The importance of dental treatment before radiotherapy for head and neck cancer

Radiontheraphy is an integral part of the treatment of head and neck cancer. However, this method of treatment has s number of side effects that result from the harmful side effects of radiation on tissues and organs in the maxillofacial region.

These include the large and small salivary glands, the lining of the oral cavity, teeth, skin and muscles of the head, neck and upper chest. Affection of these structures is clinically manifested by xerostomia, mucositis and loss of taste.

Post-radiation cavities, trismus and skin burns are also found. Complications arising from bone involvement in the irradiated field are a major problem.

The most serious complication of radiotherapy in the head and neck region is osteoradionecrosis. This is a very serious, difficult-to-treat disease to which the jaw bone are most susceptible. However, it is also encountered in various forms in other bones that have been exposed to radiation (cheeckbone, frontal or temporal bone, clavicle, but we can also encounter osteoradiomyelitis of the vertebrae)

It is important to remember that these complications make threatment more difficult and impair the quality of life of patients. In some cases, they are even a reason to stop cancer treatment. With proper management of threated patients, these unwanted side effects can be mitigated or even avoided altogether.

The importance of dental treatment of the patient before RT

During the treatment of malignancy, various complications arise in the oral cavity due to the side effects of cancer therapy. This has long been a know fact, yet the involvement of the dentist in the therapeutic algorithm of cancer patients has not been the norm to date.

These complications can have a direct impact on the patient's treatment itself, as well as on their longevity and quality of life after treatment.

Up to a third of patients who are long-term survivors of head and neck cancer report moderate to severe levels of physical and psychological distress. Patients most often report eating problems. These difficulties can be alleviated, and some even prevented, by early intervention and careful planning of dental treatment.

Organization Recommendations:

  • Cancer patients should be treated in specialised centres. They are experienced, the treatment is coordinated and the multidisciplinary team provides facilities for dealing with various situations, including complications.

  • The oncology team should include a dentist who is responsible for assessing the patient's oral health and organising their treatment, communicating with the patient and their general dental practitioner (GP). The latter should be informed about the patient's condition and provide the oncology team dentist with the necessary information about the patient.

  • The PZL remains the patient's treatment dentist. During cancer treatment, the dentist from the cancer centre should be available for consultation.

  • There should be a dental hygienist who is trained and experienced in the subject.

  • A minimum length of oral health dispensary care should be established within the cancer centre. Thereafter, the patient will be handed back to the care of the PZL who, with appropriate instructions from the cancer centre dentist, will continue to provide dental care to the patient.

Recommendations before starting treatment:

  • Patient education

    it is necessary to inform the patient about the side effects of RT or CHT and provide nutritional guidance, ideally in collaboration with a nutritionist

  • Dental hygiene

    detailem oral hygiene instructions should be given to the patient. In the presence of gum disease, professional dental hygiene should be performed, and rinses with alcohol-free, preferably chlorhexidine-based mouthwashes should be performed. Topidla application of fluoride and calcium products to strengthen the hard tissues of the teeth should not be missed

  • Preservative treatment of teeth

    The various teeth should be treated with a suitable fillings material (composite or glass ionomer), bearing in mind that all cancer therapy must be carried out as soon as possible after diagnosis. It is important to consider whether the condition of the tooth can be better to extract the tooth. It is crucial that the condition of the tooth is revolver by the start of oncological treatment, i.e. in the shortest possible time. Endodontic therapy is not contraindicated, but should be completed with a reliable result before treatment begins. Teeth with periodontitis infecton or signs of pulpitis should be extracted. This is to eliminate the risk of developing osteoradionecrosis (ORN)

  • Prostheses

    removable dentures should be worn as little as possible and should always be removed overnight. It is also important to clean them thoroughly because of the possible development of mucositis and oral candidiasis.

  • Extraction

    if surgical treatment of the malignancy is indicated, teeth directly related to the tumour will be extracted as part of the oncosirgical procedure. Here, communication between the dentist and the maxillofacial surgeon is necessary.

