Stomatitis during chemotherapy - causes, symptoms and diagnosis

Oncological diseases continue to grow. Of course, diagnostics have become better, tumor processes are detected in the early stages, and with timely treatment, oncologists achieve impressive results. But the absolute numbers are growing. The success of cancer and tumor treatment can only be increased by following sound recommendations and early diagnosis. There is such a concept in medicine - the doctor’s oncological alertness. Every medical specialist, no matter what field he practices, must know the general signs of cancer, be able to separate the processes of oncogenesis from ordinary inflammatory diseases, and if the latter are identified, refer the person to a specialized oncologist. Early diagnosis and timely access of the patient to the appropriate specialist is the main factor in the success of treatment. And delay in prescribing treatment, ignoring its basic principles often makes the situation hopeless.

The main methods of treatment remain surgery in combination with radiotherapy and chemotherapy. Regarding the latter, a number of side effects are known, one of the most common being various inflammatory manifestations in the oral cavity.

The most common complications and unpredictable reactions

Sometimes antitumor therapy has such a severe toxic effect on the body that the quality of life becomes worse than during the disease. This may be accompanied by the following symptoms:

• changes in taste, loss of appetite, nausea, vomiting;
• weakness not associated with physical activity, dizziness, drowsiness;
• muscle pain, neuropathy (numbness of the hands, feet);
• depressed state, panic attacks;
• decreased cognitive abilities – deterioration of memory, concentration;
• bowel disorder - diarrhea or constipation;
• increased body temperature;
• hair loss, change in color of nail plates and skin;
• swelling, redness, ulceration in the mouth area;
• in men – loss of libido and erection, reproductive functions; in women – failure of the ovaries.

Weakened immunity and an increased risk of bleeding are directly related to changes in blood composition, namely a drop in the number of neutrophils and platelets. After such destructive symptoms that do not go away on their own, recovery from chemotherapy for oncology will be required.

The WHO classification considers several degrees of severity of side effects:

• 0 – no changes in condition and laboratory tests are observed;
• I – recording of minor deviations that do not affect the general condition and do not require correction;
• II – moderate changes in internal organs, noticeable deterioration in test data and decreased activity. The patient needs therapeutic assistance;
• III – severe violations requiring the cancellation of sessions and mandatory intensive somatic treatment;
• IV – changes in the body that pose a threat to human life.

Changes in skin and nails during chemotherapy

During chemotherapy courses you may experience: dryness, itching, redness, pain of the skin, increased sensitivity to sunlight. Hives may appear on the skin. Nails become brittle and brittle. All these symptoms should be reported to your doctor.

Skin care recommendations

• Take short showers and baths with warm water. Do not use hot water.
• When washing, do not rub the skin with a washcloth; gently stroke it.
• When using lotions and creams, ask your doctor or nurse how to use them correctly.
• The cream should be soft and gentle on the skin. Never use products that contain perfume or alcohol.
• Sometimes in the area of ​​​​skin folds (in the armpits, under the mammary glands, in the popliteal hollows) it is worth applying corn starch. This will help prevent irritation and itching.
• If shaving causes discomfort or irritation, then you should shave less often, or not shave at all.
• Protect your skin from sun rays. When leaving the house, wear long sleeves and long pants, use sunscreen and chapstick.
• Do not visit the solarium.

Nail care tips

• Keep your nails short.
• When washing dishes and cleaning, wear rubber gloves.

What should you ask your doctor?

• How to properly care for your skin and nails? What products are best to use?
• What soaps, shampoos and lotions should you not use?
• Which sunscreen and chapstick should you buy?
• What products should you use to treat your nails?
• Is it possible to get a manicure?
• What to do if your skin itches a lot?
• How to care for your skin and nails after treatment? How long will it take to do this?
• In what cases should you consult a doctor?

Organs most susceptible to chemical influence

Most often, vital organs and systems are negatively affected.

Lungs

After a course of chemotherapy, there is a sharp reduction in white blood cells, causing a weakening of the immune system. As a result, patients are susceptible to infectious diseases. Various microorganisms, entering the respiratory tract, provoke inflammatory processes in the lungs and bronchi, for example, acute pneumonia. Body temperature rises to high levels, pain in the sternum, wet cough, weakness, heavy sweating appear, pulse and breathing become more frequent, the nail plates and nasolabial triangle turn blue. With shortness of breath, the level of carbon dioxide in the blood increases, and the load on the heart muscles increases. Respiratory failure is accompanied by cardiac failure, which provokes dystrophic changes in the myocardium.

