The treatment objective is a decrease in the amount of exposed bone, the resorption of nonviable bone, and the absence of inflammation. Healing of oral tissue after radiation treatment may take as long as 6 weeks. 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. 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.
Taste changes during the first six months following radiation therapy are common. Periodic oral examinations to evaluate the condition of the mucosa are needed. The head and neck surgeon can significantly reduce the incidence of osteoradionecrosis by instituting strict preventative measures before starting radiation therapy. Limited jaw opening is a significant complication after radiation therapy. 
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.
Add liquid food supplements to increase caloric intake until your appetite returns. Separate them by at least one hour. Caloric and protein intake must be maintained during cancer therapy. 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. During radiation treatment, patients may also experience mouth sores. Continued fluoride treatments with fluoride trays twice a day. 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. By continuing you agree to the use of cookies. These are all very irritating and drying to a sore mouth. For adults: 877-442-3324For children: 888-733-4662. Many patients will be uncomfortable performing their usual oral hygiene regimens. When looking solely at attendance to posttreatment surveillance appointments, travel time to treatment site was found to be a significant component [39].
Resin-modified glass ionomers, composite resins, and amalgam restorations are preferred over conventional glass ionomer cements.49 Dental implants can be considered in patients after a minimum of 24 months has elapsed from the end of RT. It is helpful to review the potential signs and symptoms of adverse effects with the patient and his or her caregiver. Mandibular teeth that will receive 60 Gy or more of radiation should be removed.7 Necessary dental surgical treatment must be completed as soon as possible before radiation therapy to allow for adequate healing. Common symptoms include pain, swelling, trismus, exposed bone, pathologic fracture, and orocutaneous fistula formation. THICKENED SALIVA AND DRY MOUTHDuring treatment the mucous membranes inside the mouth become dry and inflamed. The phone number is (631) 444-2328, Monday through Friday, 8:00am - 4:30pm. Unfortunately, this may not always be possible as patients need to start their cancer treatment in a timely manner. These definitions do not obviously include patient involvement in the care plan. Procedures that may be included in the first dental visit are: During treatment it is important to adhere strictly to your mouth care plan. The regions most commonly involved, in decreasing order of incidence, are posterior mandible, anterior mandible, posterior maxilla, and anterior maxilla. This makes you more at risk for infection and/or bleeding. Osteoradionecrosis can develop spontaneously; however, it is most commonly precipitated by tooth extraction.
See your dentist so that (s)he may identify potential sources of dental infection or irritation. In many cases, both oral and facial soft-tissue coverage will be required. 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. Encourage the patient to continue with the regimen of oral care as discussed above: use of a soft toothbrush, antimicrobial oral rinses, and fluoride trays. Clodronate is not approved by the Food and Drug Administration for use in the United States. The treatment of ORN involves conservative measures initially, with surgical methods reserved for cases where these measures fail. Any tooth that cannot be maintained for the life of the patient should be removed. Positive results have been achieved using physical therapy rehabilitation devices such as TheraBite and Dynasplint systems.
Repeat this routine twice a day. Rinse your mouth with warm salt water or baking soda and water (a teaspoon of either dissolved in eight ounces of warm water). Brian L. Schmidt, in Complications in Head and Neck Surgery (Second Edition), 2009. It is delivered to the head and neck area to destroy cancer cells but unfortunately, some normal cells are injured as well. The head and neck surgeon must always consider the possibility of recurrent tumor when faced with osteoradionecrosis. Normal oral hygiene routines may cause excessive gingival bleeding, and the patient may only be able to tolerate oral rinses during this time. Farzan Siddiqui MD, PhD, Benjamin Movsas MD, FASTRO, FACR, in Seminars in Radiation Oncology, 2017. Conservative measures include hyperbaric oxygen (HBO) therapy and pharmacologic combination therapy. 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. Additionally, clinical improvement in the discontinuation of analgesics, new fractures, healing of fistulas, and radiologic improvement were noted in 64%, 89%, and 96% at 6, 12, and 30 months, respectively. Fluoride trays should be fabricated, and daily fluoride treatment will be required for the life of the patient. This usually lessens within a couple of weeks after therapy ends.
