer1 (includes “adenocarcinoma [acinar and ductal]”, “transitional cell [urothelial] cancer”, “squamous cell carcinoma”, and “small cell prostate cancer”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Unlikely, but depends on severity of disease, severity of complications arising from treatment (e.g., medication-related osteonecrosis of the jaw [MRONJ]), and procedure being contemplated.
Is medical consult advised?
- Yes, if the patient/client is about to undergo, or is undergoing, radiation therapy.
- Yes, if the patient/client is undergoing chemotherapy and has, or is suspected to have, certain oral conditions or systemic manifestations.
- Yes, if the patient/client is taking a bone antiresorptive agent, such as a bisphosphonate (either orally or by injection) or denosumab.
- Yes, if the patient/client appears debilitated.
- Yes, prior to dental hygiene procedures, if permanent seed interstitial brachytherapy2 has taken place within the past two months in a patient/client and you, the dental hygienist, are, or may be, pregnant. In such a circumstance, input should be sought from a radiation oncologist regarding radiation safety precautions.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, if the patient/client is undergoing radiation therapy and/or chemotherapy.
- Yes, if the patient/client has MRONJ (as can be the case in advanced prostate cancer, depending on treatment).
Is medical consult advised?
- See above. Additionally, pre- and post-radiotherapy/chemotherapy medical and/or dental consultation is often warranted.
Is medical clearance required?
- Yes, if the patient/client is undergoing radiotherapy and/or chemotherapy.
- Yes, if MRONJ exists or is suspected.
- Yes, if patient/client is being treated with medications associated with immunosuppression +/- increased risk of infection and/or adrenal suppression (e.g., prednisone — a corticosteroid — is prescribed concurrently with abiraterone and ketoconazole in the treatment of advanced prostate cancer ).
Is antibiotic prophylaxis required?
- Possibly, for some patients/clients undergoing radiotherapy and/or chemotherapy according to blood indices and/or delivery mechanism (e.g., in-dwelling central venous catheter or port).
Is postponing treatment advised?
- Possibly, depending on blood indices (which indicate degree of immunosuppression and/or thrombocytopenia3) in patients/clients undergoing radiotherapy or chemotherapy. Elective invasive procedures should be deferred until after radiation- or chemo-induced immunosuppression ceases.
- Potentially, if MRONJ exists, informed by medical/dental consultation. Ideally, all necessary invasive dental and dental hygiene treatments should be performed before administration of injectable bisphosphonate drugs.
- Potentially, if permanent seed interstitial brachytherapy has taken place within the past two months in a patient/client and you, the dental hygienist, are, or may be, pregnant.
Oral management implications
- Refer also to Radiation Therapy, Chemotherapy, Xerostomia, and/or MRONJ Fact Sheets, as applicable.
- Metastatic disease to the mandible or maxilla may uncommonly be the first sign of malignancy, including prostate cancer. If undiagnosed metastatic cancer of the jaw (or elsewhere in the oral cavity) is suspected, prompt medical referral is indicated for work-up to identify the primary site and to stage the degree of metastatic involvement (i.e., solitary jaw lesion or, more frequently, a clinical sign of disseminated skeletal disease).
- Oral assessment before, during, and after active chemotherapy and radiotherapy is important. Coordination of care between the oncology and oral health teams is essential for patient/client safety.
- Following radical prostatectomy surgery, dental hygiene appointments should generally be kept short, because the patient/client may have difficulty sitting for extended periods. This is also a consideration during and following external beam radiation therapy to the prostate and/or prostate bed.
- Men taking enzalutamide (an antiandrogen drug) are prone to dizziness and hence are more likely to fall, which may lead to injuries. Appropriate preventive action should be taken.
- Refer also to Radiation Therapy, Chemotherapy, Xerostomia, and MRONJ Fact Sheets for details regarding cancer treatment-related dry mouth, caries, mouth sores, gingival bleeding, dysgeusia, infections, periodontitis, tooth decay, and osteonecrosis.
- While cancer metastases to the mandible and maxilla are unusual, about 1% of all malignant neoplasms do metastasize to the jaws4. About 80% of these metastases affect the mandible5, 14% affect the maxilla, and 5% affect both jaws. In men, primary prostate cancer accounts for about 12% of jaw metastases.