The pathology often ends in death. Therefore, the sooner preventive treatment with antibacterial drugs begins after the end of chemotherapy, the greater the chance of recovery. To increase white blood cells, a blood transfusion is sometimes prescribed to restore the body's protective functions.

Liver

Liver cells are most susceptible to the negative effects of chemotherapy drugs, since it takes an active part in the metabolism and neutralization of harmful substances. It is she who is assigned the role of a conductor of cytostatics, and at the end of therapy, a protector of the body from toxic effects.

The degrees of organ damage are divided into four forms: mild, moderate, high, severe. They are determined based on the biochemical parameters of bilirubin and blood enzymes. If a person has not previously worked in an enterprise with harmful conditions, has not abused alcohol, or suffered from hepatitis, then they are usually normal.

With a high and severe degree, metabolic processes fail, the blood supply to cells is disrupted and changes in their structure, and chronic diseases worsen. Fortunately, the liver is regenerating safely. And with the help of drug therapy and an appropriate diet, this happens easier, faster and more reliably.

Stomach

Functional disorders in the gastrointestinal tract are the most common complications observed after the end of chemotherapy. Due to damage to the mucous membrane, patients experience unpleasant symptoms - heartburn, nausea, vomiting, pain in the epigastric region, bloating, weakness. Inflammatory-dystrophic changes cause intolerance to certain foods, and lack of appetite leads to weight loss.

To heal the mucous membrane and restore normal functioning of the gastrointestinal tract, doctors recommend a gentle diet and a standard treatment regimen for gastritis.

Intestines

One of the side effects of the anticancer drug is inflammation of the colon mucosa - colitis. The walls of the colon swell, peristalsis and mucus production worsen. The balance between harmful and beneficial microflora is disrupted, pathogenic bacteria become the cause of dysbacteriosis.

A person experiences lethargy, weakness, abdominal cramps, flatulence, instability and irregularity of stool, constipation alternates with diarrhea. The urge to defecate is painful, and there is mucus and blood in the stool. Possible increase in body temperature.

Treatment is aimed at reducing the inflammatory process and healing the mucous membrane, as well as relieving symptoms.

Kidneys

Another consequence of chemotherapy is nephrotoxicity. Necrotic degeneration of renal tissue cells occurs with damage to the tubular epithelium, and then the process of intoxication spreads to the glomerular tissue. This complication is called tubulointerstitial nephritis. Initially, it is acute in nature, but with prolonged treatment it develops into a chronic stage.

The degree of renal failure is determined after tests based on the level of residual nitrogen or creatinine in the blood, red blood cell counts and protein in the urine. Kidney failure leads to long-term anemia, which appears due to improper production of the hormone erythropoietin.

Bladder

Inflammation of the epithelium of the bladder - cystitis, is expressed in pain or burning, frequent urge to urinate, the appearance of mucus and blood in the urine. Sometimes accompanied by a feeling of chills and fever.

In such cases, it is recommended to drink as much fluid as possible, at least 2-2.5 liters per day. The diuretic effect provokes the flushing out of toxins, which helps to minimize the irritating effect of toxic substances on the mucous membrane of the excretory system.

Anemia during chemotherapy

Oxygen is delivered to the tissues of the body by red blood cells - erythrocytes. Each of them lives only 3-4 months, so new ones must constantly form in the red bone marrow. Chemotherapy drugs attack red bone marrow cells, the content of red blood cells and hemoglobin in the blood decreases, and anemia develops.

Manifestations of anemia:

• weakness;
• dizziness;
• shortness of breath, feeling of lack of air;
• cardiopalmus.

Tell your doctor if you begin to experience these symptoms. Anemia requires immediate treatment. There are drugs that increase the activity of red bone marrow. In severe cases, red blood cell transfusion is indicated.

Recovery Tools

Medicines that reduce the effects of chemotherapy and restore health are prescribed individually for each patient, depending on the diagnosis and the cytostatic agent used. These can be either traditional pharmaceuticals or herbal ones.

Drug therapy is carried out in a hospital setting. Since the liver takes the first blow, it initially needs support. In this situation, the patient takes hepatoprotectors and enterosorbents.

