Head and Neck Cancer
My First Appointment
At your first appointment, you will meet one of the dentists and assistants who will complete: your medical history, x-rays, comprehensive dental exam, fluoride tray impressions, and a MST score.
What is a comprehensive dental exam?
This is similar to a new patient exam when you are meeting a dentist for the very first time. Dr. Glogauer will assess all your tissues and teeth. At this appointment, a treatment plan will be determined. The dentist will also communicate with your ENT surgeon and radiation oncologist. Sometimes, but not always, treatment is completed at the first appointment.
What are fluoride trays?
Fluoride trays are similar in texture to a sports guard. They are made custom to fit only your mouth. After radiation, most patients experience dry mouth. Dry mouth can cause cavities and can even cause the cavity to grow at a faster rate. Fluoride trays are used once a day to help decrease cavities. Instructions for fluoride trays will be given at the appointment when you pick them up and try them in.
What is a MST (Modified Schirmer Test) score?
An MST score measures the amount of saliva in your mouth at the 1 minute, 2 minute and 3 minute mark. The highest score is 35. At your first appointment, and at subsequent appointments, a dental assistant will take your MST score. This is done so that we can compare your saliva after radiation to your initial amount.
Side Effects During Radiation
Every patient has a different and unique experience based on the diagnosis and amount of radiation being received. Please keep in mind, each patient may have none, all, or some of these side effects.
These are considered ACUTE side effects. Your radiation therapy will be delivered in daily fractions over several weeks. Most side effects are predictable and expected. These side effects are usually limited to the area that is being treated.
Below is a list of side effects that may occur during your radiation treatment:
- Skin redness
- Loss of tase or change in taste
- Thickened saliva
The dental clinic will book a check-up appointment to see you mid-radiation. Yes, we understand you will be sore and uncomfortable, but, we won’t be completing any treatment. This appointment will just be a check-up.
During radiation, no dental treatment will be completed. But, there are some things you can do to help with some of the acute side effects:
- Use the mucositis rinse prescribed by your oncologist
- Regular rinsing with baking soda solution
- Sometimes, you may be placed on an antifungal medication
Side Effects Post-Radiation
These are considered CHRONIC side effects. Once your radiation is completed. The dental clinic will see you 1-month post-radiation. This is another check-up to see how your mouth is healing. We understand that the healing process takes time! Do not expect that you will immediately go back to how everything was before. There will definitely be changes and every one’s healing process is different!
Below is a list of CHRONIC side effects that may occur post-radiation therapy:
- Dry mouth (xerostomia)
- Salivary flow begins to drop off after 1 week of radiation, particularly if all majory salivary glands are included in the radiation field. Xerostomia is a permanent (life-long) side effect.
- Post-radiation cavities/caries
Because of the decreased salivary flow, the acid content in your mouth is increased. Which means that cavity-producing bacteria outnumber non-cavity producing bacteria. You will now be more prone to getting cavities and this may occur in all teeth at the SAME TIME.
Clinically evident radiation caries may develop within 3 to 6 months after completion of radiation. Excellent oral hygiene and daily application of your fluoride gel will help prevent this from happening.
Avoidance of sugary foods may also be necessary to reduce caries. We understand that if you get a cavity, you may think “Well, just put a filling it”. Sometimes, it gets to a point where you can not just do a filling but have to extract/pull the tooth. This is what we, the dental team, are trying to avoid because of SIDE EFFECT #4.
ORN refers to a condition where part of the irradiated jaw bone becomes exposed and does not heal. The normal bacteria found in the mouth may secondarily infect the exposed bone and this could result in a deep bone infection.
ORN may occur spontaneously, but has also been known to happen where there is inadequate post-extraction healing prior to commencement of radiotherapy, poor or delayed healing when teeth are extracted after radiation, and nutritional factors.
Even trivial trauma, such as denture irritation may lead to the development of ORN. It is a joined effort between your dental team and your commitment to help prevent this from happening!
Taste can potentially be altered indefinitely. Recovery ranges from 1 to 6 months. Common foods that patients can be adverse to are: caffeine, alcohol, acidic and mint-flavoured items.
With a dry mouth, the papillae or taste buds on the top of the tongue may appear longer than usual. This may lead to the appearance of a “hairy tongue” that can vary in colour depending on diet. The longer taste buds have an easier time collecting bacteria and food. Tongue brushing/scraping can help reduce the bacteria and food present on your tongue. Once the taste buds have elongated, they do not return to being short again.
Limited mouth opening (trismus)
Tissues have had radiation can become less elastic over time and become scar tissue or fibrotic. This can affect the ability to open your mouth making dental care challenging. The normal range in opening is approximately 35 – 45mm. Passive mouth-movement exercises can be completed during and after radiation so that you can maintain as much jaw mobility as possible.
Dry mouth (xerostomia)
There are a lot of products that are over-the-counter that could be tried. The Biotene company makes: a mouthrinse, toothpastes, gel and spray. Oral Science has: xylimelts, chewing gum, mints, and rinses.
Carrying a bottle of water around with you and sipping water throughout the day will be the most important thing you can do to help moisturize your mouth.
Excellent oral hygiene which includes: brushing 2 to 3 times per day, flossing, using your fluoride trays, sipping water, and seeing your dentist on a regular basis will be important
Patients Receiving Bone Marrow Transplants
During the initial phases of the transplant, the patient is at risk for developing mucositis, ulcerations, hemorrhage, infections and xerostomia. The acute oral complications will start to resolve a couple months after transplant and when the hematologic status begins to improve.