- Persons more likely to be affected by metastatic prostate cancer of the jaws are in the older age brackets, which reflects the higher prevalence of prostate malignancy in this population. The prognosis for patients/clients with metastatic carcinoma of the jaws is poor, with 5-year survival rates in the 10% range.
- Most metastatic jaw lesions involve one oral site, with only a few occurring in 2 or 3 sites.
- Bone pain, tooth ache, loosening of teeth, bone (and hence jaw) swelling, lip or chin paresthesia, gingival mass, trismus, and pathologic fracture may result from metastatic jaw lesions. In contrast to the radiographic appearance of most metastases6, metastatic prostate adenocarcinoma is characterized by an osteoblastic process, and hence nodular, fairly well circumscribed, radiodense (i.e., radiopaque) lesions.
- More rarely, metastatic deposits occur in the gingiva (especially the attached gingiva, with hyperplastic or reactive lesions initially resembling the clinical appearance of pyogenic granuloma7 and periodontal abscess). Metastatic lesions in other areas of the oral soft tissues tend to manifest as submucosal masses, particularly in the tongue, with very occasional presentation as ulcers.
- Oral metastases can grow rapidly, causing pain, difficulty in chewing, dysphagia, disfigurement, and intermittent bleeding.
- Medication-related osteonecrosis of the jaw may occur secondary to medications used to manage metastatic cancer affecting the bones. Osteonecrosis may also be caused by metastatic disease itself.
- Androgen deprivation therapy (ADT) can cause alveolar bone loss, and it has been linked to elevated rates of periodontal disease.
Related signs and symptoms
- Refer also to Radiation Therapy and Chemotherapy Fact Sheets.
- Excluding non-melanoma skin cancer, prostate cancer (PC) is the most commonly diagnosed cancer among Canadian men, accounting for 20% of all new cancer cases in males. 1 in 8 Canadian men will develop prostate cancer in his lifetime. Annually, about 9,100 men are diagnosed in Ontario (24,000 in Canada), and 1,700 (4,500) die from the disease. The 5-year net survival rate is 91%.
- In many men, PC is slow growing, and affected men may live many years without having the cancer detected8. Age is the strongest risk factor for prostate cancer, with risk increasing at age 50 years, and most cases being diagnosed in men over age 65 years. Other risk factors include having a first-degree relative (father or brother) with prostate cancer, being of African or Caribbean descent, being overweight, and eating a low-fibre, high-fat diet.
- For men with prostate cancer, depending on individual circumstances, treatment options might include: watchful waiting or active surveillance; surgery (prostatectomy or orchiectomy9); cryotherapy (cryosurgery); high intensity focused ultrasound; transurethral resection of the prostate (TURP); radiation therapy (external beam or interstitial brachytherapy); hormone therapy (i.e., androgen deprivation therapy10); chemotherapy (e.g., docetaxel and cabazitaxel); immunotherapy, including vaccine treatment (sipuleucel-T); targeted therapy; bone-directed treatment (e.g., bisphosphonates or denosumab); and pain management and other palliative care.
- Common signs/symptoms of PC include difficulty urinating (including starting or stopping urine flow), frequent urination (especially at night), urgent need to urinate, decreased force of urination, pain when urinating, painful ejaculation, and blood in urine or semen.
- Prostate cancer is particularly likely to give rise to skeletal metastases, and bone pain is a common result. At present, metastatic prostate cancer is not curable, but it is treatable.
- Depending on the type(s) of treatment (particularly prostatectomy and radiotherapy), men with PC (whether cured or not) may suffer from urinary incontinence and/or overactive bladder.
- Bloating, as well as rectal and bladder irritation, can result from radiation to the pelvis.
- Orchiectomy and LHRH agonists and antagonists cause similar side effects from lower levels of testosterone. These include hot flashes (i.e., intense heat sensation, flushing, and diaphoresis11, which are sometimes accompanied by anxiety and palpitations); reduced or absent libido; impotence (erectile dysfunction); shrinkage of testicles and penis; hair loss on torso and in genital area; breast tenderness and growth of breast tissue; anemia; loss of muscle mass; weight gain; fatigue; increased cholesterol levels; labile mood; depression; and decreased mental sharpness.
- Antiandrogens cause similar side effects to LRLH agonists and antagonists but with fewer sexual side effects. Additionally, diarrhea, nausea, and liver problems may occur.
- Abiraterone can cause joint or muscle pain, high blood pressure, fluid build-up in the body, hot flashes, gastrointestinal upset, and diarrhea.
