Oral complications in radiation therapy

The dentist is integral to managing care for patients with head and neck cancer. Oral complications may manifest during and/or following radiation therapy and can last for the lifetime of the individual. This article reviews a number of these complications as well as the resources available to dentists for managing care of radiation oncology patients and improving their quality of life.     

Diagnosis and management of acute and chronic oral complications of nonsurgical cancer therapies.

This article has reviewed selected oral complications that can develop in the myelosuppressed or head and neck radiation cancer patient. Many of these complications can be prevented by treating diseased oral sites prior to initiation of cancer therapy. Further, cancer treatment often causes changes in oral tissues that require long-term management. The dentist thus can play an important role in the overall care of many cancer patients.     

Use of dental X rays on postirradiated patients with head and neck cancer

As cancer therapy becomes more successful and cancer survival rates increase, the dentist will be treating more patients who have received radiation therapy for head and neck cancer. Occasionally, patients and health professionals have indicated a belief that patients who have received irradiation to the head and neck regions should not be subjected to additional radiation through dental diagnostic X-ray exposures. A literature search failed to find any references that specifically addressed this question. This study reflects the opinions of 278 radiation oncologists (400 surveyed) who responded to questions about contraindications of dental X rays for the patient with head and neck cancer.     

Technique for construction of dental molds for high-dose-rate remote brachytherapy

High-dose-rate remote (HDR) brachytherapy eliminates radiation exposure hazard to personnel, allows for optimum dosage planning (dosimetry), and delivers high radiation dose close to the tumor in only a few minutes. The catheters can be Incorporated into a fixed geometry within a mold, allowing for repeated treatments without the need for repeated implantation of radioactive Isotopes or repeated dosimetry. This article presents the use of HDR brachytherapy in three patients to Illustrate the advantages of HDR brachytherapy for the treatment of head and neck cancers in the following circumstances: (a) for outpatient therapy, (b) as an addition to or potentiation of external beam irradiation, (c) for preservation of function of regional structures, (d) for optimization of dosimetry, and (e) for palliation. It requires close interaction among the radiation oncologist, head and neck surgeon, and the dental oncologist and/or maxillofacial prosthodontist in order for optimum benefit for the patient to be achieved.     

A Technique for Shielding Electron Beams Used in Radiotherapeutic Management of Head and Neck Cancer

One of the major complications of radiation therapy in the management of maxillofacial tumors is the postradiation damage to the healthy tissues adjacent to the tumors. The success of radiation therapy is often limited by the treatment sequelae. The use of shielding prostheses reduces the number of potential treatment sequelae caused by the administration of therapeutic radiation for head and neck tumors. A technique for shielding uninvolved tissues from external electron beams used in therapeutic radiation treatment of head and neck cancer is described. The materials required are readily available and the shielding prosthesis can be easily fabricated by any dentist with a thorough understanding of radiation therapy, dosimetry, and the goals of treatment with radiation therapy.     

Is 0.4% stannous fluoride gel an effective agent for the prevention of oral diseases?

Research does not support the concept that 0.4% stannous fluoride gels are the preferred preventive or treatment agents for hypersensitivity, plaque, gingivitis, or periodontitis. The only clinically proved, cost-beneficial indications for use of these materials are for the prevention of enamel decalcification in patients wearing banded orthodontic appliances and for the prevention of dental caries in patients who have had head and neck radiation therapy. Even for these applications, other fluoride products may have equal effectiveness.     

Dental management of chemoradiation patients

The utilization of combined chemoradiation therapy has recently increased in the treatment of head and neck cancers. This patient population is significantly more prone to various oral complications during and after medical therapy. Oral complications and long-term effects include mucositis, xerostomia, alterations in taste, vascular compromise, mucosal thinning and increased risk of rampant caries and periodontal disease. The most serious oral complication that can arise is osteoradionecrosis. Managing patients properly prior to medical treatment can help decrease these potential complications during and after treatment. This purpose of this article is to review the different radiation and chemotherapy regimens used to treat patients with head and neck cancers, as well as protocols in the dental management of these patients before, during, and after medical treatment.     

Fabrication of a radiation bolus prosthesis for the maxillectomy patient

Radiation therapy has been used in the treatment of numerous head and neck malignancies. Unfortunately, this treatment also causes complications by increasing the morbidity to the surrounding tissues. The fabrication of a tissue bolus prosthesis is recommended to compensate for the loss of tissue and to help distribute the radiation homogeneously to the tissues. This article describes the procedures necessary for making an impression and fabricating a tissue bolus prosthesis. This custom-made prosthesis is simple, efficient, and atraumatic for the patient. Use of a tissue bolus prosthesis allows the radiation oncologist to adequately irradiate the tissues.     

