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.