dental management principles - memberclicks

Dental Management Principles (Before, During, After)

Lauren L. Patton DDSProfessor, University of North Carolina at Chapel Hill

Objectives

1.Become familiar with the current protocols for the dental management of patients undergoing cancer treatment

2.Understand the role of the dental professional during cancer treatment

3.Understand the rationale for dental management of patients who underwent cancer therapy

Dental Management Principles | Lauren L. Patton, DDS

Disclosures

• Grant/Research Support: NIDCR #2U01DE022939-06A1 Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (ORARAD).

• Consultant/member: ADA Council on Scientific Affairs-volunteer

• Other: • Oral Medicine Section Editor, Oral Surg Oral Med Oral Pathol Oral

Radiol• Book Editor: ADA Practical Guide to Patients with Medical

Conditions, ed. 2 John Wiley and Sons, Inc. 2016


Supportive Care BeforeChemoradiation in Head and Neck Cancer


Before• Oncology team referral to a dentist for pretreatment oral

examination, ideally one month before treatment starts.

• Oncology team communication to dentist regarding cancer treatment plan and timeline.

• Dental team educates patient on oral sequelae of chemo/radiation/surgery and initiates a good oral hygiene program.

• Dental team eradicates current oral infection, conducts risk assessment of teeth in future dry mouth environment and provides any needed dental/oral surgical care, and initiates daily prescription topical fluoride preventive regimen.• Allow at least 14 days healing after oral surgery before radiation.

• Consider methods of salivary gland protection, e.g. IMRT, Amifostine


Patient, cancer, and dental related factors affecting pretreatment dental assessment

Patient Cancer Dental

Motivation Location Dental caries/remaining tooth structure

Socioeconomic status Staging Periodontal disease

Race/Ethnicity Cancer type Parafunctional habits

Support system Radiation type Prosthodontic considerations

Nutrition Radiation damage Oral hygiene risk factors

Smoking Biologic risk factors

Kufta K, Forman M, Swisher-McClure S, Sollecito TP, Panchal N. Pre-Radiation dental considerations and management for head and neck cancer patients. Oral Oncol. 2018 Jan;76:42-51.


Approach to pretreatment dental assessment


• Cancer Diagnosis

• Dental History

• Social History

• Comprehensive Clinical and Radiographic Examination

• Develop Prognosis of Dentition

• Communicate Directly with Radiation Oncologist

• Develop Comprehensive Treatment Plan

• Patient Education




• Cancer Diagnosis

• Dental History• Prior dental work completed or Not completed (suggests motivation

and compliance)

• Assess current motivation and oral hygiene

• Social History• Support system – Marital status? Life partner? Family?

• Living environment – alone?

• Finances




• Comprehensive Clinical and Radiographic Examination• Comprehensive oral evaluation• Radiographic evaluation

• Develop Prognosis of Dentition

• Communicate Directly with Radiation Oncologist• Type of Radiation to be used• Median and maximum planned dose to maxilla, mandible, parotids• Start date

• Develop Comprehensive Treatment Plan

• Patient Education• Importance of oral health complications associated with radiation

and chemotherapy


High risk factors with poor oral health prognosis

Cancer Factors Radiation Factors Patient Factors Tooth Factors

Advanced stage cancer requiring RT

>26 Gy to parotids £ Poor history of compliance

Endodontic disease

Nasopharyngeal or oropharyngeal tumors

>50 Gy to mandible ¶ Oral hygiene status Periodontaldisease

Tongue cancer >40 Gy (mean); >70Gy(max) to mandible ¥

Low socioeconomic status (withoutinsurance)

Periapical pathosis

3DRT or Conventional RT Prosthetic factors


£ Denotes increased risk for future dental caries¶ Denotes increased risk of ORN to jaws¥ Denotes increased risk for future dental extractions


A Prognostic Evaluation based on dental pathology severity

Tooth Status DefinitionGood No or minimal treatment needed;

Minimal risk of being lost in the forseen future.

Fair Treatment is needed and outcome is predictable; Low risk of being lost in the forseen future.

Questionable Has one or more problems and can be treated and maintained; Medium risk of being lost in the forseen future.

Compromised Includes teeth with no active pathology requiring immediate extraction, but may not be in the patient’s best interest to invest in such a tooth. External factors influencing the overall case and patient factors will play a major role in determining how to approach such a tooth. High risk of being lost.

Nonsalvageable Cannot be restored or presents pathology that dental treatment cannot resolve;includes teeth that may pose risk to the patient’s health.Indicated for extraction.