After discharge, the patient is advised to radically change his lifestyle and diet. In most cases, rehabilitation takes about 4-6 months. Experts are developing programs to effectively cleanse the body and protect against attacks by pathogenic flora.

Our experts also recommend taking VIALIFE chlorophyll capsules, which will help minimize side effects in the shortest possible time due to the properties of the maximum possible dosage of chlorophyll in the composition.

Changes in memory during chemotherapy

About one in five patients who receive chemotherapy experience problems with memory and thinking. They can be caused by two reasons:

1. side effects of chemotherapy drugs;
2. fatigue, anxiety, stress due to illness and treatment.

The doctor must understand the causes and prescribe treatment. Sometimes memory impairment is not severe and does not cause any special problems, in other cases it interferes with everyday activities.

Useful tips to help with memory loss:

• Plan ahead. Write them down in a diary or on colored sticky notes placed in a visible place.
• The most difficult tasks should be completed when you feel good and can concentrate as much as possible.
• Get more rest.
• , special boxes, and marks in a calendar or diary will help you take your medications on time and correctly
• Don't be shy to ask family and friends for help if you can't handle things on your own.
• Ask your family to remind you about taking medications and procedures.
• If you feel that your condition has worsened, your consciousness is confused, you need to call the doctor and ask that someone close to you be with you at all times.

What should you ask your doctor?

• Why did my memory deteriorate?
• What medications can improve it?
• What recommendations should you follow?
• How long will these violations last?
• In what cases should you urgently consult a doctor?

General recommendations for recovery

Of no small importance during recovery is given to replenishing the deficiency of microelements and vitamins. To find out which ones you need to get, blood tests are taken.

Nutritional supplements containing magnesium, iron, zinc, copper, etc. are prescribed, in which each component complements and enhances the effect of the others. Dosages and duration of administration are selected by the attending physician.

The effect of diet on tumor recurrence has been scientifically proven. A classic diet should include:

• a large number of various greens, berries and fruits;
• seaweed, seafood;
• nuts, pre-soaked in water for 6 hours;
• white meat chicken, turkey, lean beef, lamb, pork;
• pickled and lightly salted cucumbers, cabbage;
• dark chocolate, cookies, candies;
• sugar free coffee. You can add Jerusalem artichoke syrup. It contains a prebiotic – inulin, which has a beneficial effect on the intestinal microflora;
• minimal amount of sweet fruits and honey.

Sleep plays a crucial role in rehabilitation. The hormone melatonin is necessary to regulate the cycles of quality sleep and wakefulness. It forms memory, participates in the restoration of immunity, improves appetite and regulates body weight. The activity of its production is observed in the period from 20 pm to 1 am.

We recommend taking VIALIFE capsules or VIALIFE solution, because they contain the highest possible concentration of chlorophyll, which:

• strengthens the immune system;
• enhances cell regeneration;
• saturates tissues with oxygen;
• has antioxidant, anti-inflammatory, detoxifying effects.

On the path to recovery after chemotherapy and radiation therapy for oncology, monitoring your health status is important. And for this it is advisable to undergo a medical examination annually.

When to see a doctor?

Tell your doctor if you are concerned about the following symptoms:

• There was no stool for more than 2 days.
• I'm worried about pain in my stomach.
• The belly has increased in size.
• Appetite has decreased, nausea and vomiting occur periodically.

How to deal with constipation?

These simple tips help many people:

• Drink enough liquid - at least 8 glasses a day. Plain water, compote, juices from fruits and vegetables, tea, coffee will do. Water will help soften the stool and make it easier to pass.
• Eat more foods rich in fiber : seeds, nuts, vegetables, fruits, whole grain bread.
• Move more. Physical activity helps strengthen intestinal motility. Walk or bike for 15-30 minutes every day. Ask your doctor what exercises may be appropriate for you.

What to ask your doctor?

• What medications will help relieve constipation?
• What's better to eat and drink?
• How much fluid should you drink daily?
• What physical exercises can you do?
• When do you need to see a doctor urgently?

Comprehensive monitoring

Laboratory research:

• general blood and urine tests;
• blood biochemistry;
• glycated hemoglobin to track average sugar levels over the past 3 months;
• thyroid profile with indicators of the level of thyroid hormones and specific immunoglobulins;
• insulin check;
• checking the homocysteine ​​value;
• lipid profile with determination of fats of different fractions in blood serum;
• vitamin D content;
• checking the value of the iron-containing protein ferritin.

