Oral and dental management related to radiation therapy for head and neck cancer

The clinical management of squamous cell carcinoma of the head and neck causes oral sequelae that can compromise patients' quality of life and necessitate abandonment or reduction of optimal therapeutic regimens, which in turn reduces the odds of long-term survival. Such sequelae can be prevented or at least better managed if dental and medical health care providers work together. It is therefore essential that dentists have an understanding of cancer therapy and a sound working knowledge of the prevention and management options for the oral sequelae of cancer treatment. This paper offers the dental team an overview of the consequences associated with radiotherapy, as well as a systematic overview of preventing or managing acute and chronic conditions before and during radiotherapy. In addition, it reviews considerations for continued treatment needs during the patient"s lifetime.     

Oral chronic graft-versus-host disease: What the general dental practitioner needs to know

BackgroundLong-term survivors of allogeneic hematopoietic cell transplantation will increasingly seek care from dental providers.MethodsThe authors highlight the importance of minimizing oral symptoms and complications associated with oral chronic graft-versus-host-disease (cGVHD).ResultsChronic GVHD is the result of an immune response of donor-derived cells against recipient tissues. Oral cGVHD can affect the mucosa and damage salivary glands and cause sclerotic changes. Symptoms include sensitivity and pain, dry mouth, taste changes, and limited mouth opening. Risk of developing caries and oral cancer is increased. Food intake, oral hygiene, and dental interventions can represent challenges. Oral cGVHD manifestations and dental interventions should be managed in close consultation with the medical team, as systemic treatment for cGVHD can have implications for dental management.ConclusionsGeneral dental practitioners can contribute substantially to alleviating oral cGVHD involvement and preventing additional oral health deterioration.Practical ImplicationsFrequent examinations, patient education, oral hygiene reinforcement, dry mouth management, caries prevention, and management of dental needs are indicated. In addition, oral physical therapy might be needed. Invasive dental interventions should be coordinated with the transplantation team. Screening for oral malignancies is important even years after resolution of GVHD symptoms. Management of the oral manifestations of cGVHD might require referral to an oral medicine professional.     

Oral management of the patient with cancer in the head and neck region

Cancer therapies--including surgery, radiation, and chemotherapy--may unfavorably affect the oral/dental health of patients. Existing dental problems can also result in serious complications that may be prevented by dental intervention prior to cancer therapy. This paper will be limited to a discussion of the detrimental effects of radiation therapy on the oral cavity and salivary glands and appropriate dental management.     

Oral and dental management for head and neck cancer patients treated by chemotherapy and radiotherapy

The incidence of head and neck cancer is rising. The attendant oral complications of cancer management make oral health maintenance a lifelong challenge for these patients. Holistic management in the context of a core multidisciplinary team is essential in optimizing outcomes. Predicting the risk of adverse oral outcomes is difficult. Effective communication between healthcare professionals in the core and extended teams and with the patient is essential. CLINICAL RELEVANCE: Primary care dental teams will be involved in the long-term management of oral care for head and cancer patients. A broad understanding of the management of head and neck cancer, consequences of treatment and the need for good communication is key to good quality patient care.     

Considerations in the pediatric population with cancer

This article is divided into three time periods according to the different phases of cancer treatment: pre, inter, and postcancer therapy. The purpose of dental protocols prior to cancer therapy and the incidence and management of acute and long term oral complications from cancer therapy in the pediatric population are discussed.     

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.     

Management of oral infections in cancer patients

The myelosuppressive and mucosal-damaging consequences of cancer and cancer therapies place patients at high risk for developing infectious complications. Bacterial, fungal, and viral infections are all commonly encountered in the oral cavity, contributing to both morbidity and mortality in this patient population. Prevention, early and definitive diagnosis, and appropriate management are critical to ensure optimal treatment outcomes. With the majority of cancer patients treated as outpatients in the community setting, oral health care professionals play an important role in managing such infectious complications of cancer therapy.     

Oral health care in diabetes mellitus

Diabetes mellitus produces many complex changes in the lives of those affected. Elevated blood glucose levels, which may occur in the absence of symptoms, lead to late complications from tissue damage. There is an increased susceptibility to infection, poor wound healing and periodontal disease. Furthermore, chronic oral infection itself may contribute to raised blood glucose levels and hence to the later complications of diabetes. Acute infection in the oral cavity needs specific and aggressive management, just as in the acutely infected diabetic foot. The dental team may not have made a significant contribution to the shared management of the person with diabetes in the past; however, recent findings suggests that the dental team may contribute greatly to the shared care of diabetes with the diabetic team itself, and regular liaison is strongly recommended.     

Oral health care in diabetes mellitus.

