Int. 3. Radiation
Oncol~
Biel. Phys.,
1976, Vol. 1, pp. 859-865.
Pergamon
hss.
Printal
in tk
U.S.A.
TECHNIQUES AND RESULTS OF A COMPREHENSIVE DENTAL CARE PROGRAM IN HEAD AND NECK CANCER PATIENTSt HENRY
M. KEYS, M.D.* and JOHN P. MCCASLAND, D.D.S.0 Walter Reed Army Medical Center, Washington, DC 20012, U.S.A.
Since 1969, alI patients witb cancer of the head and neck at Waker Reed Amy Medical Center have been enrolkd in a comprehensive program of dentaf evaluation and care. Thii program consists of three phases: Phase I-These cuagnostk and treatment procedures carried out prior to treatment for the prhnary disease; Phase II- Adjunctive and supportive procedures during and hmnediate.fy after primary treatmenti and Phase III-Al1 subsequent defìnitive dentaf and prosthetk care rendered along with the essenti periodic follow-up examinations. Comparison of the 172 pat&& entered in the program with the last 74 patients treated before instftution of the program reveals that the treatment group had fewer extractions, fewer clhdc visits, 75% fewer caries. Oniy 1 patient developed osteoradionecrosis and improved tolerante to treatment. Radiation
caries, Head and neuk cancer.
INTRODUCTION The deleterious eff ects of radiation therapy on dental condition have long been known. There was a period of time when prevention of these effects was attempted by whole mouth extraction, or at least extraction of teeth within the field of irradiation. The emphasis of this type of program in previous decades was to prevent the development of osteoradionecrosis of the mandible, felt to be the most serious problem developing from the use of radiation therapy in the oral cavity area. The development of radiation induced dental caries is a second problem, and the rapid onset and progression of such caries formation gave further impetus to the desire to extract teeth prior to the institution of radiation therapy. However, osteoradionecrosis still occurred in patients with whole mouth extraction prior to treatment and a sizable proportion of patients were unable to successfully use whole mouth
dentures after their course of radiation therapy. In the light of the experience in the past decade or more at several institutions, the practice of routine whole mouth extraction seems unwarranted. Several observations increased enthusiasm for establishing a new dental program for head and neck cancer patients. First, the prosthetic treatment of edentulous cancer patients was successful in only about half of the patients despite the considerable care given to this task by the prosthodontic services. Second, a sizable number of post radiation dental extractions had been performed without significant sequelae. Third, a randomized trial at M.D. Anderson Hospital was demonstrating the efficacy of the fluoride treatment in preventing radiation caries.’ Recognizing the role which an active dental program could play in the management of
tpresented in part at the American Society of Therapeutic Radiologists’ Armual Meeting, 8-12 October 1975, San Francisco, Califomia. SFormerly Chief, Radiation Therapy Service, Walter Reed Army Medical Center. Present address: Division of Radiation Oncology, Strong Memorial Hospital, University of Rochester Cancer Center, 601 Ehnwood Avenue, Rochester, NY 14642, U.S.A.
§Chief, Removable Prosthedontic Service, Dental Department. Reprint requests to: Henry M. Keys, M.D. at his present address. Acknowledgements-These fine results are a tribute to the skill and dedication of the dental specialists involved, and to the committment to the program made by the Department of Dentistry and by Walter Reed Army Medical Center. 859
860
Radiation Oncology ?? Biology 0 Physics
September-October
head and neck cancer patients, a comprehensive program of dental management was organized in 1%9 at Walter Reed Army Medical Center (WRAMC). The objectives of the program were: To reduce the incidence of radiation caries. To preserve as many useful teeth as possible for optimal dental function and avoid creating edentulous arches for which prosthodontic alternatives are limited. To prevent significant osteoradionecrosis. To provide a mechanism for continuing maintenance of optimal dental health during and after cancer therapy. Conceptually, the program can be divided into three phases: Phase 1 consists of those diagnostic and treatment procedures carried out prior to institution of medical treatment for the primary disease. Phase 11 consists of adjunctive and supportive procedures which are carried out during, and imrnediately following prirnary treatment of the tumor. They are performed by an Oral Hygienist, in conjunction with whatever dental specialty care is required. Phase 111 consists of all subsequent definitive dental and prosthetic care rendered along with the essential periodic follow-up examinations.
