Head and Neck Cancer
Approximately six percent of all cancers diagnosed each year are associated with the head or neck. Most of these patients will receive some type of chemotherapy and/or radiation therapy to fight the invading tumor cells. Radiation and chemotherapy tax the health of both normal and cancerous tissues, which is exceedingly evident in the mouth. Doctors Groh and Souviron have extensive experience and knowledge in preparing patients for and assisting them through their cancer treatment. They emphasize the prevention and early treatment of side effects so that patients can return to normal function as soon as possible, and help patients maintain good nutrition and a positive outlook.
Smoking increases a person's risk of head and neck cancer by about 3.5 times. Heavy drinking increases a person's risk by about the same amount. Smoking AND drinking increase a person's risk of head and neck cancer by about 350 times! Second hand smoke, smokeless tobacco, Epstein-Barr virus, and heredity also are strong risk factors.
Recently it has become well understood that HPV, the Human Papilloma Virus in a few of its over 100 varieties, is a leading cause of head and neck cancer. This is the same family of viruses that commonly causes abnormal pap-smears and cervical cancers in women. Unfortunately this virus can be transmitted sexually, is unknown to many who have it, and should be of great concern.
At Dental Leaders we cannot give medical advice. However, we STRONGLY recommend that parents have a serious discussion with their children's pediatricians or family medicine physicians in regard to vaccinating girls AND boys with one of the available HPV vaccines (Gardasil). When advisable, this vaccine should be administered prior to the age of sexual activity.
Dental Considerations for Chemotherapy Patients
- Chemotherapy kills cancer cells by taxing the life cycles of those cells more than that of most normal cells. Some normal cells can be especially susceptible to the stress of chemotherapy. The mucus membranes, or skin inside mouth and throats, are especially tender to these lifesaving medications. People on chemotherapy for tumors anywhere in their bodies often are plagued with oral mucositis.
- Mucositis is soreness or even blistering of the mucus membranes. Unchecked, it can prevent a person from eating and performing normal oral hygiene activities. Studies show a strong relation between gum health and resistance to mucositis. Scheduling aggressive dental care prior to starting chemotherapy, and then keeping one’s mouth and teeth as clean as possible during cancer treatment is imperative.
- Spicy foods, abrasive foods, and alcohol should be avoided so as not to aggravate the sore tissues. Drinking lots of water is vital to maintaining fluid balance and the moistness of tissues.
- Dentists or oncologists may prescribe viscous lidocaine (numbing agent) or some type of "Miracle Mix" (coating and numbing mixture) to assist in comfort if mucositis is especially bad.
- During and shortly after chemotherapy, patients should consult their oncologist before seeking dental care. Often white blood cell counts and clotting factors are at low levels and dental treatment should be postponed until after a blood test is conducted.
- Any patients undergoing chemotherapy should be sure that their dentist is aware and educated in the issues regarding their chemotherapy treatment. Oncologists should be able to help with any questions.
Dental Considerations for Radiation Therapy Patients
Radiation therapy kills cancer cells by shrinking blood vessels in the affected area. Fast-growing tumor cells require more oxygen than normal cells, becoming "oxygen starved." Some normal body cells can be especially susceptible to the effects of radiation. The mucus membranes, or skin inside our mouth and throats, are tender to this lifesaving treatment, as are salivary glands. Therefore, people on radiation therapy for head and neck tumors frequently have side effects associated with the radiation itself or with decreased blood flow. Radiation to other parts of the body does not have such an effect on oral tissues unless given in combination with chemotherapy. Below is a list of the common side effects of head and neck radiation therapy and some palliative measures that can be taken to improve your lifestyle.
- Dry mouth, or xerostomia, is the most common side effect of radiation to the head or neck. Salivary gland cells are directly susceptible to radiation and often shut down. The full function and flow of the salivary glands does not generally return fully. Dry mouth is made even worse by the continued use of tobacco products, alcohol in beverages and mouthwashes, caffeine, and many commonly used medications. Alcohol and tobacco use, frequently the cause of head and neck cancer, must stop immediately with the diagnosis of a tumor. Medications should be changed or adjusted by the prescribing doctor.
Some medications, such as salagen or pilocarpine, can increase saliva flow. Chewing sugarless gum and diatetic (no sugar) citrus candies can also help. Oral Balance, an over-the-counter gel, is a nice moisturizing coating for the inside of the mouth. Its manufacturer, Laclede Pharmaceuticals, has a nice variety of products for dry mouth patients, including mouthwashes and chewing gum. Most "saliva substitutes" have been, in the experience of Dental Leaders, less acceptable to patients. The practice recommends acquiring the habit of drinking frequent sips of water to maintain the moisture inside the mouth. As will be explained below, one must not ever get in the habit of using sugared drinks, sports drinks, fruit juices, or carbonated sodas for this purpose. Constant exposure to sugar or carbonic acid could mean disaster for the radiation patient. Water is the best possible solution.
