The degree of xerostomia correlates with both the amount of glandular tissue radiated and the total dose, primarily to the major salivary glands.8 The acinar portion of the salivary glands is radiosensitive, with the serous acini being more sensitive than the mucinous acini. Coronavirus (COVID-19) information for Dana-Farber patients & families Learn more. Perhaps when working with patients in a survivorship program, this approach could be implemented by providers to engage the patient in their own care goals. Osteoradionecrosis is one of the most difficult complications that the head and neck surgeon will encounter after radiation therapy. HBO has been used to prevent and treat osteoradionecrosis. Conservative measures include hyperbaric oxygen (HBO) therapy and pharmacologic combination therapy. It may help to: Try different foods, if they are not agreeable, you can try again at another time. Dental visits with scaling and cleaning at least three times a year. This is known as bone marrow suppression (another name is myelosuppression). (631) SB-CANCER (722-2623). Some products using an alternate to sucrose as a source of carbohydrate calories are available. Extractions should be done at least one week before the start of chemotherapy or radiation therapy to provide enough time for proper healing. Weigh yourself frequently until weight stabilizes. THICKENED SALIVA AND DRY MOUTHDuring treatment the mucous membranes inside the mouth become dry and inflamed. When patients do not follow recommendations, extra face-to-face time is required to understand obstacles interfering with patient implementation of the care plan. Though any bone of the face or neck may be affected, the incidence is highest in the mandible.55 The incidence of ORN was previously reported to be 2%-22%.53,54 However, with the use of IMRT and delineation of the mandible as an organ at risk, the current incidence is much lower at 0%-6%.56. Failure to have proper nutrition during treatment may result in weight loss and a decreased tolerance for treatment, which may include worsening of side effects.

Fluoride is used to help prevent the formation of cavities. Lauterbur Drive Separate them by at least one hour.

Teeth with evidence of pulpal infection or teeth that are periodontally involved should be extracted. Radiation caries refers to tooth decay or breakdown of teeth that can occur because of RT. However, they will find that, as the day progresses and they perform the jaw-opening exercises, they are able to attain a significantly wider opening. Complications in Head and Neck Surgery (Second Edition), Oral Cancer: Prevention, Management, and Treatment, Treatment Planning in Dentistry (Second Edition), Diagnosis and Treatment Planning in Dentistry (Third Edition), (the development of painful mouth sores), trismus, and xerostomia may develop during treatment. Success of the procedure appears to be closely associated with compliance with physical therapy and mouth-opening exercises and less so with the type of procedure for scar lysis. Patients are also fitted for, Surviving and thriving: Survivorship in the 21st century: Developing a multidisciplinary survivorship care program, Novel Therapies in Head and Neck Cancer: Beyond the Horizon.

Encourage the patient to continue with the regimen for oral care using a soft toothbrush, antimicrobial oral rinses, and fluoride trays. Chemotherapy may also cause mouth sores (mucositis). Also, stage II patients who do not respond to surgical debridement and HBO are classified as stage III.

The first and second molars are commonly the site of trauma and initial osteoradionecrosis. Take analgesics (pain medication) as ordered. These sores usually heal in one to two weeks; however, more serious ulcers may become infected with bacteria or yeast that are commonly found in the mouth. This could include lack of medical literacy, limited comprehension of risk secondary to noncompliance, or absence of observable improvement. The vascularity of the tooth is significantly reduced. Although the primary closure of the mucosa is ideal, it should not be achieved at the expense of the periosteal coverage of the alveolar bone. In patients presenting with such symptoms it is imperative to first rule out recurrent disease or other malignant processes with careful physical examination and biopsy if necessary. In some cases, trismus is associated with osteoradionecrosis, and the treatment of the osteoradionecrosis may improve the limited mouth opening. Patients who are receiving cancer therapy often have changes in the mouth. Apply one drop of fluoride gel into each depression on the inside of the lower and upper applicator. If the trismus is due to tight and resilient mucosal fibrosis in the tonsillar and/or retromolar areas (typically the pterygoid musculature), a significant increase in opening may be achieved by excising this tissue and replacing it with a viable skin paddle from either a myocutaneous or a free microvascular flap. Phillips Family Cancer Center,

