Head, neck, and oral cancer: A general reference for treatment

June 11, 2013
Dr. Stacey Simmons believes that oral care for cancer patients is essential, and the key to successful treatment is ardent communication between all parties involved — the patient, oncologist, general practitioner, and dentist.

Elisabeth, a healthy 56-year-old female, had been a patient of mine for two years. Aside from a six-unit bridge that we placed from Nos. 6 through 11, her care primarily involved managing her periodontal disease. Molars with 7-plus mm pocketing and slight mobility were not entirely in her favor, but Elisabeth did not want to remove any of her teeth and was willing to do what was necessary to save them, including surgical scaling and root planing with grafting.

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All intended efforts came to a halt when she was diagnosed with squamous cell carcinoma in the left neck/submandibular region. She was going to have localized radiation and chemotherapy; her oncologist wanted my clearance to commence with treatment. Time was of the essence.

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Elisabeth is one of millions of diagnosed with cancer each year; furthermore she is one of 50,000 diagnosed with head, neck, and oral cancer. What types of things need to be done for these patients? After all, we are physicians of the oral cavity and with this title comes the crucial responsibility to treat more than just teeth.

Oral care for cancer patients is essential. Our goal should be to to modify the acute complications and long-term consequences of cancer therapy.

Upon being diagnosed with cancer, our first consideration should be to obtain a complete and thorough dental examination. Consider the following as part of a comprehensive assessment:

  • Treat/restore all carious teeth.
  • Remove broken down, nonrestorable teeth. Patients with moderate to advanced periodontal disease (pocketing in excess of 6 mm, bone loss, mobility, and furcation involvement) should be considered for removal.
  • There is a three-week minimum recommendation for wound healing prior to treatment — this reduces the risk for osteoradionecrosis, especially in the areas directly in line of the radiation.
  • Examine/treat inflammatory lesions in the oral cavity.

For Elisabeth, the outcome for her periodontally involved teeth was inevitable. Since her battle with the disease had spanned years prior to seeing me, we had to think comprehensively in our approach. Teeth Nos. 2, 3, 18, and 31 all had 7 mm to 8 mm pocketing with furcation involvement. Although she was a candidate for surgical scaling and root planing with bone grafting, we had to consider the fact that her oncologist wanted her to commence with treatment as soon as possible. Furthermore, treatment of the aforementioned would not be a guarantee. We had to ask ourselves if the risk was worth it. Ultimately, after discussion with the patient and oncologist, we removed teeth Nos. 2, 3, 18, and 31. We discussed alteration in function and partial fabrication in the near future — our immediate concern was to get her to treatment!

Fabrication of oral appliances, such as fluoride gel carriers and radiation shields for use during treatment is beneficial to patients as the side effects of treatment — the most common being xerostomia, caries, and mucositis — begin to take effect. An in-depth discussion with the oncologist regarding radiation dose, frequency, and duration should direct the dentist as to which type of appliance is needed.

1. Fluoride gel carriers (general instruction/guidelines – may not apply to every patient)

a. For use with a prescription of 1% neutral sodium fluoride gel (usually daily or every other day). Acidulated gels are not recommended as they can cause decalcification, mucosal irritation, and ulceration.
b. Facial surfaces need to be blocked out prior to suck down; trim material about 1/8 inch past teeth on buccal and ¼ inch on lingual
c. Billed out under dental procedure code D5986
d. If the carrier is recommended for use during radiation treatment (as requested or recommended by the oncologist), then a minimum thickness of 0.150 is required. Thinner materials may not adequately absorb the secondary low energy radiation and thus break down, which is prevalent with teeth that have metal crowns and amalgam fillings.

2. Radiation shields

a. Tongue depressing or deviating stents are recommended to shield tissues during high doses of radiation.
b. Billed out under dental procedure code D5984
c. The June 2013 issue of the Journal of the American Dental Association has an article on the fabrication of such appliances.

Three days after Elisabeth’s extractions, we took models for her fluoride trays. We used the soft flexible mouthguard material and fabricated them in-house, ensured their fit, and reviewed application of fluoride. Her oncologist requested that she use her trays during her radiation treatments. Due to the amount of radiation she received, we did not fabricate a radiation shield.

A detailed discussion on the changes that will take place and thus affect normal day-to-day function, is also recommended. These include, but are not limited to, xerostomia, taste alteration, secondary infections, delayed onset of radiation caries, hypersensitive teeth, nausea, and vomiting (acid introduction into the oral cavity). Over-the-counter and prescriptions medications can be recommended and offered to patients to alleviate these changes.

Elisabeth is currently at the tail end of her treatment. She has noticed a drier mouth and a generalized increase in sensitivity. We have implemented the use of dry mouth and sensitivity products. She developed an ulcer under her tongue midway through treatment — a concern was secondary infection and was monitored closely for healing. We see her every three months for her periodontal maintenance. She is diligent with her home care and her prognosis overall is excellent.

I have treated several cancer patients and have found that the key to successful treatment is ardent communication between all parties involved — patient, oncologist, general practitioner, and dentist. Each individual case is unique and must be thoroughly reviewed and planned to help ensure a satisfactory outcome for the most important person involved, the patient.
Dr. Stacey Simmons grew up in Hamilton, Mont. She did part of her undergraduate work at Purdue University and then received her bachelor’s degree in exercise physiology from the University of Utah. After applying to both medical and dental school, she decided that dentistry was her career of choice. She received her DDS degree from Marquette University School of Dentistry in Milwaukee, Wisc., in 2004. In private practice, she focuses her care on prosthodontics and cosmetic dentistry. She is a guest lecturer in the Anatomy and Physiology Department at the University of Montana. Outside the office, she trains for triathlons and spends time with her family.