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«The personal and financial commitment of the following individuals and organizations was pivotal to the conference’s success: 2008 CONFERENCE ...»

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The first edition of Oral Health in Cancer Therapy: A Guide for Health Care Professionals emerged from a February

1999 consensus conference convened by the Dental Oncology Education Program cosponsored by the Texas Cancer

Council and the Oral Health Education Foundation. In February 2008 a similar consensus conference was convened

for the purpose of updating the content of the second edition of the Oral Health and Cancer Therapy monograph.

There is an acknowledged lack of evidence-based research in the prevention and management of the oral complica- tions of cancer therapy. The information contained in this edition of the monograph reflects the best evidence-based and empirical knowledge of the nationally recognized experts in the field who participated in the conference. No indi- vidual section of this edition is attributed to a single author as the content represents a truly generous, collaborative effort on the part of all the authors.

The personal and financial commitment of the following individuals and organizations was pivotal to the conference’s success:

2008 CONFERENCE CO-SPONSORS Cancer Prevention and Research Institute of Texas Baylor College of Dentistry, Texas A&M University Health Science Center University of Texas Health Science Center, San Antonio The content of this monograph is based in part on the speaker presentations and the dialogue of the conference participants.


February 21 - 22, 2008 Oral Mucositis Stephen Sonis, DMSc, DMD Bisphosphonate-Induced Osteonecrosis Michaell Huber, DDS Chemotherapy-Related Infections Douglas Peterson, DMD, PhD Xerostomia Joel Epstein, DMD, MSD IMRT Nicholas Sanfilippo, MD This document represents the compilation and distillation of the proceedings of the 2008 Oral Health in Cancer Therapy Conference. It is a product of the editorial board, and as such does not necessarily represent the opinion of any individual speaker, conference participant, institution, or sponsoring organization. Product references by brand should not be construed as endorsement nor should the lack of inclusion of a specific brand be interpreted negatively. The scientific literature on the defini- tive management of oral complications of cancer therapy is in many instances equivocal, and occasionally controversial.

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We are indebted to the speakers, authors and conference participants without whom the third edition would not have been possible. No individual section of this edition is attributed to a single author as the content represents a truly generous, collaborative effort on the part of all the authors.

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Stephen T. Sonis, DMSc, DMD Brigham and Women's Hospital Department of Oral Medicine and Diagnostic Sciences Boston, MA Maribeth Stitt Kingwood College Dental Hygiene Program Director Kingwood, TX Ruth Tornwall, RDH Lamar Institute of Technology Department of Dental Hygiene Beaumont, TX Bela Toth, DDS, MS UT, MD Anderson Cancer Center Department of Head and Neck Surgery Houston, TX Pam Wade, RDH, MS, CFCS Tyler Junior College Department of Dental Hygiene Tyler, TX Robert V. Walker, DDS University of Texas Medical Center Southwestern Medical School Department of Oral and Maxillofacial Surgery Dallas, TX Donna Warren, RDH, MEd University of Texas, Dental Branch, Houston Department of Dental Hygiene Houston, TX Steven Westbrook, DMD University of Texas Health Science Center Department of Dental Diagnostic Science San Antonio, TX G. Wright, DDS Austin Community College Department of Dental Hygiene Eastview Campus Austin, TX


HEAD AND NECK RADiATioN introduction

Figure 1: Axial view of radiation therapy for an oropharyngeal squamous cell carcinoma.............. 1 side effects of head and neck radiation

oral management

Figure 2: Radiation fields for the most common head and tumor locations.

Table 1: Mouthrinses

Table 2: Anti-fungals

combined radiation and chemotherapy



Table 3 Gums and Mints

Table 4 Mouth-wetting agents

Table 5 Rx Sialogogues

Table 6 Rx Chlorhexidine Mouthrinses - 0.12% Chlorhexidine Gluconate, 11.6% Alcohol............ 14 Table 7 Fluoride Varnishes - 5% Sodium Fluoride - 22.6 mg/ml F, 22,600 ppm F

Table 8 Fluoride Gels - 1.1% Sodium Fluoride, 5000 ppm, pH 7.0

Table 9 Fluoride Toothpastes - 1.1% Sodium Fluoride, 5000 ppm, pH 7.0

Table 10 Fluoride Mouthrinses

Table 11 Remineralizing Products

Table 12 Antifungal Products

bacterial sialadenitis


Table 13 Supportive Measures for Chemotherapy Patients Undergoing Invasive Dental Procedures. 26 Table 14 Mouth Rinses

Table 15 Medications for HSV Infection Associated with Chemotherapy Mucositis


bisphosphonate-related osteonecrosis of the jaw (bronj)

Table 16 Staging


Table 17 Recommended Therapies




types of donors for hsct


Table 18 Therapies for Intra-oral Chronic GVHD


pain management for mucositis: general principles

stepped oral mucositis pain management model

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Table 20 Foundations of Care

oral mucositis pain control model

level 1: foundations of care

levels 2-4: mild to severe oral mucositis pain and oral dysfunction

Table 21 Topical Anesthetics for Management of Mucositis Pain

pharmacologic pain control

Table 22 Non-Steroidal Anti-Inflammatory Drugs

Table 23 Oral Mucositis Pain Control: Level III and IV

Table 24 Adjuvant Drugs

special considerations: elderly patients

special considerations: pediatric patients






BACKGROUND At the time of a cancer diagnosis, the patient and family are overwhelmed with information, treatment options and decisions that must be made with all due speed. Coupled with the emotional impact of a cancer diagnosis, these factors converge to create one of the most difficult physical and emotional periods of life. Coordination by a comprehensive oncology “team” can significantly reduce the emotional toll and contribute to successful treatment outcomes. Pre-treatment oral assessment and supportive oral care during and after cancer therapy can increase quality of life and decrease higher treatment and supportive care costs.