Also, plaque and tarter deposits occur faster, which places you more at risk for cavities and gum disease. Surgical intervention is needed in patients with more advanced ORN, pre-existing fractures, fistulas, and those refractory to conservative therapies. In a larger series of 442 patients of oropharyngeal cancer treated using IMRT, again no cases of ORN were seen.59 Some recent publications have reported an event rate of 5.5% (36/653 patients) and 7.5% (30/402 patients). If you are unable to eat or drink because of severe mouth sores. Telehealth may be useful to provide survivorship services for patients who live far away from the treatment site.

Gel-Kam is a common fluoride gel. Patients report changes in both the quantity and quality of their saliva during and after radiation therapy. A cool mist humidifier will add moisture to your room. The dental evaluation should involve a clinical dental examination, a panoramic radiograph, and, possibly, a series of bitewing and periapical radiographs. Regrettably, findings suggested subpar compliance [40]. In the HBO group, the rate of subsequent ORN was 5.4% as opposed to the antibiotic group where the ORN rate was 29.9%.61 In a subsequent multicenter randomized trial from France, the role of HBO was challenged as the patients randomized to the treatment arm had worse outcomes compared to the placebo arm.62 This trial was critiqued by others as no surgical intervention was done in this study. Salivary flow will gradually increase, but may not completely return to normal. From: Complications in Head and Neck Surgery (Second Edition), 2009, Patricia M. Crum, Paul E. Vankevich, in Treatment Planning in Dentistry (Second Edition), 2007. This information can help you understand possible side effects of cancer treatment, including tips for mouth care that may help prevent or minimize these changes. Patient education in oral hygiene is critical so as not to increase risk of dental disease. As side effects, such as mucositis and xerostomia, develop during the cancer therapy, many patients will become uncomfortable while performing their usual oral hygiene regimens. Patients who have had radiation therapy can be treated with general dental care. fluoride voice trays This measurement can either be in terms of millimeters (if using the TheraBite appliance) or in terms of the number of tongue blades. Any complication, such as an exposed bone spicule, should be treated promptly. Before the commencement of radiation therapy, the patient must be told of his or her maximum jaw opening. It is delivered to the head and neck area to destroy cancer cells but unfortunately, some normal cells are injured as well. Copyright 2022 Dana-Farber Cancer Institute In addition, your gums may bleed easily if they are irritated or swollen. You may find that chewing sugarless gum or sucking on sugarless candy is helpful. Your doctor will tell you which symptoms you are likely to experience, when you will notice them and how long you will experience them. Attention should be directed to establishing the correct occlusion after resection. The head and neck surgeon can significantly reduce the incidence of osteoradionecrosis by instituting strict preventative measures before starting radiation therapy. Healing of oral tissue after radiation treatment may take as long as 6 weeks. One of the major contributing factors is RT-induced xerostomia.

Use a humidifier or vaporizer in your main living area during the day and in your bedroom at night. 3 Edmund D. Pellegrino Road Washing gently with any unscented soap that also moisturizes (Dove, Tone, Caress, etc. These are all very irritating and drying to a sore mouth. The local pharmacist or dietician can assist in choosing an appropriate product for the patient's nutritional needs. Caloric and protein intake must be maintained during cancer therapy. Brush your teeth with a fluoride toothpaste. Local debridement can then be performed, and this should be followed by 10 more HBO dives. It has been effectively used in rehabilitation to help patients follow clinicians recommendations to achieve their specific goals [43]. Applying pure Aloe Vera gel three to four times daily, very sparingly to the treated area will soothe and protect your skin. Outlined below are helpful suggestions for mouth care inpatients undergoing cancer treatment. In many cases, both oral and facial soft-tissue coverage will be required. Coronoidectomies are also performed in patients who have undergone surgery in the area of the coronoid and who will undergo radiation on the premise that the release of the temporalis attachment will reduce the amount of scarification that can occur on the temporalis.