A good tooth

Parameter Condition

Periodontal health and alveolar support

80%-100% bone support. Can be easily maintained.

Remaining tooth structure

80%-100% remaining sound coronal tooth structure. Can be easily restored.

Endodontic condition

A tooth that can receive a straightforward primary endodontic treatment, or already has good endodontic therapy.

Occlusal plane and tooth position

A tooth that is in the correct occlusal plane and/or position, or one that is slightly deviated from ideal and may require minimal enameloplasty.



A fair toothParameter Condition


50%-80% bone support, which can be well maintained with rigorousperiodontal and maintenance therapy. Vertical defects or furcations that can be periodontally treated to become easily cleansable or treated predictably with regenerative therapy. Molars are at higher risk than single rooted teeth.


50%-80% remaining sound coronal tooth structure. Involved restorative procedures result in no infringement on biologic width, adequate ferrule, or good crown-root ratio and could minimally affect adjacent structures (if at all).


A failing endodontic treatment with obvious causes of failure and that can be predictably retreated. Or a tooth that requires a difficult primary endodontic treatment.

Occlusal planeand tooth position

A tooth that is out of the occlusal plane and can be adjusted so that it functions within the correct occlusal plane. Such a tooth may require additional treatment to seal exposed dentin.



A questionable toothParameter Condition


30%-50% of bone support. No ongoing acute outbreaks, but maintaining cleansability is difficult. Periodontal therapy and a thorough maintenance program will enable the tooth to be maintained for an acceptable period of time.


30%-50% remaining sound coronal tooth structure. Or a tooth with so little tooth structure that achieving adequate ferrule would result in compromising the crown-root ratio to some extent, and/or may affect adjacent structures.


An acute/chronic failing endodontic treatment that presents difficulty to predictably retreat.


A tooth that is out of the occlusal plane and requires multiple procedures to function within the occlusal plane.



A compromised toothParameter Condition


A tooth with <30% bone support, and/or one that cannot be cleansed or maintained well and has evidence of active periodontal disease.


A tooth with <30% sound tooth structure, or one in which the extent of the lost tooth structure does not enable a good ferrule to be achieved without totally compromising the support of the adjacent tooth structures or crown-root ratio.


A tooth with a failing endodontic treatment that cannot predictably be retreated.

Occlusal plane and tooth position

A tooth so severely out of the occlusal plane or severely tilted that after extensive treatment will exhibit reduced crown-root ratio, which will prevent it from serving as a long-term unit in the arch. Or a tooth whose position impacts the health of the adjacent structures.



A nonsalvageable tooth

Parameter Condition


A tooth with <30% bone support and cannot be cleansed or maintained without acute outbreaks of periodontal infection.


No remaining supragingival sound coronal tooth structure. Loss of tooth structure deep into the root dentin/canals.


A vertical root fracture, or a tooth that has been retreated several times endodontically and/or surgically without resolution.


A tooth so far super-erupted or tilted out of the occlusal plane that it cannot be restored into correct function, or would interfere with the restoration of that arch or the restoration of the opposing arch.



Findings from ORARAD (prospective, longitudinal observational multicenter study)

• Dental Disease before Radiation (assessed 4/2014-6/2016)

• Baseline visits for 356 subject, 77% men, 83% white, 71% education beyond high school, mean age 60 (SD 11) yrs, 97% with some insurance coverage.• 23 -Mean number teeth

• 37% had at least one tooth with caries

• 47% had at least one tooth with PPD 5mm or greater

• Based on pre-RT exam, 50% had preradiation dental treatment recommended, with cleaning (42%), extractions (35%) and restorations (25%) being the most often recommended.

Brennan MT, Treister NS, Sollecito TP, Schmidt BL, Patton LL, Mohammadi K, Simpson LL, Voelker H, Hodges JS, Lalla RV. Dental disease before radiotherapy in patients with head and neck cancer. JADA. 2018 Jan;76:42-51.


Fluoride, Fluoride, Fluoride

Randomized study in France of 1% (450 ppm) Fl- in carrier x 5 min QD vs. 1350 ppm Fl- toothpaste x 3 min BID.

Horiot JC, Schraub S, Bone MC, et al. Dental preservation in patients irradiated for head and neck tumours: A 10-year experience with topical fluoride and a randomized trial between two fluoridation methods. Radiother Oncol 1983;1:77-82.