What is Graft-Versus-Host Disease (GVHD)?
Patient’s receiving allogeneic bone marrow transplants or transplants from someone other than themselves are at risk for developing acute and chronic GVHD.
Some GVHD oral side effects include:
- Mucositis > inflammation of the tissue inside your mouth
- Xerostomia with secondary cavities
- Mucosal atrophy > gum thin and recede
- Oral infections > for example: candidiasis
- Immune-related complications > for example: lichenoid reactions, limited mouth opening and tongue mobility
Why is it important to see dentistry before having a bone marrow transplant (BMT)?
The goal of pre-BMT dental evaluation and treatment is to eliminate sources of infection and irritation. If dental treatment is needed, it will be scheduled in consultation with the oncologist.
Many patients will remain immunosuppressed for up to one year post-BMT and all elective dental work will be held until the patient has been deemed fit for treatment.
My First Appointment
At your first appointment, you will meet one of the dentists and assistants who will complete: your medical history, x-rays, and comprehensive dental exam
What is a comprehensive dental exam?
This is similar to a new patient exam when you are meeting a dentist for the very first time. At the dental clinic, a dentist will assess all your tissues and teeth. At this appointment, a treatment plan will be determined. The dentist will also communicate with your oncologist. Sometimes, but not always, treatment is completed at the first appointment.
Patients Prior to Chemotherapy
Do I need treatment before I start chemotherapy?
The objective prior to starting chemotherapy is to eliminate existing infection and to manage potential sources of infections.
Patients with hematologic malignancies may be or become immunosuppressed and thrombocytopenic prior to starting chemotherapy. Your dental treatment will be scheduled in consultation with your oncologist.
Patients During Chemotherapy
What if I need treatment during chemotherapy?
The most appropriate time to schedule dental treatment during chemotherapy is after your blood counts have recovered. This is usually just prior to your next scheduled round or course of chemotherapy. The majority of the time, your dentist will order blood work prior to dental treatment to confirm levels are at a level reasonable for treatment.
If you do blood work, what are you looking for in the results?
Bleeding may be a complication when your platelet count is < 50,000/mm3. Neutrophil Count
There is risk of infection when your neutrophil count is low. If you are receiving immunosuppressive chemotherapy will usually reach the lowest blood counts approximately 7 – 14 days after the start of therapy.
When your neutrophil count is extremely low but you require necessary treatment, the oncologist will be contacted and you will be provided with antibiotics.
Sometimes the combination between low clotting factors and low neutrophil count means no treatment may be rendered but when emergencies do present themselves, the dental clinic is more than happy to see you!
Normal Complete Blood Count
|Red blood cells||4.2 – 6.0 million/mm|
|Hemoglobin||12 – 18 g/dl|
|Hematocrit||36 – 52%|
|Platelets||150,000 – 450,000/mm|
|White blood cells||4,000 – 11,000/mm|
Can I still brush and floss during chemotherapy?
The ultimate answer is YES; unless, your oncologist has told you to stop. AN oral hygiene program is individualized to meet YOUR needs and is modified throughout therapy according to YOUR medical status.
I have dry mouth when I’m on chemotherapy, what do I do?
Dry mouth can be temporary as the chemotherapy can cause a decrease in salivary flow. Once chemotherapy is complete, your dry mouth will slowly start to go away. During this time, there are a couple things you can do: 1. Carry a bottle of water and sip throughout the day, 2. Biotene products – which help moisturize the mouth, 3. Oral Science products – which can help moisturize the mouth as well.
If you need help figuring out which works for you, your dentist is more than happy to discuss the options available
Patients with Multiple Myeloma
Your oncologist may have started you on a medication to help with your bones. This group of medications are bisphosphonates and most of the time it is administered in an IV form. There are two names which include: Zometa and Pamindronate. Visiting the dentist is extremely important as this medication can affect future extractions.
Bisphosphonates stop bone remodeling and turnover. This means that if teeth need to be extracted then there is a high risk that the sockets will not heal properly, leaving bone exposed and could lead to both acute and chronic infections, specifically medication-induced osteonecrosis of the jaw (MRONJ).
This is why it is imperative to see PMH dental clinic either before the start of IV bisphosphonates or at early number of doses. One of the PMH dentists will complete a comprehensive exam and have a discussion about this medication and tooth extractions, if deemed necessary. Moving forward, recommendations include: no extractions, no implants, no surgeries. Acceptable dental procedures include: fillings, cleanings, crowns and root canals.
Can I have teeth extracted if I have been on IV bisphosphonate for years?
Ultimately, the answer is no. At this stage, there is a high risk that the socket will not heal properly and will lead to medication-induced osteonecrosis of the jaw (MRONJ). If a tooth infection is present, a root canal will be the treatment option of choice before extracting the tooth
How long is the first dental appointment?
The appointment roughly takes 45 mins.
Does fluoride whiten teeth?
No, fluoride does not whiten teeth.
How long do I have to use the Fluoride trays for?
Until your dentist says otherwise, you continue to use the Fluoride trays indefinitely!
Can I still have xrays after radiation?
Yes, you should still have check-up xrays taken periodically to diagnose cavities
When can I start to see my own dentist?
You can start to see your regular dentist once you have been approved by Dr. Glogauer to return.