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. Radiation caries refers to tooth decay or breakdown of teeth that can occur because of RT.
Ideally 14 days should be allowed between the extractions and start of RT. Gel-Kam is a common fluoride gel. Other topical anesthetics are available at your pharmacy. If you must shave in the treated area, please use an electric shaver to reduce the risk of "nicking" or scraping your skin thereby opening an "avenue of infection.".
These changes may result in a decrease in appetite. Foods that are slightly chilled may be better tolerated, such as milkshakes, Jell-O. Before starting radiation therapy, the patient must be taught aggressive jaw-opening exercises using either tongue blades or a TheraBite (Atos Medical, Horby, Sweden). Xerostomia is a very common complication among patients receiving radiotherapy for head and neck cancer. It can be administered in a monoplace or multiplace chamber. The dental evaluation should involve a clinical dental examination, a panoramic radiograph, and, possibly, a series of bitewing and periapical radiographs. A cool mist humidifier will add moisture to your room. Attention must be directed to dental caries, odontogenic infections, periodontal disease, and impacted or partially exposed teeth. Ask your Radiation Oncologist when to start fluoride treatment. Dana-Farber assumes no liability for inaccuracies that may result from using this third-party tool, which is for website translation and not clinical interactions.
It is best if the extractions can be performed at the time of surgical resection. Patients who are receiving cancer therapy often have changes in the mouth. Radiation therapy is often used to treat individuals with cancer of the head and neck. First, patients must attend survivorship clinic appointments. You may want to carry a small plastic bottle or water in your purse or pocket when you leave home. Risk factors for ORN include pre-RT or post-RT dental extraction or surgery close to the tumor, RT dose >60Gy, dental disease, and time from pre-RT extraction to start of radiation <14 days. Your dentist will provide you with a fluoride treatment regimen to include a fluoride tray and fluoride gel. If taken half an hour before meals it may be more comfortable to eat. Teeth with severe infection or those that may cause problems during or after therapy should be removed (extracted). The management of the intervening viable mandible must be carefully considered. The ductal portion of the glands is relatively radioresistant. Call us: 617-632-3000, Please note that some translations using Google Translate may not be accurately represented and downloaded documents cannot be translated. Follow instructions to rinse frequently with baking soda and salt water mixture.
Patients must be referred to dentists who are familiar with and comfortable managing these patients. Trismus can be especially difficult for patients who require a maxillary obturator, because they may experience difficulty inserting the obturator. Dietary counseling is also important during this phase of treatment. As a result of the treatment, foods and liquids lose or change their taste resulting in a bitter, metallic or chalk-type taste.
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. Lauterbur Drive
For dental issues, any loose gaps should be fixed to prevent food impaction. - Ivory tends to be very drying), will help to keep your skin clean and reduce chance of infection. In some cases, trismus is associated with osteoradionecrosis, and the treatment of the osteoradionecrosis may improve the limited mouth opening. Another side effect of radiation treatment to the head and neck is severe bone infection. Patient education in oral hygiene is critical so as not to increase risk of dental disease. 3 Edmund D. Pellegrino Road Place approximately four drops of fluoride gel into the tooth depressions in the plastic tray and spread it with a cotton swab.
Attention should be directed to establishing the correct occlusion after resection.
As a comfort, ask for ice chips or sugar free popsicles to suck on while you are receiving chemotherapy. An alternative to toothbrushing is to use wet gauze or sponge-tipped swabs to gently wipe plaque and debris from the teeth and gums. Telehealth may be useful to provide survivorship services for patients who live far away from the treatment site. Use the sap from an aloe vera plant or buy the clear, uncolored gel (no additives, no color). Clean both applicators under running water, towel dry and store in a dry space. To prevent discomfort when eating, you may apply Viscous Xylocaine to your mouth, especially before meals. Stony Brook Southampton Hospital Impressions for fluoride trays. ScienceDirect is a registered trademark of Elsevier B.V. ScienceDirect is a registered trademark of Elsevier B.V. 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. 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.