Patients entered

Patients evaluated

Diffuse dental caries

Osteoradio-necrosis

Gel 109 99 3 (3%) 0

Toothpaste 131 91 10 (11%) 0

• Caries related to poor patient compliance.• No patients adhering to the programme instructions failed in

either arm.• Non-significant Intergroup comparison (p=0.1) favors gel due

to less active patient participation.


Post-radiation dental disease management

• Update through June 30 2016 of 2010 Systematic Review.

• Conclusions:

• 1. Recommend use of Fluoride products to prevent dental caries in post head and neck radiation patients. Important to reinforce use as compliance decreases over time. Type of fluoride delivery system did not significantly influence caries activity (Level of Evidence: II, Grade of Recommendation: B)

• 2. Recommend use of chlorhexidine mouth rinse 0.12-0.2% once to twice daily for reduction of plaque and strep mutans counts in patients undergoing radiation. Potential side effects of chlorhexidine should be taken into account. (Level of Evidence: II, Grade of Recommendation: B)

• Recommend use of composite resin, resin modified GIC and amalgam restorations over conventional GIC in compliant fluoride users. (Level of Evidence: II, Grade of Recommendation: B)

Hong CHK, Hu S, Haverman T, et al. A systematic review of dental disease management in cancer patients. Support Care Cancer 2018;26:155-74.


Restorations: Glass IONOMER or Resin• Aim: To evaluate the clinical performance of adhesive

filling materials in class V cavities in xerostomic head-and neck-irradiated cancer patients.

• Patients: 35 high-caries-risk, post-radiation, xerostomic adults with ≥3 cervical carious lesions in the same arch.

• Methods: Each received a KetacFil (KF), PhotacFil (PF) and Herculite XRV (HX) restoration; instructed to use daily neutral 1% sodium fluoride gel in custom trays. After 6, 12, 18 and 24 months, the restorations were examined for material loss, marginal integrity and recurrent caries. Fluoride compliance assessed: compliance of ≤50% = NFUs, >50% = FUs. DeMoor RJ, Stassen IG, van’t Veldt Y et al. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic health-and neck-irradiated cancer patients. Clin Oral Investigations 2011;15:31-8.


Restorations: Glass IONOMER or Resin

• Results: Class V restoration failures, independent of cause and patient Fl- use

• For each period, groups with the same letter are not signifdifferent at p<0.05

• Summary: glass ionomers (especially the conventionally setting formulation) provide clinical caries inhibition but erode easily, while composite resin provides greater structural integrity.

KF-glass ionomer

PF-glass ionomer

HX- nanohybrid composite

DeMoor RJ, Stassen IG, van’t Veldt Y, et al. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic health-and neck-irradiated cancer patients. Clin Oral Investigations 2011;15:31-8.

Time of Recall Appointment

Cumulative failures/recall evaluations (%)

Restorative material

6 months(n=30)

12 months(n=28)

18 months(n=28)

24 months(n=27)

KetacFil 12/30 (40%)a 19/28 (68%)a 23/28 (82%)a 26/27 (96%)a

PhotacFil 6/30 (20%)a,b 9/28 (32%)b 16/28 (57%)b 21/27 (78%)a

Herculite XRV 5/30 (17%)b 8/28 (29%) b 9/28 (32%)b 13/27 (48%)b


Supportive Care During Chemoradiation in Head and Neck Cancer

• Oral Hygiene Management

• Pain Management

• Sepsis Management

• Trismus Prevention


Oral Hygiene Management

• Basic oral care will reduce the frequency and severity of oral mucositis and associated pain• Make sure patient follows recommended oral hygiene

regimen.• Brush teeth and tongue on waking, after meals, and at bedtime.• Floss teeth at bedtime.• Take out dentures at night and clean denture when clean

mouth.

• Monitor mucosa and oral structures for bleeding and infection.

• Advise patients not to wear removable appliances (partial or full dentures) during treatment.


Pain Management• In (chemo) radiation therapy-induced mucositis, escalation of

pain intensity generally starts at week 3, peaks at week 5, and persists 2-4 weeks post therapy with gradual remission of signs and symptoms.

• Pain correlates with radiation treatment fields, dose and fractioning; concomitant chemotherapy or cetuximab results in increased frequency, severity and duration of mucositis pain.

• Pain may be evoked by eating hot/spicy or acidic foods or liquids or dry air.

• In clinical practice, numerical rating scale or visual analog scale must be used regularly to assess background, breakthrough and swallow-related pain.

• Treatment will be discussed later today and is scaled according to intensity and type of pain experienced.

