Oral health considerations in head & neck cancer survivors

Nathaniel S. Treister, DMD, DMSc, DABOMDivision of Oral Medicine and DentistryDana Farber/Brigham and Women’s Cancer Center

April 3, 2010

Why do we care about the mouth?

• Oral function critical for overall health/ADLs

• Cancer treatment related long-term complications– xerostomia– dental caries– candidiasis– trismus/fibrosis– jaw osteonecrosis

• Risk of recurrent disease

Crit Rev Oral Biol Med 2002;13:197-212

Salivary gland hypofunction

• Radiation therapy– irreversible changes >25 Gy – IMRT attenuates effect

• Quantitative/Qualitative changes– xerostomia– pain/discomfort– difficulty eating/swallowing– taste changes– dental caries (cervical, interproximal)– recurrent oropharyngeal candidiasis

Candidiasis: treatment

• Identify predisposing factor(s)– treat denture by soaking in 1:10 dilution of bleach

• Topical antifungal therapy – nystatin 100,000 units/ml, rinse 2 - 3 minutes;

swish and spit or swallow if throat involved– clotrimazole troches (QID)– Mycolog II cream (nystatin/triamcinolone)

• Systemic antifungal therapy– fluconazole 100 mg QD (5-7 days)– prophylaxis for recurrent candidiasis (QW, BIW)

Caries prevention

• Fluoride 5,000 ppm daily– custom trays, 30 min– up to 90% reduction

• Regular dental visits• Diet counseling

– decrease refined sugar intake

– regular meals rather than snacks

– avoid sugary drinks

• Oral hygiene instruction• Compliance

Sialogogue therapy

• Cholinergic agonists– pilocarpine hydrochloride (5 mg TID)– cevimeline hydrochloride (30 mg TID)

• ~50% response rate• May require > 8 weeks for benefit• LT therapy generally well-tolerated

– sweating– GI intolerance– contraindications

Trismus & Fibrosis

• Radiation and/or Surgery • Pain/Dysfunction• Xerostomia common• Oral health implications

– limited ability to maintain oral home care– difficult to provide dental treatment– frequent visits, radiographs, early treatment of

caries

• Requires long-term physical therapy

Osteoradionecrosis

• Radiation-induced bone changes– hypovascular– fibrotic marrow– hypodynamic bone

• Incidence < 3.0%• HBO, antibiotics…limited evidence• Most heal, improve, or stabilize w/

conservative therapy• Surgery when necessary

5/08

2/09

11/08

8/08

Recurrent malignancy

• Symptoms– pain/paresthesia/neuromotor changes/growth– change in fit of removable prosthesis

• Clinical examination findings– red/white/non-healing ulcer– mass– asymmetry

• Biopsy any suspicious lesions

Summary

• H&N cancer survivorship growing• Importance of oral health• Prevention and patient education• Requires multidisciplinary approach

– oncology– primary care– oral health specialists