(631) SB-CANCER (722-2623), Carol M. Baldwin Breast Cancer Center Chew sugar free gum or suck on sugar free sour drops.
A fundamental aspect of a survivorship programs success is patient compliance. Patients who have had radiation therapy can be treated with general dental care. Dinesh K. Chhetri, David A. Rapkin, in Novel Therapies in Head and Neck Cancer: Beyond the Horizon, 2020. Map & Directions, Outpatient Cancer Center Chemotherapy cannot tell the difference between normal cells and malignant cells and sometimes injures both. It is important to avoid using aspirin or non-steroidal medication (Advil, Motrin) products while on chemotherapy since they may cause bleeding problems. Avoid spicy food and food that is difficult to chew. Your doctor will tell you which symptoms you are likely to experience, when you will notice them and how long you will experience them. Any tooth/teeth showing caries should be fixed and ones that are loose or infected should be extracted. Scar bands are released and the post-laser ablation wound is manipulated with extensive physical therapy to avoid the recurrence of dense scar. In the absence of infection, mucositis usually resolves within 2 to 4 weeks after completion of cancer therapy. Motivational interviewing is an evidence-based counseling method that helps a patient find their own specific internal motivation to change their behavior. If your doctor prescribes both an antibacterial rinse (Peridex) and an antifungal rinse or lozenge (nystatin), do not take them together because they will not work as well.
Osteoradionecrosis is one of the most difficult complications that the head and neck surgeon will encounter after radiation therapy. Carry a water bottle to wet your mouth as needed. 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. Unlike chemotherapy, radiation therapy has long-term side effects in the mouth. As a result, your saliva can become thick and your tongue can become coated. Pediatric vaccines for ages 5-11, visitor updates and more, Radiation Therapy Treatment to the Head and Neck, Radiation Oncology Department at Stony Brook, Outpatient Cancer Center and Research Facility, The Kavita and Lalit Bahl Center for Metabolomics and Imaging, Information for Patients Receiving Radiation, Food Suggestions to Help Prevent Diarrhea, Notice of Non-Discrimination and Accessibility. During radiation treatment, topical 1% sodium fluoride gel should be applied daily using trays for both the upper and the lower teeth. This is caused by a decrease in the blood supply to the bones of the head and tissue of the neck during radiation treatment.
HBO therapy as described by Marx15,21 has been shown to be an integral part of the effective management of osteoradionecrosis, depending on the stage.2224. 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. Patients report changes in both the quantity and quality of their saliva during and after radiation therapy. Stephanie M. Munz, Mark Fitzgerald, in Diagnosis and Treatment Planning in Dentistry (Third Edition), 2017. Patients must be advised about proper orodental hygiene including the use of soft-bristle brushes, fluoride toothpaste, fluoride tray treatments, and avoiding cariogenic foods. An alternative to tooth brushing is to use wet gauze or sponge-tipped swabs to gently wipe plaque and debris from the teeth and gums. Jaw-opening exercises should be performed three times per day. Radiation caries should be treated early with caries excavation and the replacement of lost tooth structures. Washing gently with any unscented soap that also moisturizes (Dove, Tone, Caress, etc.