General complications associated with radiation therapy to the oral cavity include mucositis, radiation-induced fibrosis, radiation caries, osteoradionecrosis, xerostomia, radiation dermatitis, fatigue, and delayed wound healing. Finally, patients need to adhere to ongoing recommendations (e.g., performing daily swallow exercises and the use of dental fluoride trays). Salivary substitutes or salt-and-baking soda rinses should be used 4-5 times per day. As soon as the patient is diagnosed with cancer, the dental status of the patient must be considered, and the patient should be evaluated by a dentist who is familiar with the management of head and neck cancer. Chew sugar free gum or suck on sugar free sour drops. Although relatively sparse, there has been some published data assessing compliance with respect to routine dental care after radiation. Dinesh K. Chhetri, David A. Rapkin, in Novel Therapies in Head and Neck Cancer: Beyond the Horizon, 2020. Place approximately four drops of fluoride gel into the tooth depressions in the plastic tray and spread it with a cotton swab.

This usually lessens within a couple of weeks after therapy ends.

Osteoradionecrosis is not a bone infection; rather, it is hypovascular, hypoxic, and hypocellular bone as a consequence of radiation therapy.7 These pathologic processes are progressive with time. Restorative and preventive dental care is very important to avoid infection. Jonathan Shum, James C. Melville, in Oral, Head and Neck Oncology and Reconstructive Surgery, 2018. On the basis of dosimetric analyses of these patients who developed ORN, the following general guidelines have been recommendedthe maximum dose to the mandible to be kept less than 70Gy, whereas the volume receiving 50Gy (V50) and 60Gy (V60) should be restricted to 62% and 20%, respectively.56,60. - Ivory tends to be very drying), will help to keep your skin clean and reduce chance of infection. Foods that are slightly chilled may be better tolerated, such as milkshakes, Jell-O. Teeth with severe infection or those that may cause problems during or after therapy should be removed (extracted). Osteoradionecrosis can develop spontaneously; however, it is most commonly precipitated by tooth extraction. Throughout treatment, the patient must use this measurement as a goal to reach each day. An alternative to toothbrushing is to use wet gauze or sponge-tipped swabs to gently wipe plaque and debris from the teeth and gums. The patient's risk for developing osteoradionecrosis increases with time after radiation therapy. If your mouth pain increases and you are unable to control it with your pain medicine. To add moisture to your mouth it is helpful to: Dentures should be made or relined about six months after treatment to allow for changes in your mouth.

These symptoms may continue throughout the treatment period. Next, patients must follow-up with referrals (e.g., lymphedema therapy, and physical therapy) resulting from the survivorship clinic visit. Patients referred for dental evaluation after surgery are extremely difficult to examine and treat. A thorough cleaning and scaling of teeth should be done to remove tartar (calculus). They must also abstain from smoking and alcohol. As a result, your saliva can become thick and your tongue can become coated. Other topical anesthetics are available at your pharmacy. Place applicator in mouth, press into position over the teeth and leave in position for five (5) minutes. Salivary changes also contribute to dental caries after radiation therapy. Continued fluoride treatments with fluoride trays twice a day. Surgical procedures include resection of the involved ORN segment up to viable bone followed by bone and soft tissue reconstruction using grafts, regional flaps, and microvascular free tissue transfer.63.