The role of dentistry in head and neck radiation therapy

In the adult patient, oral complications of cancer radiotherapy stem from the deleterious effects of radiation on salivary glands, oral mucosa, mandibular musculature and alveolar bone. Clinical consequences of such treatment include xerostomia, rampant dental decay, mucositis, taste loss, osteoradionecrosis, infection, trismus, and nutritional stomatitis. These alterations to the normal state occur both during and after completion of head and neck radiation. Fig. 1 outlines the time frame involved in the development of each particular problem. In the past 20 years, many changes have occurred in the management of patients receiving radiation therapy. The traditional regimen of dental care in these patients was one of extracting all teeth encompassed by the radiation field. However, 15 years ago, this concept was questioned due to the incidence of post radiation caries (PRC) outside the zone of irradiation. The purpose of this paper is to review the major consequences of radiation treatment to the head and neck as well as outline the role of the dentist in the management of these patients.     

Management of the oral sequelae of cancer therapy

Oral cancer and the oral sequelae of treatment for oral and other malignancies can significantly affect a patient's oral and systemic health, as well as have a profound impact on quality of life. Compromised oral health prior to, during, and following cancer therapy can affect treatment outcomes. Increasingly, dental professionals in the community are being called upon to provide care for these individuals. Radiation therapy is routinely used for tumors of the head and neck, delivering a concentrated radiation dose to the tumor, but also to the immediately surrounding tissue. Oral complications are related to the site radiated and the total radiation dose. Cancer chemotherapy is provided as a primary treatment for some cancers and as an adjunctive modality for other cancers. The goal is to eradicate the rapidly growing cells of the tumor, but chemotherapy is often toxic to other cells that rapidly divide normally including the oral mucosa. The use of combined chemotherapy and radiation is now considered standard for most locally advanced tumors of the head and neck. The toxicities of this combined therapy are essentially the same as with radiation alone, but develop more rapidly and are typically more severe when they reach maximum level. The most common oral sequelae of cancer treatment are: xerostomia, the sensation of a dry mouth as a result of damage to the salivary glands and/or medication; mucositis, the inflammation and ulceration of the oral mucosa; and infection as a result of the loss of mucosal integrity. Management of oral health during cancer therapy includes identifying at-risk patients, patient education, appropriate pretreatment interventions, and timely management of complications. Appropriate preventive and therapeutic measures will help minimize the risk of oral and associated systemic complications, improve treatment outcomes, and improve the patient's quality of life.     

Oral adverse effects of head and neck radiotherapy: literature review and suggestion of a clinical oral care guideline for irradiated patients

Radiotherapy, alone or associated with surgery or chemotherapy, produces a significant increase in cure rates for many malignancies of the head and neck region. However, high doses of radiation in large areas, including the oral mucosa, may result in several undesired reactions that manifest during or after the completion of therapy. The multidisciplinary management is the best alternative to minimize or even prevent such reactions, and the dentist has a fundamental role in this context. This paper reviews the literature related to the main oral sequelae from head and neck radiotherapy and establishes clinical oral management protocol for these irradiated patients.     

A Convenient Method for Guarding Against Localized Mucositis During Radiation Therapy

Metal restorations, such as full gold crowns and dental implants, can cause forward and back scatter radiation during radiation therapy with a dose enhancement to adjacent tissues. Mucositis, one of the most common complications of the radiation treatment of oral, as well as other head and neck malignancies can result. A method for constructing a buccolingual guard in the clinical setting using hydroplastic material is described. The guard can be easily oriented and adapted to an existing radiation stent, adding positional stability and patient comfort. When adequate thickness of material is used, the guard can attenuate forward and back scatter radiation, separate the adjacent tissues from metal restorations, and protect the oral mucosa from localized incidents of mucositis.     

Patient alignment device for cobalt-60 radiation therapy

A technique has been described for fabrication of a radiation therapy stent that can help to stabilize the head when adjustable alignment devices are used to position a patient during radiation therapy. The technique can save time for the radiotherapist, enhance accuracy in treatment, increase patient comfort, and save the dentist time in stent fabrication.     

Perineural spread of squamous cell carcinoma of the lip: the importance of follow-up and collaboration

Perineural spread (PNS) of mucosal squamous cell carcinoma of the head and neck region occurs with a reported frequency of 2% to more than 27%. Patients previously diagnosed with and treated for head and neck cancer should be closely followed by both their physician and their dentist in order to facilitate the coordination of care. This case history demonstrates the results that can occur when a team approach to head and neck cancer is not followed, especially in a patient who is an infrequent and somewhat reluctant health care utilizer. Despite mandibular pain, the patient, who had a history of a carcinoma of the lower lip and had developed PNS, was not referred to a dentist. In patients with a previous history of squamous cell carcinoma, sensory and/or motor changes must be closely monitored when there is a suspicion of PNS. The outcome of this case supports improved collaborations between physicians and dentists in following head and neck cancer patients.     