- Enzalutamide can cause fatigue, worsening of hot flashes, diarrhea, and nervous system effects such as dizziness and, rarely, seizures.
- Some research suggests that the risk of high blood pressure, diabetes, stroke, myocardial infarction, and even death from heart disease is higher in men treated with hormone therapy, although not all studies have found this. Androgen deprivation therapy also causes bone loss leading to osteoporosis.
- Patients/clients receiving prostate vaccine treatment may have side effects such as fever, chills, fatigue, joint and back pain, nausea, and headache.
References and sources of more detailed information
- Aksoy S, Orhan K, Kursun S, Kolsuz ME, Celikten B. Metastasis of prostate carcinoma in the mandible manifesting as numb chin syndrome. World Journal of Surgical Oncology. 2014;12:401. doi:10.1186/1477-7819-12-401.
- Famili P, Cauley JA, Greenspan SL. The Effect of Androgen Deprivation Therapy on Periodontal Disease in Men With Prostate Cancer. The Journal of Urology. 2007;177(3):921-924.
- Kumar G, Manjunatha B. Metastatic tumors to the jaws and oral cavity. Journal of Oral and Maxillofacial Pathology. 2013;17(1):71-75.
- Heindel W, Gübitz R, Vieth V, Weckesser M, Schober O, Schäfers M. The Diagnostic Imaging of Bone Metastases. Deutsches Ärzteblatt International. 2014;111(44):741-747.
- O’Sullivan GJ, Carty FL, Cronin CG. Imaging of bone metastasis: An update. World Journal of Radiology. 2015;7(8):202-211.
- Canadian Cancer Society
- Cancer Care Ontario (Ontario Health)
- Cancer Research UK
- American Cancer Society
- Mayo Clinic
- The Angeles Clinic and Research Institute (Cedars Sinai Affiliate)
http://www.theangelesclinic.org/Home/PatientEducationLibrary/tabid/19283/ctl/View/mid/35200/Default.aspx?ContentPubID=421 (Brachytherapy — Intracavity and Interstitial)
- The Dentist’s Quick Guide to Medical Conditions
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Ibsen OAC and Peters SM. Oral Pathology For The Dental Hygienist (8th edition). St. Louis: Elsevier; 2023.
- Regezi JA, Sciubba JJ, and Jordan RCK. Oral Pathology: Clinical Pathologic Correlations (7th edition). St. Louis: Elsevier; 2017.
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
2 Brachytherapy can involve either temporary or permanent radioactive seed implantation near or within cancerous tissue (interstitial brachytherapy) or radioactive seed placement within a body cavity (intracavitary brachytherapy). Permanent radioactive seed implantation is used to treat prostate cancer in some men.
3 thrombocytopenia = low blood platelet count
4 The mechanism of spread to the jaws is usually hematogenous (i.e., via the blood stream) from the primary neoplasm or from lung metastases.
5 The premolar region, the angle, and the body of the mandible are most commonly affected by metastatic disease.
6 Most metastases appear radiographically as poorly marginated, radiolucent, osteolytic defects.
7 Pyogenic granuloma is a benign, vascular “overgrowth” lesion that occurs on the mucosa or skin due to irritation, physical trauma, or hormonal factors.
8 Population-based screening (using the prostate-specific antigen [PSA] blood marker) for prostate cancer is controversial, and is not currently recommended by Cancer Care Ontario for men not at elevated risk.
9 Bilateral orchiectomy is surgical removal of both testicles, which is a permanent castration alternative to ongoing administration of androgen deprivation therapy. Prostate cancer is often testosterone-fuelled, and reduction of testosterone levels inhibits growth and spread.
10 In castrate-sensitive prostate cancer, ADT medications (some oral, many injectable) may be used, including antiandrogens such as bicalutamide, flutamide, and nilutamide; luteinizing hormone-releasing hormone (LHRH) agonists such as leuprolide, goserelin, triptorelin, and histrelin; and the LHRH antagonist degarelix. In castrate-resistant cancer, more powerful antiandrogens — such as apalutamide, enzalutamide, and darolutamide — or androgen synthesis inhibitors — such as abiraterone — may be the next step; abiraterone may also be useful in castrate-sensitive PC. Less commonly, estrogens and ketoconazole (an antifungal) are sometimes used to achieve androgen suppression.
11 diaphoresis = excessive, abnormal sweating relative to ambient environment and activity level
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.