- Bad cavities, or radiation caries, can be a consequence of decreased saliva flow, as described above. Saliva provides three protective functions for teeth: 1) physically washing the teeth to remove food particles, sugars, and starches; 2) containing antibodies and enzymes which kill or deter cavity forming bacteria; 3) serving as a chemical neutralizer, or buffer, for the acids produced by plaque bacteria. Cavities often start at the gumline and strangulate the teeth.
Decades ago, patients were sent to the dentist to extract all of their teeth prior to radiation therapy. With current knowledge, this is necessary only for patients under the most dire circumstances. Careful dental examination prior to radiation therapy will reveal whether any teeth need to be extracted. Teeth with a hopeless, poor, or questionable prognosis must be extracted prior to radiation therapy. Patients should allow 14 to 21 days to heal completely prior to starting radiation therapy after an extraction, especially in the lower jaw.
To prevent radiation cavities, head and neck radiation therapy patients must give themselves daily fluoride treatments for the rest of their lives. This is usually done in custom applicators provided by a dentist. The fluoride is a prescription medication and comes in many flavors. Cavity-prone individuals may even need these treatments twice a day. The fluoride is kept in the mouth for four and one-half minutes, usually before bed and after other hygiene. The fluoride should be spit out, not swallowed, and nothing should be put in the mouth for at least 30 minutes after. Some salivary function usually returns, but it will not be the same. Fluoride protection, and care with dietary sweets and acids, well be a life-long need.
- Sterile necrosis, technically called osteoradionecrosis or ORN, is a complication of radiation therapy that is undesirable. In the event of an extraction or surgery, especially in the lower jaw, this condition leaves patients at risk of not healing due to the decreased blood supply. Such a problem can cause massive destruction of the jawbone and can even be fatal. This is the reason for discriminatory examination and aggressive treatment before radiation therapy.
When indicated or absolutely necessary, extractions and other surgical treatments, including bone grafts and implants, can be accomplished with a special pre-treatment called hyperbaric oxygen, or HBO. This treatment increases the blood supply and allows for improved healing. Dental Leaders has been able to give patients a second chance with careful use of this treatment and judicious use of implants.
IMPORTANT: After radiation therapy, a dentist should never extract a tooth without first consulting the patient’s radiation oncologist. Any dental professional working with patients suffering from osteoradionecrosis must understand the seriousness of this complication. Second opinions or specialist consultations are recommended prior to acting on any invasive or traumatic treatment to the lower jaw.
- Mucositis is a soreness or even blistering of the mucus membranes, comparable to a bad sunburn inside the mouth and throat. Unchecked, it can prevent a person from eating and performing normal oral hygiene activities. Mucositis can be partly prevented by maintaining the healthiest possible conditions prior to starting radiation therapy. Studies show a strong relation between gum health and resistance to mucositis. Patients should schedule aggressive dental care prior to starting radiation therapy, and then maintain the mouth and teeth as clean as possible during cancer treatment. Even if patients are not taking much food by mouth it is still necessary to follow through with consistent oral hygiene.
Spicy foods, abrasive foods, and alcohol should be avoided so as not to aggravate the sore tissues. Water is the best way to maintain fluid balance and moistness of tissues. Dentists or oncologists may prescribe viscous lidocaine (numbing agent) or some type of "Miracle Mix" (coating and numbing mixture) to assist in patient comfort if mucositis is especially bad.
- Decreased Taste, or dysgeusis, is another side effect of radiation therapy to the head and neck. This is a direct result of radiation on the taste buds. It is usually one of the first side effects noticed, and thankfully recovery is usually close to 100 percent. Patients experiencing dysgeusis should resolve themselves to the fact that, for a few months, food will not taste as good. With this in mind, foods and beverages should not be over-spiced or over-sweetened.
- Swallowing Problems, or dysphagia, is usually a minor side effect of radiation therapy unless it is accompanied by chemotherapy. Mucositis can be the cause of swallowing pain, and is easily compensated for by taking smaller bites and accompanying each bite with a sip of water to wash it down. If too painful, a gargle with prescribed viscous lidocaine or benadryl elixir to numb the throat usually helps. Radiation oncologists may provide a special cookbook to help with a few tough weeks. Dysphagia is not usually a persistent or long-lasting condition.
- Muscle spasm, or trismus, is a fairly uncommon side effect of radiation therapy. Occasionally, muscles in the neck, throat, or jaw region will cramp up and go into spasm. This effect tends to limit movement and/or cause pain. Dental Leaders has had a few patients with limited mouth opening, which took years to return to adequate function, though this is uncommon.
As well, Dental Leaders has seen a condition called Eagle Syndrome, in which a pre-existing bone anomaly in the neck is exacerbated by radiation therapy. This condition is easily diagnosed in a panorex x-ray. The practice continues to study this phenomenom and appreciates any reports from patients or dentists regarding this condition.
Long-term concerns: Patients should make sure that their dentists are aware and educated in the issues regarding radiation therapy. Not every dentist is aware of the potentially lethal issues surrounding treatment of patients long after radiation therapy. For patients who feel as though their dentist takes these serious considerations lightly, they should seek a second opinion prior to any surgical treatment or extractions, especially in the lower jaw. Radiation oncologists should be able to help with any questions.