Consultations with a gynecologist, urologist-andrologist, and dentist are also scheduled. Hardware diagnostics: fluorography of the chest organs, ultrasound. Patients who have crossed the 40-year mark will have to additionally visit the following offices:

• for women - mammography, densitometry (detection of bone fragility);
• for men - ultrasound of the prostate gland, PSA (laboratory marker of the condition of the prostate gland);
• for both sexes - ECG, colonoscopy, coagulogram, duplex scanning of the thickness of the intima-media complex of the carotid artery.

Nausea and vomiting during chemotherapy

Nausea and vomiting usually occur on days when chemotherapy is not administered. Medicines and some recommendations can help cope with these side effects:

• Limit spicy, sweet, salty, fried, fatty foods.
• If you can't stand the smell of raw food, ask your loved ones to cook it for you.
• Allow food to cool, do not eat it hot.
• Eat little, but more often. 5-6 small meals throughout the day are better than three “big” ones.
• If you find it difficult to drink a lot, take small sips of liquid throughout the day.
• During the administration of chemotherapy, you should try to relax and breathe deeply. Your loved ones can help and distract you.
• Find the best meal time for you. Some people feel fine if they eat a little before the procedure. Others are better off not eating anything.
• It is not recommended to eat or drink anything for at least an hour after the administration of chemotherapy drugs.
• Acupuncture helps some people cope with nausea.

Foods and drinks that will help improve your condition:

• Transparent broths: beef, chicken, vegetable.
• Grape or cranberry juice.
• Soda.
• Tea.
• Rehydron and other salt solutions for rehydration.
• Semolina.
• Skinless chicken, boiled or baked.
• Oatmeal.
• Cookies, crackers.
• Boiled potatoes.
• Pasta, noodles.
• Croutons (from white bread).
• White rice.
• Yogurts.
• Applesauce.
• Canned peaches and pears.
• Bananas.
• Sherbet.
• Fruit ice.
• Kissel.

What should you ask your doctor?

• What foods are recommended for me to eat?
• What foods should you limit?
• What foods should you completely avoid?
• How much fluid should you drink daily?
• Can physical therapy and acupuncture be helpful in my case? Where can you find specialists?
• Where can I find a nutritionist who can create an optimal diet?
• In what cases should you immediately consult a doctor?

Our clinic's capabilities

Is there really no way to mitigate the effect of anti-cancer drugs? - thinks every sane person. Of course it is possible, but the whole point is that this will reduce not only the toxicity, but also the therapeutic effect of chemotherapy.

Recently, photodynamic therapy has been increasingly used in the treatment of cancer. PDT is a technology proven by more than twenty years of successful practice. Selective chronophototherapy (SCPT), which is based on photodynamic therapy, is capable of activating a cascade of biochemical and cellular reactions to regulate the level of immune status indicators. A special substance is introduced into the body - chlorophyll (a natural photosensitizer of the latest generation), which accumulates in cancer cells. A laser beam is sent to the site of accumulation, capable of synchronizing with the patient’s rhythms, which makes it possible to reduce or increase the intensity of the effect. Penetrating to the required depth, it concentrates on pathological cells, destroying them, without touching healthy ones. Over the course of several months, the tumor disintegrates.

PDT is used not only to remove tumors, but also instead of chemotherapy, unlike which it does not have a destructive effect on the body. The manipulation can be performed on an outpatient basis.

Fatigue and weakness during chemotherapy

Increased fatigue can be associated with chemotherapy, anemia, stress and depression, insomnia, and chronic pain. Sometimes fatigue occurs only at certain times, other times it lasts all day. Be sure to tell your doctor if this makes it more difficult for you to cope with daily activities or if your fatigue does not go away even after resting.