Mirabile A, Airoldi M, Ripamonti C, et al. Pain management in head and neck cancer patients undergoing chemo-radiotherapy: Clinical practice recommendations. Crit Rev Oncol Hematol. 2016 Mar;99:100-6.

Treatment options:Topical:• Coating agents• Anesthetics- 2%

lidocaine (duration: 15-30min)

• Topical morphine based mouthwash (duration:4-6h)

Systemic:• Fixed and rescue

medication with short release opioids

• NSAIDS, gabapentin, anti-spasmodics as needed


Sepsis Management

Mirabile A, Numico G, Russi EG, et al. Sepsis in head and neck cancer patients treated with chemotherapy and radiation: Literature review and consensus. Crit Rev Oncol Hematol 2015 Aug;95(2):191-213.

• Empiric management of presumed oral source1. Local candida infection or critical colonization:

• Topical fluconazole, itraconazole, nystatin suspension intra-orally

2. Bacterial sepsis

Ampicillin/sulbactam 3g q8h (IV)

PLUS

If suspected mycosis: Fluconazole 100mg q12h or Itraconazole oral solution 100mg q12h or Echinocandins (anidulafungin, caspofungin, and micafungin) or liposomal amphotericin B, only if very severe and in refractory cases.


Trismus Prevention• If muscles of mastication will be in field of radiation (typically cancer of the BOT, tonsil,

oropharynx or nasopharynx):

Instruct patient to exercise jaw muscles 3 times a day, opening and closing the mouth as far as possible without pain, move lower jaw to right and hold and left and hold, repeat 20 times.

Aids:

• Range of motion aids: Therabite® Jaw Motion Rehabilitation System™, Jaw Dynasplint® System

• Passive stretching exercises with thumb and middle finger of one hand or index finger of one hand and thumb of other.


Supportive Care AfterChemoradiation in Head and Neck Cancer


AFTER• Consult with dental team about reintroducing dentures and other

appliances after mucositis subsides. Friable tissues and dry mucosa may limit use.

• Make sure patient follows up with the dentist for fluoride gel/home care compliance. Lifelong, daily applications of fluoride gel are needed for the patients with severe xerostomia.

• Monitor patients for trismus. Check for pain or weakness in masticating muscles in radiation field. Reinforce jaw opening exercises.

• Advise against oral surgery on highly (>60 Gy) irradiated bone because of the risk or osteoradionecrosis. Tooth extraction, if unavoidable, should be conservative with use of antibiotic coverage.

• Consult the dentist to monitor irradiated craniofacial and dental structures for abnormal growth and development in pediatric patients.


Resources • For patients

• For dental team

• For oncology team

Available at: https://www.nidcr.nih.gov/health-info/cancer-treatmentsand https://catalog.nidcr.nih.gov/OrderPublications/


https://www.nidcr.nih.gov/health-info/cancer-treatments

https://catalog.nidcr.nih.gov/OrderPublications/

References:• Kufta K, Forman M, Swisher-McClure S, Sollecito TP, Panchal N. Pre-Radiation dental

considerations and management for head and neck cancer patients. Oral Oncol. 2018 Jan;76:42-51.

• Brennan MT, Treister NS, Sollecito TP, Schmidt BL, Patton LL, Mohammadi K, Simpson LL, Voelker H, Hodges JS, Lalla RV. Dental disease before radiotherapy in patients with head and neck cancer. JADA. 2018 Jan;76:42-51.

• Horiot JC, Schraub S, Bone MC, et al. Dental preservation in patients irradiated for head and neck tumours: A 10-year experience with topical fluoride and a randomized trial between two fluoridation methods. Radiother Oncol 1983;1:77-82.

• Hong CHK, Hu S, Haverman T, et al. A systematic review of dental disease management in cancer patients. Support Care Cancer 2018;26:155-74.

• DeMoor RJ, Stassen IG, van’t Veldt Y, et al. Two-year clinical performance of glass ionomer and resin composite restorations in xerostomic health-and neck-irradiated cancer patients. Clin Oral Investigations 2011;15:31-8.

• Mirabile A, Airoldi M, Ripamonti C, et al. Pain management in head and neck cancer patients undergoing chemo-radiotherapy: Clinical practice recommendations. Crit Rev Oncol Hematol. 2016 Mar;99:100-6.

• Patient and team educational materials- Available at: https://www.nidcr.nih.gov/health-info/cancer-treatments and https://catalog.nidcr.nih.gov/OrderPublications/


https://www.nidcr.nih.gov/health-info/cancer-treatments

https://catalog.nidcr.nih.gov/OrderPublications/

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