Stomatological management of head and neck cancer patients treated with chemotherapy and radiotherapy

Treatment of head and neck cancer with radiotherapy and/or chemotherapy can cause oral damage. Long-term treatment can damage the salivary glands, the oral mucosa, and the maxilla, leading to altered production of saliva and to multiple infections. These lesions can be prevented, limited or avoided by thorough evaluation prior to treatment and by therapeutic follow-up and preventive measures. The dentist must have strong medical knowledge of the possible short-, medium-, and long-term oral complications of the cancer treatment, and must have knowledge of the protocols for oral management of cancer patients. The availability of a multidisciplinary medical team together with a dentist to attend to the patient prior to the cancer treatment, as well as close communication between team members during and after treatment, is crucial. The aim of the present study was review the stomatological management of head and neck cancer patients treated with chemotherapy and radiotherapy and summarizing current treatments, therapeutic innovation and tissue regeneration perspectives.     

Managing complications of radiation therapy in head and neck cancer patients: Part II. Management of radiation-induced caries

Head and neck cancer is becoming a more recognizable pathology to the general population and dentists. The modes of treatment include surgery and/or radiation therapy. Where possible, pretreatment dental assessment shall be provided for these patients before they undergo radiation therapy. There are occasions, however, whereby head and neck cancer patients are not prepared optimally for radiation therapy. Because of this, they succumb to complicated oral complications after radiation therapy. The management of xerostomia has been reviewed in Part I of this series. In this article, the management of dental caries, a sequalae of xerostomia following radiation therapy is reviewed.     

Multidisciplinary approach to the differential diagnosis of facial, head and neck pain

Pain in the region of the head and neck is one of the most common complaints that bring patients to the dentist. Because of the complexity of the anatomy as well as the vagueness of presenting symptoms, head and neck pain often is a diagnostic problem. Many different specialists may ultimately be consulted to make a comprehensive diagnosis and institute effective therapy. It is up to the one who coordinates the diagnostic sequence to have an understanding of the various pathologic conditions that can be manifested as pain in the head and neck. Although a comprehensive knowledge of all disciplines is not necessary, an overall understanding of the various disciplines of medicine as they relate to head and neck pain is valuable. The primary provider should establish a group of specialists to whom patients can be referred for further diagnosis and treatment when necessary to provide optimum care.     

Dental management of patients irradiated for head and neck cancer

Patients undergoing radiation therapy as either primary, adjuvant, combination therapy or palliative management of head and neck malignancies are prone to a range of dental complications. Strategies for prevention and management of such complications may be controversial. This article aims to highlight the current understanding and management of the dental needs for patients before, during and after radiation therapy.     

The prevalence of herpes simplex virus shedding and infection in the oral cavity of seropositive patients undergoing head and neck radiation therapy

OBJECTIVE: Herpes viruses are characterized by their ability to establish and maintain a latent infection that can reactivate. Only 2 preliminary studies have examined herpes simplex virus (HSV) reactivation in patients receiving head and neck radiotherapy. The role of radiation therapy in the reactivation of a latent virus has not been established. The purpose of the present study was to evaluate the incidence of HSV reactivation in patients receiving radiation treatment for head and neck malignancies. METHODS: Twenty patients, 19 of whom were HSV seropositive, undergoing head and neck radiation therapy were assessed weekly before and during radiation therapy, and HSV cultures were completed during cancer treatment. RESULTS: Only 3.6% of the cultures were positive for HSV during radiation therapy. HSV was cultured in 4 men receiving a mean of 6,000 cGy to the head and neck area. Recovery from HSV was seen in patients nearing completion of radiation therapy. CONCLUSIONS:The results of this study suggest that HSV reactivation is not common during radiation therapy. Therefore, this study does not support prophylaxis of HSV in patients undergoing head and neck irradiation.     

Prosthodontics for pediatric patients with congenital/developmental orofacial anomalies: a long-term follow-up.

Patients afflicted with congenital/developmental anomalies of the oral/head and neck regions present the prosthodontist with unique esthetic and functional restorative challenges. This article reviews the various pediatric patient categories that would benefit from placement of "vital" overdentures. A long-term follow-up of patients seen over 25 years of practice is presented with a focus on complications such as temporomandibular joint stability, caries, soft tissue and bony support changes, and denture adaptation. Longitudinal follow-up of these patients indicates that, although problems occur with overdenture therapy, the benefits of this treatment far outweigh the complications.