Cancer treatment is no longer exclusively delivered in large cancer centers staffed by a multidisciplinary team. Furthermore, therapeutic modalities are no longer considered in isolation, nor are the oral complications. Clinicians across the spectrum of healthcare in the community must by necessity become the patient’s treatment team. Compromised oral health prior to, during and following cancer therapy dramatically affects treatment outcomes and quality of life. The intent of this monograph is to provide the most current, practical clinical information and guidance to the practitioner to assist in providing patients and their families with appropriate services and advice prior to, during and following cancer therapy. The clinical orientation is evidenced by the organization of sections by treatment modality and the stage of cancer therapy (pre-therapy, during therapy and post-therapy).

intent of the monograph The intent of this monograph is to provide current, practical clinical information and guidance to the practitioner outside the major cancer treatment center to assist in providing their patient family with appropriate advice as they progress through therapy at a distant site or the information to provide a continuum of oral health care in preparation for cancer therapy, during therapy and after therapy.

organization of the monograph Treatment modalities are addressed in individual sections, while the concept of care appropriate to the stage of cancer treatment is preserved within sections. Because many of the oral complications manifest across treatment modalities, specifically management of hyposalivation and pain, these are addressed in detail in individual sections and referenced as appropriate within the treatment modality sections.

A number of factors, including but not limited to growth and development, preclude addressing cancer therapy and oral health in children in the context of this monograph. The most recent position paper issued by the American Academy of Pediatric Dentistry is reprinted here with the permission of the Academy.

dedication This monograph is dedicated to all the men and women working in the field of oncology who have committed themselves to the tireless tasks, frustrations and rewards of helping individuals meet the challenges of cancer.

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Radiation therapy is routinely used for tumors of the head and neck. It may be used in the primary setting as the sole treatment or after surgery as adjuvant therapy. It may be given by itself or with chemotherapy. Recently, immunotherapy has emerged as an adjunct to radiation therapy. Cetuximab, or epidermal growth factor inhibitor, has been shown to improve cure rates for oral cancer when given with radiation therapy.

Generally radiation therapy is given once a day five days per week. The radiation schedule is termed “fractionation” and standard fractionation refers to treatment once a day Monday through Friday. Other schedules have been used to intensify treatment for more advanced tumors and this is called accelerated fractionation or in some instances hyperfractionation. Oral complications are related to the site radiated, the total radiation dose, the fractionation schedule and integration with other cancer therapies such as chemotherapy. Most tumors of the head and neck region are squamous cell carcinoma, which require relatively high doses of radiation for local tumor control. Typically 50 Gray (Gy) of radiation, which corresponds to a five week course, is needed for microscopic disease control and 70 Gy is needed for gross tumor control. Chemotherapy must also be used to control locally advanced tumors. Most radiation for head and neck tumors is given externally, where the patient lies on a table and the machine spins on an axis to deposit radiation from different directions.

Prior to approximately 1995, radiation was often given using opposed lateral portals, meaning that all the tissue between the portals received the same dose. In figure 1a this is represented as a constant shade of gray throughout the exposed area.

Over the last 10-15 years, most centers have adopted what is called intensity modulated radiation therapy (IMRT). With this method, the radiation beam is not static and the blocks in its way are constantly moving so radiation can be deposited in a specific pattern. Planning for IMRT involves a team of physicians, physicists and dosimetrists. An IMRT treatment plan for oropharyngeal carcinoma is shown in Figure 1b where higher radiation doses are represented by the darker shading and lower doses are represented by progressively lighter shading. As illustrated, the high dose or “hot spot”, represented by the darkest shading, can be localized in the tumor and surrounding tissues are preferentially spared. In this case the darkest tumor area would receive approximately 70 Gy and the lightest area of the anterior mandible would receive only 25 Gy. Perhaps the greatest contribution of IMRT is sparing of the parotid glands. Numerous authors have shown that if the mean dose to the parotid can be limited to 24-26 Gy, reasonable salivary flow can be maintained. Of course, there is still some collateral irradiation to other tissues and while high doses to normal oral mucosa or mandible, for example, can be avoided, low doses to a larger volume often occur, and the clinical significance of this is still uncertain. This dose gradient, however, is critical when performing dental evaluations on patients who have received IMRT, since the dose to certain regions of the mandible will differ, as is evident in Figure 1b. The radiation oncologist should furnish dental specialists with the actual isodose plan so that they can determine exactly what dose was received when making post-radiation management decisions. Unfortunately, this information is not available to the dentist before radiation is given, so it cannot be used for pre-radiation decisions.

Figure 1: Axial view of radiation therapy for an oropharyngeal squamous cell carcinoma.

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side effects of head and neck radiation Radiation side effects occur in two categories with respect to time. Acute effects are those occurring during treatment or shortly afterwards. Late effects may occur months or even years after therapy.

Mucositis Mucositis is an acute effect with a complicated pathogenesis resulting in early cell death in the epithelial basement membrane.

Clinically, mucositis typically begins in the second week of radiation therapy and subsides slowly several weeks after radiation therapy is complete. Mucosa in the radiation field often becomes atrophic and prone to ulceration. Patients with mucositis are at increased risk of infection and should exercise good oral hygiene.

Hypogeusia/Dysgeusia Permanent taste loss may occur at a dose of 60 Gy if the tongue is largely within the high dose volume. Below this level, recovery usually takes several months. Both mucositis and decreased saliva flow may contribute to taste alteration. Chemoreceptors on the dorsal tongue that allow discriminative taste acuity can be markedly affected by mucosal ulceration that can last months to years.

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