Head and neck radiation patients are a significant challenge relative to both intratherapy and posttherapy oral complications resulting from radiation therapy. Unlike the oral complications of chemotherapy that are of shorter duration and significant for only a short period (a few weeks to 2 months) after the cessation of therapy, the oral complications of head and neck radiation are more predictable, are often more severe, and can lead to permanent tissue changes that put the patient at risk for serious chronic complications.
Preradiation Dental Evaluation and Oral Disease Stabilization
Elimination of oral disease and implementation of oral care protocols designed to maintain maximum oral health must be components of patient assessment and care before radiation therapy begins. During and after radiation therapy, oral management will be dictated by the following:
Specific needs of the patient.
Specifics of the radiation therapy.
Chronic complications caused by radiation therapy.
Ongoing oral assessment and treatment of complications are essential because radiation to oral tissues typically conveys a lifelong risk of oral complications. In addition, invasive oral procedures can cause additional sequelae. Dental care typically needs to be altered because of underlying chronic radiation-induced tissue damage.
Patients should receive a comprehensive oral evaluation several weeks before high-dose upper-mantle radiation begins. This timing provides an appropriate interval for tissue healing in the event that invasive oral procedures, including dental extractions, dental scaling/polishing, and endodontic therapy, are necessary. The goal of this evaluation is to identify teeth at significant risk of infection and/or breakdown that would ultimately require aggressive or invasive dental treatment during or after the radiation that increases the risk of soft tissue necroses and osteonecroses. The likelihood of these lesions occurring postradiation increases over the patient's lifetime as the risk of significant dental disease (restorative, periodontal, and endodontic) increases. Salivary gland hypofunction and xerostomia frequently occur postradiation. It is thus especially important that preradiation dental care strategies are instituted to reduce the impact of the complications of severely decreased saliva secretion and the associated high risk of dental caries.
In addition, three radiation-specific issues emerge:
Radiation injury is oral tissue–specific and dependent on dosage and portals of therapy.
Radiation-induced oral mucositis typically lasts 6 to 8 weeks, versus the approximate 5 to 14 days observed in chemotherapy patients. The extended radiation treatment protocols are chiefly responsible for this difference.
The primary cause of oral cancer is tobacco use; alcohol abuse further escalates risk. It is therefore critical that head/neck cancer patients permanently cease tobacco use. (Refer to the PDQ summary on Smoking in Cancer Care for more information.)
Most patients with smoking-related cancer appear motivated to quit smoking at the time of cancer diagnosis.
Continued smoking substantially increases the likelihood of recurrence or occurrence of a second cancer in survivors, particularly in those who previously received radiation therapy.
A stepped-care approach to tobacco cessation is recommended, including direct physician advice to quit and provision of basic information to all patients at each contact during the first month of diagnosis, followed by more intensive pharmacologic treatment or counseling for those having difficulty quitting or remaining abstinent.