Some tips will help improve your condition:

• Plan ahead. Do the most important ones first when you feel good.
• Ask your family for help if you can’t cope on your own.
• If you plan to continue working during treatment, take time off early and take fewer working hours .
• It is useful to keep a diary. Write down how you feel every day. This will help your doctor better monitor your condition and prescribe the best treatment.
• Eat well . Cook meals when you feel good and freeze for later.
• It is better to have 5-6 small meals during the day than 3-4 solid ones.
• Drink at least 8 glasses of liquid per day. You can take small sips throughout the day.
• Try to exercise for at least 15 minutes a day.
• Rest often . If you feel tired, don’t force yourself and continue working.
• Train yourself to nap during the day . It should last at least an hour.
• Always go to bed at the same time.
• Before going to bed, try to relax. For example, pleasant music helps.
• Your night's sleep should last at least 8 hours.

What should you ask your doctor?

• What medications will help cope with fatigue?
• What should I eat and drink?
• How much fluid should I drink every day?
• What physical exercises can make me feel better?
• How can I properly control my well-being? What information should you write down in your diary?
• In what cases should you urgently consult a doctor?

Diagnosis of cancer of the oral mucosa

The diagnosis is established based on visual examination and confirmed by histological examination of tissue obtained from a biopsy of the affected area. If there is a suspicion that the tumor has spread into the bone tissue, a skull x-ray is indicated.

Ultrasound examination of the abdominal organs and chest radiography are prescribed to detect distant metastases. For the same purpose, it is possible to use PET-CT.

Nervous system during chemotherapy

Chemotherapy can cause some nervous system side effects. If you notice them, you should immediately tell your doctor:

• Pain while walking.
• Rapid fatigue of the arms and legs, tingling, burning, numbness.
• Loss of balance, falling.
• Dizziness.
• Muscle spasms, cramps, pain.
• Deterioration in hand function: it has become more difficult to lift and hold objects.
• Hearing loss.
• Stomach ache.
• Constipation.

Helpful tips for people with neurological disorders:

• Remove or move carpets in your home to avoid tripping hazards.
• Screw on special grab bars in the bathroom.
• Place a non-slip mat in the bathroom.
• Wear comfortable shoes without high soles.
• Use a cane.
• Buy comfortable shoes for indoors.
• Wear rubber gloves when working in the kitchen or cleaning.
• Regularly examine your feet with a mirror, ask your loved ones for help.
• An ice pack will help reduce pain and discomfort.
• When doing chores around the house, take your time and don't overexert yourself.
• If you find it difficult to do some things, do not hesitate to ask your loved ones for help.

What should you ask your doctor?

• What medications can help treat neurological disorders?
• Should I see a chiropractor?
• What neurological problems might I have and when is it most likely to happen?
• How long will these side effects last?
• In what cases should you consult a doctor?

Swelling during chemotherapy

The occurrence of edema can be provoked by chemotherapy drugs, hormonal changes in the body, and general health (in particular, the cardiovascular system). Call your doctor immediately if you experience the following symptoms:

• Difficulty breathing.
• Feeling that the heart is not working properly.
• Rapidly, sharply occurring swelling that quickly increases.
• Unexplained weight gain - This may also be due to swelling.
• Very rare urination, a small amount of urine - this indicates that fluid is retained in the body.

Some recommendations will help improve your condition:

• Wear loose shoes.
• Try not to stand for long periods of time.
• When lying or sitting, try to raise your legs so that they are no lower than the level of your heart.
• Weigh yourself at the same time every day, keep a diary and record your results every day.
• Avoid adding salt and soy sauce to your food.
• Avoid foods that contain a lot of salt: ham, chips, sauerkraut, pickles.
• When you buy foods, be sure to read labels and check how much salt they contain.

What should you ask your doctor?

• How much salt can I consume per day?
• Should I wear compression garments?
• What kind of weight gain should you pay attention to?
• What foods should you not eat?
• How can you reduce swelling and improve the condition?

Read more about swelling due to cancer in a separate article.

Causes

Let's look at the causes of dental cancer

:

• Oral injuries of various origins. Poor-quality dentures rub the gums; the presence of piercings in the tongue or lip can cause inflammation
• Bad habits (smoking, drinking alcohol and drugs).
• Untreated caries.
• Inflammatory diseases of soft tissues.
• Herpes virus, HPV, Bowen's disease.
• Poor oral hygiene.
• Hot or spicy foods that constantly irritate the mucous membranes.
• Work in conditions harmful to health (hot workshop, dusty room).
• A history of cancer of the stomach, kidneys and lungs. In this case dental cancer

  is a secondary pathology.

