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