Diabetes mellitus produces many complex changes in the lives of those affected. Elevated blood glucose levels, which may occur in the absence of symptoms, lead to late complications from tissue damage. There is an increased susceptibility to infection, poor wound healing and periodontal disease. Furthermore, chronic oral infection itself may contribute to raised blood glucose levels and hence to the later complications of diabetes. Acute infection in the oral cavity needs specific and aggressive management, just as in the acutely infected diabetic foot.' The dental team may not have made a significant contribution to the shared management of the person with diabetes in the past; however, recent findings suggest that the dental team may contribute greatly to the shared care of diabetes with the diabetic team itself, and regular liaison is strongly recommended.     

Access to special care dentistry, part 4. Education

Many groups of patients with disabilities have a higher risk of oral disease due to compromised oral hygiene as a consequence of their impairment, oral manifestations of their particular condition and/or the side effects of drug regimes, notably xerostomia and sugar in medicines. This article looks at education related to oral health and its management for both patients and carers. It will encourage a tailored routine for oral hygiene, taking account of the best time of day for the person concerned, the facilities available to them, appropriate preventive measures and the support and adaptations required to minimise the effect their impairment has on managing their oral hygiene. Additionally, it considers educational issues for the dental team related to some elements of managing oral health of people with disability, the dental team's responsibility in educating other health professionals and the availability of undergraduate and postgraduate education in special care dentistry.     

Bisphosphonate osteonecrosis of the jaws; an increasing problem for the dental practitioner

Osteonecrosis of the jaws is an increasingly recognised complication of bisphosphonate therapy. Although this has generated a large amount of literature in the last few years, it is difficult to know how the complications associated with bisphosphonates are impacting on general dental practitioners (GDPs). Bisphosphonates are commonly prescribed in the management of osteoporosis, hypercalcemia and multiple myeloma. The risk of osteonecrosis in patients taking bisphosphonates is low but difficult to quantify. The risk associated with oral therapy is in the order of 0.01% although with parenteral therapy it may be as high as 10%. Associated factors in the development of osteonecrosis include poor dental health, odontogenic infection and invasive dental treatment. Guidelines on managing patients who are currently taking or have previously taken bisphosphonates have not yet been published in the UK. The management of patients relies on existing experience in managing patients with apparently similar conditions such as osteoradionecrosis. Most GDPs do not routinely make specific efforts to identify patients who have taken bisphosphonates, and as patients may be poor at providing such information voluntarily, it is likely that many patients are currently not identified when they attend general dental practice. The dental management of patients with a history of bisphosphonate treatment is based around prevention and minimally traumatic treatment. Failure to recognise these patients and manage them appropriately could contribute to the development of osteonecrosis, which can be very difficult to manage.     

Dental treatment planning and management in the patient who has cancer

The oral cavity has the potential to be a major source of short-term and long-term complications from cancer therapy. Appropriate evaluation and elimination of potential sources of oral infection before cancer therapy is vital because oral bacteria are a known source of bacteremia and septicemia during cancer therapy. Cancer diagnosis with previous and planned treatment, past medical history, past dental history, current medications, drug allergies, social history, family history, laboratory values, extraoral findings, intraoral findings, and radiographic findings must all be evaluated in planning dental treatment for these complex cases.     

Oral cancer. Etiology, recognition, and management.

The cure rate for oral cancers remains dismally low at approximately 50%. The dental profession is, to a large extent, responsible for decreasing the morbidity and mortality of oral cancer even though 50% of the population do not present for routine examination and care. The dental office team must accept the charge of educating all patients concerning the devastating role of tobacco and ethanol in promoting oral cancer, as well as malignancies at other sites. Dental clinicians play a vital role on the oral cancer team. Therefore, they must make themselves well aware of the diverse nature of oral cancer and must have an appropriate triage protocol in place so that lesions will be identified and managed correctly or referred promptly to the correct tertiary health care professionals. Early detection and prompt proper management can make a difference as we await the development of new and better ways of treating oral and oropharyngeal cancers.     

Dietary and nutritional needs of patients after therapy for head and neck cancer

BackgroundThe number of cancer survivors in the general population is increasing. Oral and dental status affects patients' quality of life and oral function, which, in turn, may affect nutritional intake and general health. The authors review the importance of oral health and the role of the oral health care provider in supporting dietary intake and providing nutritional guidance.MethodsThe authors provide a brief review of oral complications of therapy and nutritional guidelines for patients with head and neck cancer.ResultsOral adverse effects of head and neck cancer treatment include salivary gland dysfunction, taste change, orofacial pain and mucosal sensitivity, oral infection, tissue defects and necrosis, trismus and fibrosis, progressive dental and periodontal disease, and problems with prosthesis function.ConclusionsManaging oral adverse effects of treatment may have an impact on dietary and nutritional intake, as well as on quality of life. Dietary modifications may be needed because of the patient's oral function and may include modification of food texture and flavor, as well as the use of dietary supplements.Clinical ImplicationsAs part of the patient's health care team, dental care professionals should be aware of the oral adverse effects of cancer therapy, as well as their role in recognizing and treating the resulting oral conditions. In addition, they should provide guidance to patients to support their oral dietary and nutritional intake.     