These salivary glands normally produce approximately one or one and one half quarts of saliva daily, which bathes and cleans the teeth and provides moisture to facilitate chewing and swallowing. Remove trays and do not rinse your mouth or take any food or drink for one hour. Call us: 617-632-3000, Please note that some translations using Google Translate may not be accurately represented and downloaded documents cannot be translated. Patients should be advised to continue close follow-up with their dental professionals after the completion of RT. implants Usually after treatment your taste returns slowly over a period of months. Clodronate is not approved by the Food and Drug Administration for use in the United States. Patients are also fitted for fluoride trays and consulted on effects of radiation mucositis, xerostomia, and overall oral health. Scar bands are released and the post-laser ablation wound is manipulated with extensive physical therapy to avoid the recurrence of dense scar.

Limited jaw opening is a significant complication after radiation therapy.

This is a rapidly progressing condition that can involve the dental pulp resulting in the loss of involved teeth. Rinse your mouth with warm salt water or baking soda and water (a teaspoon of either dissolved in eight ounces of warm water). Artificial saliva can be tried and is available in most pharmacies. Coating your lips with a lip balm such as Vaseline or Chapstick will help prevent them from cracking. Trismus can also prevent adequate oral hygiene, including the application of daily fluoride; this may lead to radiation caries.

This problem of noncompliance has been identified in physician-directed management across a variety of chronic diseases including diabetes and posttransplant care [41,42]. This results from treatment to the salivary glands, which are located in the mouth and upper neck. Stage III osteoradionecrosis is defined as exhibiting one of the following: (1) pathologic fracture; (2) orocutaneous fistula; or (3) osteolysis to the inferior border of the mandible. The current general consensus is that HBO should be used as an adjuvant therapy with surgery rather than as a single modality in the treatment of ORN.53,63 A recent Cochrane meta-analysis concluded that there is moderate quality evidence that HBO therapy was more likely to achieve mucosal coverage in patients with ORN and the absence of HBO therapy resulted in a higher chance of wound breakdown after surgical treatment.64. Add liquid food supplements to increase caloric intake until your appetite returns. Meat commonly becomes distasteful after several weeks of treatment. Because of radiation to the salivary glands, the composition of the saliva changes and becomes thick and sticky and the pH changes from 7.0 to 5.0.52 This results in reduced buffering capacity of the saliva and makes it more cariogenic. Your salivary glands will be making less saliva and you will still be at risk for developing cavities and gum disease. Radiation-induced fibrosis of the pterygomasseteric sling (including the masseter and medial pterygoid muscles) and fibrosis of the mucosa limit mouth opening. The phone number is (631) 444-2328, Monday through Friday, 8:00am - 4:30pm. During radiation treatment, topical 1% sodium fluoride gel should be applied daily using trays for both the upper and the lower teeth. for 6-12 months. It is important to avoid using aspirin or non-steroidal medication (Advil, Motrin) products while on chemotherapy since they may cause bleeding problems. Copyright 2022 Elsevier B.V. or its licensors or contributors. Ask your Radiation Oncologist when to start fluoride treatment. Any extractions performed at the time of reconstruction carry a risk for additional osteoradionecrosis at a separate site and should only be performed after careful consideration. During radiation treatment, patients may also experience mouth sores. Additionally, socioeconomic factors, such as being able to afford out-of-pocket expenses or transportation costs, and psychosocial stress (e.g., depression or anxiety) may be barriers to care. brush three times a day with a soft toothbrush, apply fluoride gel to teeth with custom tray twice daily, eat a nutritionally balanced diet, low in sugar.

ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. Cancer cells and some normal cells, such as those lining the mouth, the gastrointestinal tract, bone marrow cells, and hair cells, divide rapidly. One particularly challenging situation is the development of bilateral osteoradionecrosis in the region of the angles (Figure 24-4). Carry a water bottle to wet your mouth as needed. fluoride trays treatments varnish dental candidate children dentist pediatric treatment

Avoid adding extra salt if you have high blood pressure.

It means the salivary glands produce less saliva and the saliva is thicker. Periodic oral examinations to evaluate the condition of the mucosa are needed. Compliance, by definition, can have a negative connotation since it is defined as the act of conforming or yielding to another.