Dental Care
All dental care was suspended by the Pennsylvania Health Department on
March 22nd, even for emergencies. This directive was
amended to allow only emergency care on March 26th,
contingent on the dental provider wearing personal protective equipment.
This has resulted in a lack of access to dental care in HNC patients,
including those who must undergo radiation treatment. We have been able
to use panorex and relay information about nonviable dentition so they
can be removed at the time of surgery.
Dental medicine’s inclusion in the multidisciplinary approach to
managing morbidity and mortality of surgical and adjuvant therapies for
HNC patients has proven to be a major contributor to enhanced outcomes.
Dentists provide care and counsel in many critical ways. Primarily, all
patients should undergo a pre-surgical evaluation of the dentition,
including full mouth radiographs, dental and periodontal diagnosis, and
prognosis for each tooth. Teeth that cannot be salvaged with
conservative restorative or endodontic therapy should be planned for
extraction. Radiation therapy to the head and neck can increase the risk
for osteoradionecrosis (ORN) of the jaw. Pre-treatment extractions
greatly reduce this risk. Additionally, this pre-treatment evaluation
offers the surgical, reconstructive, and maxillofacial prosthetics team
the opportunity to plan reconstruction together, affecting better
outcomes of care.
Additionally, the dental evaluation is critical to assessing the
patient’s motivation and compliance based upon discussions with the
patient and his or her family. Patient education regarding the need for
meticulous personal oral hygiene and three-month follow-up dental
cleanings and exams must be stressed. This evaluation appointment allows
the dentist to give patients proper expectations for treatment burdens
as well as offer support and homecare tips that make side effects more
manageable.
To start the path to better outcomes, the dentist should perform
prophylaxis, periodontal scaling, simple caries control, and fabrication
of fluoride trays. To prevent radiation caries, patients should begin
daily fluoride treatment with 1% neutral sodium fluoride gel in
prefabricated trays for five minutes each day and be prescribed
prescription-strength fluoride toothpaste. The use of fluoride trays
usually continues for life, or until a stable neutral oral pH is
achieved.
Since pandemic protocols have caused most non-emergent dental procedures
to be delayed indefinitely, this pre-treatment regimen has been almost
completely put on hold. The Centers of Disease Control and Prevention
and the American Dental Association, as well as almost all state and
local health departments, have adopted severe pain and acute infection
treatment only mandates. For HNC patients, this means reducing the
above-outlined interventions to telehealth counseling and support
regarding home care and managing treatment side effects. The use of
prescription-strength toothpaste can and should be implemented for these
patients.
The area of most concern is the inability, based on the current state
and local restrictions, to perform a complete clinical evaluation of
each patient. Radiographic examination is still possible and is being
used to diagnose acute infection that will be addressed within current
guidelines as well as to coordinate possible extraction of non-infected
yet non-restorable teeth at the time of tumor resection. The
pre-treatment planning between the surgeons resecting and reconstructing
with the maxillofacial prosthodontist who will design restorative
appliances can occur as best as possible in this manner as well.
Ideally, extractions should be performed three weeks prior to beginning
radiation therapy, and extraction of teeth during radiation therapy
should be discouraged and delayed until the completion of treatment with
resolution of
the oral
mucositis. A window of one to four months post-radiation where the risk
of ORN is low is still available to the dentist and patient. At this
time, we are maintaining contact with patients who we believe will need
extractions. We hope that pandemic protocols will be lifted within this
post-treatment window.
Regarding initial hygiene appointments, fabrication of fluoride gel
trays, and rigorous three-month recalls, at this time, we are providing
patients with telehealth check-ins. We will resume aggressive hygiene as
soon as pandemic protocols are lifted.