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Late Complications of Head and Neck Radiation

    continued...

    Oral and dental management of the xerostomic patient

    Patients who experience salivary gland hypofunction and xerostomia must maintain excellent oral hygiene to minimize the risk of oral lesions. Periodontal disease can be accelerated and caries can become rampant unless preventive measures are instituted. Multiple preventive strategies should be considered.

    Oral hygiene protocol

    Perform systematic oral hygiene at least 4 times per day (after meals and at bedtime):

    • Brush teeth (if soreness of oral mucosa and trismus are present, use small ultrasoft toothbrush).
    • Use a fluoridated toothpaste when brushing.
    • Floss once daily.
    • Apply a prescription-strength fluoride gel at bedtime to prevent caries.
    • Rinse with a solution of salt and baking soda 4 to 6 times a day (½ tsp salt and ½ tsp baking soda in 1 c warm water) to clean and lubricate the oral tissues and to buffer the oral environment.
    • Sip water frequently to rinse the mouth and alleviate mouth dryness.
    • Avoid foods and liquids with a high sugar content. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)

    Fluorides

    Prescription-strength fluorides should be used because nonprescription fluoride preparations are inadequate for moderate to high risk of dental caries. If drinking water does not contain enough fluoride to prevent dental decay, oral fluoride (e.g., drops or vitamins) should be provided.

    Use of topical fluoride has demonstrable benefit in minimizing caries formation. During radiation treatment, it has been recommended that mouth guards be filled with topical 1% sodium fluoride gel and placed over the upper and lower teeth. The appliances should remain in place for 5 minutes, after which the patient should not eat or drink for 30 minutes.

    Remineralizing solutions:

    • Fluoride and calcium/phosphates.
    • Topical high-concentration fluorides.
    • Children: topical and systemic.
    • Adults: topical.

    Management of xerostomia

    Prevention of salivary gland hypofunction and xerostomia

    To prevent or reduce the extent of salivary gland hypofunction and xerostomia, parotid-sparing intensity-modulated radiation therapy (IMRT) is recommended as a standard approach in head and neck cancer (HNC), if oncologically feasible. In addition, treatment should focus on approaches to further reduce the radiation dose to the submandibular and minor salivary glands, as these glands are the major contributors to moistening of oral tissues.[9]

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