Dental Care in Head and Neck Cancer
Many head and neck cancer patients are treated with radiation therapy. Radiation fields that include the salivary glands can cause both short and long-term damage to these glands, leading to a lack of saliva production. Saliva plays a very important role in preventing cavities and tooth decay, and in speech and swallowing. Saliva production can improve over time, but can become a long-term issue for some patients, which can have significant effects on your quality of life and dental health.
In addition, radiation can increase the risk of osteonecrosis of the jaw. This complication is an inability of the bone to heal after minor trauma. It may occur after a dental procedure (such as pulling a tooth) or present as jaw pain or an inability to open the jaw. Dental care is an important part of head and neck cancer treatment and survivorship to limit these issues and support quality of life.
Dental Management Post-treatment
By taking the proper steps to care for your mouth after radiation, you may be able to prevent or lessen some of the long-term effects associated with radiation. These side effects include xerostomia (dry mouth), tooth decay/loss, trismus (inability to open the jaw normally), osteonecrosis, and candidiasis (yeast infection). Below are suggestions for preventive care and treatment of these side effects.
- Hydration: Make sure you are drinking enough water and non-caffeinated, alcohol and sugar free fluids. Typically, eight glasses a day is recommended. Keep water handy to keep the mouth moist.
- Saliva Substitutes: There are a number of over the counter and prescription gels, lozenges and sprays that can be used in the mouth as a saliva substitute. One may work better for you than another, so you may have to try a few different products. Make sure to follow the directions on the package for proper use.
- Alcohol-free mouthwash: Alcohol can increase the dryness in your mouth. When using mouthwash, use one that is alcohol-free.
- Stimulation of the salivary glands: Chewing is the best way to simulate the flow of saliva. Chewing sugarless gum is an easy way to stimulate your salivary glands. Sucking on sugar free candies, particularly sour ones, can stimulate saliva. Acupuncture and/or massaging the masseter muscle (sideburn area) may help as well.
- Use a cool mist humidifier at night to provide humidity.
Tooth Decay (Cavities/Caries)
- Avoid food and drinks that are sweet, acidic, or carbonated.
- Rinse your mouth and brush your teeth after meals and at bedtime.
- Fluoride can be applied to the teeth in a number of ways including as a gel, in custom dental trays or as a varnish application done three times per year. You and your dentist will decide which fluoride treatment will work best for you and what your insurance coverage is for these treatments- in some cases it can be covered under medical insurance.
Trismus (Reduced Opening of the Jaw)
- Trismus is the inability to open the mouth normally. This can lead to difficulty eating, speaking and performing dental/mouth care. Trismus is caused by damage to the muscles and nerves that perform chewing or opening the jaw, which can be caused by radiation or surgery.
- Exercises to prevent trismus should start before radiation treatment and continue indefinitely. You will be taught how to perform exercises that maintain maximum opening of the jaw. These exercises should be done 3-4 times a day. How wide you can open your jaw will be measured before, during and after treatment.
- Physical therapy may use tongue depressors or devices such as TheraBite® and Dynasplint to exercise and stretch the muscles to restore mobility and flexibility.
Osteonecrosis (Bone Death)
- Prevention of osteoradionecrosis includes good oral care and removal of damaged teeth prior to starting radiation. Treatment once it occurs is difficult and the side effect itself can be very painful.
- Hyperbaric Oxygen Therapy: the patient sits in in a chamber that increases atmospheric pressure, which allows them to breathe in highly concentrated oxygen. This increases the amount of oxygen exposed to the damaged area and promotes healing. Therapy usually lasts from 1.5-2 hours per day for up to 80 sessions. You may have surgery to remove parts of the damaged bone prior to hyperbaric therapy.
Oral Candidiasis (Thrush)
- Perform proper oral hygiene, following the advice of your dentist. This is particularly a concern for patients who wear dentures.
- Antifungal medications treat the actual infection. They may also be used to prevent or treat thrush.
Dental care in the head and neck cancer patient is very complicated and may differ from patient to patient. It is important that you work with your cancer care providers and your dentist concerning your mouth care and any side effects you are experiencing. You will most likely see your dentist at least every 6 months. You may be seen more often if you are experiencing side effects. Insurance coverage varies and these treatments may be covered under dental or medical insurance, depending on the company and policy. Speak with your insurance company regarding your coverage.
Jawad H et al. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 1 and 2. British Dental Journal. 2015. V218 (2).
Murdoch-Kinch CA and Zwetchkenbaum S. Dental management of the head and neck cancer patient treated with radiation therapy.
NCCN Guidelines. Head and Neck Cancers. Version 2.2016.
Oral Cancer Foundation. Osteoradionecrosis. Found at: http://oralcancerfoundation.org/complications/osteoradionecrosis/