A combination pharmacologic therapy with vitamin E and pentoxifylline has also been tested in prospective and randomized trials and shown to be beneficial in reducing radiation-induced fibrosis and ORN.53,63 The combination of these 2 drugs with clodronate, an oral bisphosphonate, was prospectively evaluated in a phase II trial (PENTOCLO trial).65 A reduction in exposed bone was seen in 77% of the patients at 6 months and 96% at 18 months. Procedures must be performed under proper antibiotic prophylaxis. When attempting to understand why a patient is unable to comply with medical recommendations, one could postulate a variety intricate factors that might be at play. If Gel-Kam irritates your teeth or gums you may find that Prevident is less irritating. Approximately two weeks after your first treatment you may begin to experience side effects, or symptoms caused by radiation therapy. The trays are left in place for 5 minutes, and the patient should avoid eating or drinking for 30 minutes after treatment. Remove trays and do not rinse your mouth or take any food or drink for one hour. Weigh yourself frequently until weight stabilizes. Apply one drop of fluoride gel into each depression on the inside of the lower and upper applicator. The management of osteoradionecrosis depends on the stage of presentation. Temporomandibular joint surgery is not indicated for the treatment of radiation-induced trismus. Many prescribed dietary supplements have high concentrations of sucrose in a thick liquid that adheres to teeth. Any complication, such as an exposed bone spicule, should be treated promptly. It is important to follow the appropriate instructions to minimize your discomfort. However, many prescribed dietary supplements have high concentrations of sucrose in a thick liquid that adheres to the teeth. Although relatively sparse, there has been some published data assessing compliance with respect to routine dental care after radiation. Please contact your nurse for any questions or concerns you may have. A thorough oral examination should be done by a dentist and all questionable dentition should be extracted due to the significant dose of external beam radiation (>60 Gy) and associated risk for osteorradionecrosis. It means the salivary glands produce less saliva and the saliva is thicker. The risk of radiation-induced dental caries and ORN and can be significantly reduced by proper preventive measures. The success of HBO was first demonstrated in 1985 in a prospective randomized trial. The patient should also have a prophylactic dental cleaning. Maintaining oral hygiene and monitoring for adverse effects are two of the more important tasks to be implemented during cancer therapy. Pilocarpine administration during radiation therapy does not ameliorate xerostomia or mucositis.11 The administration of amifostine during radiotherapy appears to reduce xerostomia.1214. Evening, weekends and holidays please call (516) 783-1610. Osteoradionecrosis (ORN) is a radiation-induced late adverse event (AE) characterized by ischemic necrosis of the bone that persists for 3 months or longer, worsens slowly and does not heal spontaneously. The extent of bone necrosis can best be assessed with the use of plain radiographs such as a panoramic radiograph.
Xerostomia is a result of radiation injury to the salivary glands. 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. Unnecessary dental procedures and biopsies must be avoided in areas close to the mandible and maxilla. Chemotherapy may also cause mouth sores (mucositis). One of the major contributing factors is RT-induced xerostomia. Use a soft toothbrush or a sponge applicator such as a toothette to brush your teeth. You may not enjoy your foods, however, it is essential that you maintain adequate nutrition and fluid intake. You may request a live medical interpreter for a discussion about your care. 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 will promote the healing of your vocal cords and return of a good quality voice. The patient's risk for developing osteoradionecrosis increases with time after radiation therapy. And gradually disappear during or after you have completed treatment. The taste buds line the surface of the tongue. Chemotherapy affects rapidly dividing cells. 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. Fax: (631) 638-7326
Take analgesics (pain medication) as ordered. Continue fluoride treatments after your treatment is completed and do not discontinue unless advised by the Radiation Oncologist. When patients do not follow recommendations, extra face-to-face time is required to understand obstacles interfering with patient implementation of the care plan. Extractions should be done at least one week before the start of chemotherapy or radiation therapy to provide enough time for proper healing. Do not eat, drink or rinse your mouth for the next thirty (30) minutes. 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. When therapy ends, you need to continue with good dental care in order to keep your teeth and gums healthy. Ten percent of patients with osteoradionecrosis have a recurrence of the cancer or a new primary cancer.16 The molar region of the mandible is the most common site affected.16,17, A number of staging systems are available for osteoradionecrosis.1820 The most commonly used is the classification system proposed by Marx.19 In this classic manuscript, Marx describes an osteoradionecrosis treatment protocol using HBO therapy based on three stages.
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