Dietary and nutritional needs of patients undergoing therapy for head and neck cancer

BackgroundNutrient and caloric intake is critical during therapy for head and neck cancer.MethodsThe authors review the oral complications experienced by, and dietary and nutritional needs of, patients during therapy. They also present recommendations for oral care and calorie and nutrient intake.ConclusionsOral health care professionals can assist patients during treatment for cancer in maintaining oral, systemic and nutritional health, as well as in controlling oral symptoms. Recovery from the acute toxicities of therapy often requires diet modification, tube feeding or both to meet patients' energy and nutrient demands.Clinical ImplicationsEffective management of oral complications of therapy for cancer is necessary to facilitate oral intake throughout treatment. Oral health care professionals should be part of the multidisciplinary team helping meet the needs of patients during treatment.     

Oral management of pemphigus vulgaris in the intensive care unit

Pemphigus vulgaris (PV) is a rare and potentially lethal autoimmune disease that affects the skin and mucous membranes. Injuries caused by the disease cause pain, risk of infection, and other complications that result in a high mortality rate. Frequently, management of the PV requires intensive care and a multidisciplinary approach. Oral lesions of PV are usually the first clinical signs of the disease and the last lesions to heal, requiring treatment by a specialized dental team. The aim of this study was to report two clinical cases of PV with involvement of the oral mucosa. The patients were admitted to an intensive care unit, and underwent multidisciplinary management of their condition along with low-level laser therapy. Both cases demonstrated the importance of specialized dental care in improving the quality of life of patients with PV.     

Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment

BACKGROUND: There is a widespread belief among dental practitioners and physicians that oral anticoagulation therapy in which patients receive drugs such as warfarin sodium must be discontinued before dental treatment to prevent serious hemorrhagic complications, especially during and after surgical procedures. OVERVIEW: The authors examine the scientific basis for properly managing the dosage of anticoagulants for dental patients who are receiving anticoagulation therapy. The authors review the appropriate laboratory test values to which dentists should refer when evaluating for dental treatment patients who are receiving anticoagulation therapy. The authors also review clinical studies, published within the past five years, that focus on the frequency and degree of hemorrhagic and related complications among dental patients who are receiving anticoagulation therapy orally to prevent thromboembolic events. CONCLUSIONS AND CLINICAL IMPLICATIONS: The scientific literature does not support routine discontinuation of oral anticoagulation therapy for dental patients. Use of warfarin sodium as it relates to dental or oral surgical procedures has been well-studied. Some dental studies of antiplatelet therapy are consistent with the findings in warfarin sodium studies. Dental therapy for patients with medical conditions requiring anticoagulation or antiplatelet therapy must provide for potential excess bleeding. Routine discontinuation of these drugs before dental care, however, can place these patients at unnecessary medical risk. The coagulation status--based on the International Normalized Ratio--of patients who are taking these medications must be evaluated before invasive dental procedures are performed. Any changes in anticoagulant therapy must be undertaken in collaboration with the patient's prescribing physician.     

The HIDEP model--a straightforward dental health care model for prevention-based practice management

With the ambition of continuously improving the effectiveness of oral health care, the concept of minimal invasive dentistry has become an issue within modern dentistry. The ultimate goal of this concept is to preserve dental tissues (teeth and their attachment).To preserve oral tissue, effective methods for management and resource allocation are needed. Involving the patient within the dental team as a member and not as a customer might also increase the effectiveness.To achieve this, a dedicated tool for managing the actions of all parties involved towards the desired goals is needed. This paper describes the development and use of a special management tool, the HIDEP model (Health Improvement in Dental Practice). The model is used to measure, steer and evaluate the actions within a dental clinic involving patients as well as professionals.     

The psychology of failure for dentists

Failure in practice is inevitable. Failure may have negative consequences both for the patient and the dental team. This article will explore the psychological impact of failure on the dental team, and how to manage this. In addition, an approach to managing, preventing and ameliorating the effects of failure based upon an analysis of healthcare systems will be described. CLINICAL RELEVANCE: This article will assist general dental practitioners and other members of the dental team in coping with the psychological impact of failure, and to design systems to minimize the harmful effects of failure in practice.     

Oral care in patients receiving radiotherapy and chemotherapy

Hospitalization of cancer patients is reduced nowadays. The dentist and the oral hygienist in dental practice are involved more and more in minimizing oral complications in cancer patients. Appropriate oral management can enhance the quality of life in patients receiving cancer radiotherapy or chemotherapy. Some of the more significant problems and their prevention or management are discussed in this paper.