To take care of your health, rule out dental cancer, causes

its development must be monitored. Careful oral care, eradication of bad habits, and regular visits to the dentist will reduce the risk of developing pathology.

Stages of cancer

Staging, as with other carcinomas, is carried out according to the TNM system, where T is the spread of the primary tumor, N is metastases to regional lymph nodes, M is distant metastases. The value “0” after the letter designation indicates the absence of the attribute.

When treated in the early stages, the 5-year survival prognosis is more than 85% for the first stage and 60-80% for the second. In later stages, this indicator is worse (20 - 50%), and the patient requires combined treatment.

Oral cavity and throat

Cells in the mucous membrane of the mouth and digestive tract are constantly multiplying and renewing themselves, so chemotherapy drugs can damage them. In some patients, 7-10 days after the start of treatment, an inflammatory process occurs in the mouth - oral mucositis. The burning sensation is disturbing, like after a burn with boiling water, ulcers may appear.

Tell your doctor if you experience any of these symptoms:

• It became difficult to eat and swallow.
• Painful spots and ulcers appeared on the oral mucosa.
• Sores appeared on the inside of the lips and cheeks.
• You began to taste and smell food and objects differently.
• Saliva production has almost ceased, and my mouth is constantly dry.
• When you eat hot or cold food, pain occurs.

Recommendations from Euroonco doctors:

• Take care of your teeth regularly. Brush your teeth and tongue after every meal and before bed.
• Use a toothbrush with soft bristles or cotton swabs.
• Toothpaste should contain fluoride - it helps strengthen teeth.
• Rinse your mouth with a solution of baking soda (¼ teaspoon) and salt (1/8 teaspoon) diluted in a glass of water. After this, you need to rinse your mouth with plain water.
• Moisturize your lips with chapstick.
• Drink in small sips or through a straw.
• Choose soft foods that are easy to swallow.
• If you have pain in your mouth, you can eat scrambled eggs, porridge, and mashed potatoes.
• Broths , gravies, and sauces will help soak solid foods.
• Don't eat hot food , let it cool.
• Avoid drinking citrus and tomato juice.
• Don't drink alcoholic beverages.
• Don't drink sweet soda , limit foods that contain sugar.
• If you smoke, try to quit.

You should visit your dentist 2 weeks before starting chemotherapy. If you are having dental treatment, the treatment must be completed.

What should you ask your doctor?

• What foods and drinks should I consume?
• Can I rinse my mouth with a solution of salt and soda?
• How can you reduce pain when brushing your teeth?
• Which toothpaste is best to use?
• What medications can reduce my symptoms?
• In what cases should you urgently consult a doctor?

Risk factors

Most malignant tumors of the oral cavity arise in already changed tissues. Usually these are long-term inflammatory changes and various precancerous conditions. Precancer is a special condition of tissues in which at some point their malignant degeneration may occur, although a benign tumor and a complete return to normal state may be a possible outcome. The causes of precancerous conditions and their progression into a malignant process are not known with certainty. Scientists suggest that this depends on the immunobiological status of a person and the characteristics of exposure to the carcinogen.

Factors that contribute to the appearance of precancerous changes can be both external damaging agents and various disorders in the body:

• Constant mechanical impact - malocclusion, poorly fitting dentures.
• Chemical agents - alcohol, tobacco smoke, spices, industrial irritants.
• Temperature agents - constant consumption of very hot food, hot tobacco smoke, work in hot shops.
• Biological agents: various microorganisms of the oral cavity, both frankly pathogenic and opportunistic, which make themselves known only under favorable conditions.
• Ionizing radiation, including due to medical procedures.
• Diseases of the digestive system.
• Some systemic lesions, in particular lupus erythematosus.

Among these factors, one of the most important is biological. There has been a proven connection between precancerous changes in the oral mucosa with caries and gum disease due to excessive bacterial growth. The second, but no less important factor is smoking - the disease is registered in smokers 6 times more often than in non-smokers.

Clinical manifestations

Symptoms of oral cancer may include:

• compaction and swelling of the affected area;
• long-term non-healing ulcer;
• white or red spots on the mucous membrane;
• weakening of tooth roots;
• bleeding gums;
• speech disorder;
• unexplained weight loss;
• soreness in the mouth;
• general malaise.

Most of these symptoms are nonspecific and are observed in chronic diseases of the dental system, and therefore are often ignored by the patient.