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  • For patients with non-head and neck cancer, there are generally no concerns with dentistry post-treatment except increased risk of metastases to jaws.

  • For head and neck cancer

    • There are no post treatment concerns associated with chemotherapy after the patient has recovered from its use 

    • Radiation therapy does have immediate and ongoing effects 

Cancer Patient:  

Post Cancer Treatment Management

Introduction

Risks to the dental patient from head and neck radiation

Management During Treatment

  • Chronic xerostomia from radiation do to direct damage to the salivary glands in the field of radiation

    • Mucositis, cheilitis, glossitis, fissured tongue, glossodynia, dysgeusia, dysphagia

    • Difficulty in lubricating and masticating food

    • Radiation caries secondary to decreased salivary flow

  • Osteoradionecrosis - risk increases as the radiation dosage increases

  • Recurrence of primary or latent metastases in the soft tissue or bony tissues of the head and neck may develop

Questions to Ask 

  • Determine level of unstimulated and stimulated salivary flow

    • Severe xerostomia < 0.2 mL/min

Diagnostic Tests 

  • For head and neck radiation, information from the radiation oncologist regarding the field of radiation and total dosage can be helpful when planning treatment for patient who has had head and neck cancer.

Clinical Findings 

  • Metastasis to the jaws - most commonly the mandible

    • Soft tissue metastasis most commonly effects the gingiva and the tongue

      • Nodular mass, may appear like reactive lesion (pyogenic granuloma), ulcerated (it does not always appear as a squamous cell carcinoma, unless it is a recurrence of squamous cell carcinoma and not metastasis)

      • Loosened teeth, pain, paresthesia, swelling, lesion may occur in a non-healing extraction site

    • Bony metastasis 

      • Pain, swelling, loosened teeth, paresthesia.  Radiographically radiolucent, well circumscribed, appearing like a cyst, or ill defined with moth-eaten appearance.  May resemble periodontal disease when the alveolus in involved.  May cause widening of the periodontal ligament.

Prevention 

  • Head and neck radiation

    • Patients should avoid wearing their dentures during the first 6 months after completion of radiation therapy; even mild trauma can result in ulceration and osteroradionecrosis

    • Prescription of concentrated (5000 ppm) fluoride toothpaste (Prevident 5000)  should be provided to the patient for use in custom trays or brush on application.

    • Management program for salivary dysfunction

    • Oral recall program for recurrence of primary lesion

      • Every 1-3 months in the first 2 years

      • Every 3-6 months thereafter

      • After 5 years at least once each year

    • Ensure continued good oral hygiene

    • Evaluate for soft tissue and bony lesions

      • Fungal infection

      • Osteoradionecrosis can arise without surgical trauma

    • Evaluate for caries

    • Evaluate for muscle trismus - daily stretching exercises, apply local warm moist heat

  • Surgical procedures in the patient who was treated with head and neck radiation therapy

    • Minimize infection: prophylactic antibiotic use

      • Rx: Pen VK 2 g orally 1 hour before the procedure

      • Rx Pen VK 500 mg 4x/day for one week

    • Minimize hypovascularity 

      • Use non-lidocaine local anesthetic (e.g., prilocaine plain or forte) for extractions

      • Minimize or avoid use of vasoconstrictor (1:200,00 or less)

    • Minimize trauma

      • Endodontic therapy is preferred over extraction (even if the crown is then removed at the level of the bone)

      • Atraumatic surgical technique

      • Avoid periosteal elevators

      • Limit extractions to two teeth per quadrant per appointment

      • Irrigate with saline, obtain primary closure, eliminate bony edges or spicules

  • Other cancer patients can usually have all types of dental treament without limitation based on other conditions.

 

Post-Operative Care

  • Maintain good oral hygiene:

    • Use oral irrigators

    • Use antimicrobial rinses

    • Use daily fluoride gels

    • Eliminate smoking

    • Frequent postoperative recall appointments

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • What kind of cancer did you have?

  • How was it treated?

  • If radiation treatment was used, what was the field of radiation, what structures of the head and neck were included in the field of radiation? 

  • What was the dosage?

  • Were you treated with bisphosphonates? IV or oral?  Dosage and length of time taken.

  • Are you considered cured, in remission or are you in palliative care?

Risks to the dental patient from bisphosphonate use

  • Chronic xerostomia from radiation do to direct damage to the salivary glands in the field of radiation

    • Mucositis, cheilitis, glossitis, fissured tongue, glossodynia, dysgeusia, dysphagia

    • Difficulty in lubricating and masticating food

    • Radiation caries secondary to decreased salivary flow

  • Osteoradionecrosis - risk increases as the radiation dosage increases

  • Recurrence of primary or latent metastases in the soft tissue or bony tissues of the head and neck may develop

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