    (or Otorhinolaryngologist-surgeon). Teeth with a doubtful prognosis (deep caries, extensive periodontal involvement, avital teeth) should be removed as soon as possible before radiotherapy. There should ideally be a there-week interval between extraction and the start of therapy. In the extreme case, 10 days is considered the minimum period (17). Clinically, the time when complete healing of the oral mucosa us occurred is considered the cut-off point. The greatest risk of ORN after extraction is in the period immediately before and after RT

Recommendations after treatment

  • Regular check-ups

    after cancer treatment, there is an increased risk of developing dental disease. Patients should attend regular check-ups, the regimen of which should be individualised based on their disability.

  • Preservative treatment of teeth

    Conservative treatments should be carried out in the simplest way possible, but with a view to preserving functionality (18). It has been shown that better results than glass ionomer restorations are achieved by using a compomeric fillings material or amalgam (19). The use of composite materials is not recommended due to the disappearance of dentin tubules after RT (20).

  • Dental hygiene

    regular check-ups with the dental hygienist continue, where the patients is instructed on the use of disinfectant rinses and fluoride preparations that help remineralise teeth.

  • Nutrition

    if the patient is able to take oral food, the composition of the diet should be adapted to his/her condition. The intake of subaru and acidic food should be reduced. However, the patient's overall nutritional status should not be forgotten, as it is very important for the patient's recovery from cancer. Dietary advice should be given in collaboration with a nutritionist

  • Xerostomia

    the patient should be educated about the possibilities of using artificial šálivá to combat dry mouth.

  • Rehabilitation

    if a contracture occurs, a recurrence of the cancer should be ruled out first. It it is not a consequence of tumour growth, then it is appropriate to start rehabilitation of the mouth opening with the help of exercises, possibly various dilators. Rehabilitation is also recommended as a preventive measure during radiation therapy.

  • Development of the orofacial apparatus

    in paediatric patients, it is necessary to bear in mind the possible abnormal development of the maxillofacial region due to cancer and its treatment. By close monitoring and timely intervention by the appropriate specialists, these consequences can be prevented or reduced.

  • Removable prostheses and obturators

    removable dentures should be worn as possible and removed at night due to the risk of developing ORN or oral candidiasis. Due to the presence of xerostomia and thus less retention of the dentures, the application of artificial šálivá and various retention preparations is recommended. Unlike dentures, obturators should not be removed at night for the first 6 months after surgery.

  • Extraction

    if possible, it is better to avoid tooth extraction. This procedure is

Osteoradionecrosis (ORN)

ORN is one of the most serious complications of head and neck readiotherapy. It is defined as a bone lesion with a broken skin or mucosal cover in the irradiated area that has not healed for more than three months and is not a residual or recurrent tumour.

It is disease that significantly reduces the quality of life of patients after cancer treatment. Treatment is difficult, requiring repeated hospitalisations, usually multiple operations, and very difficult healing is expected. It is also important to remember that these are patients who have had difficult cancer treatments. In addition, ORN treatment will make it temporarily more difficult for patients to manage their health. However, if we do not start it, the patient's condition will continue to deteriorate to an unbearable level and managing these situations is extremely challenging. This is very specialised care that should be under the care of a centre with experience in this area.

Conclusion

Caring for a patient with a head and neck malignancy is a challenge for members of the oncology team.

Every doctor must deal with his condition knowing that everything must be done in the shortest possible time and with absolute precision.

All party of the therapeutic protocol must build on each other. Coordination of the individual steps and communication between the members of the treating staff is important.

Of course, it is also important to communicate with the patient and gain their trust.

These are patients with a high level of risk and complications who require a complications who require a comprehensive approach.

The above written recommendations serve as a guide to how to proceed, but do not cover all situations a clinician may encounter, It is therefore essential that these patients are carem for by a cancer centre that is able to provide comprehensive care and is equipped with the capacity and staff to deal with all possible situations quickly.