1976, Vol. 1, Number 9 and Number 10
METHODS AND MATERIALS Patient material From 1969 to 1974, 172 patients with cancer of the head and neck were entered into this program; 115 received irradiation as part of al1 of their treatment while the remaining 57 were treated only by surgery. The only patients excluded were those with early laryngeal carcinoma. These 172 patients are compared to the last 74 patients treated with radiation prior to the institution of this program (Table 1). The records of all 246 patients were carefully reviewed. The treatment policy, the treatment techniques, and dose levels remained fairly constant during the time interval under study. A 4 MV accelerator was added to the Cobalt teletherapy unit in 1971 and the head and neck cancer patients were treated almost interchangeably on the two units, thereafter.
Methods Phase 1. All patients were referred to the Dental Department prior to treatment and a careful clinical and radiographic examination was performed by trained specialists in oral endodontics, periodontal, oral diagnosis, surgery, fixed prosthodontics and removable prosthodontics. Joint treatment planning conferences were held to explore all dental problems in depth. The location, size and
Table 1. Head and neck cancer: patients’ dental status (Waker Reed Army Medical Center) Number of patients (%) Whole mouth extractions No. % Radiation before 1970
Edentulous No. %
Dentulous % No.
Total No. %
21
28
16
22
37
50
74 100
Radiation 1970-74
5
4
25
22
85
74
115 100
Surgery 1%9-74
0
0
12
21
45
79
57 100 246
Dental care program in head and neck patients 0 H.M. KEYS and J.P. MCCASLAND
histopathology of the tumor were considered, as well as the anticipated mode of therapy. After al1 the altematives were considered, a treatment plan was developed to combine predictability of results with the lowest possible risk. A maximum of 14 days was allowed for the completion of the recommended treatment procedures so that initiation of radiation therapy was not delayed unduly. Sequelae that could require long term management were anticipated and plans made to treat or avoid them without reducing rehabilitation alternatives. The treatment was presented to the medical team responsible for cancer management for approval. This plan consisted of al1 therapeutic and restorative procedures required and and preprosthetic included extractions surgery , periodontal therapy, endodontic therapy, dental restorations and removable prostheses when necessary. A most important step is the institution of a preventative dentistry program. Patients who are judged unwilling or unable to follow the prescribed preventative measures should not be considered for retention of teeth. The details of management have been presented elsewhere.’ Essentially, Phase 1 consists of evaluation followed by a caries control program (Table 2). This program emphasizes the establishment of an oral and dental environment that is easily maintained by the patient along with education of the patient in his responsibilities in the control of radiation caries and periodontal disease. A follow up mechanism for reinforcement of home care responsibility and the timely recognition of deteriorating dental conditions requiring early intervention was built into the third phase of the overall program. Base 11. Phase 11 dental management Table 2. Caries control program 1. 11.
111. IV. V.
Control active caries (restorations) Control of dental placque A. Thorough dental prophylaxis B. Oral hygiene instructions C. Follow up reinforcement Daily application of stannous fluoride gel Dietary counseling Extractions
861
consists of adjunctive and supportive procedures carried out during radiation therapy. This involves maintaining a high degree of oral hygiene and monitoring the effect of prostheses on the soft tissues. Surgical and radiation patients were followed by an Oral Hygienist who assisted in the maintenance of oral hygiene on the ward. The oral hygiene program was designed to decrease the quantity of oral microflora, which could decrease the severity of mucositis in the irradiated patient. Exercises to prevent trismus and deviation were prescribed. Temporary obturators may be fabricated during this phase; immediate obturators and extraoral prostheses were modified as the healing process occurred. Phuse 111. Phase 111 management consists of al1 subsequent definitive dental and prosthetic care rendered. Any procedures deferred during Phase 1 were carried out at this time. Periodic examinations permitted early recognition of caries, periodontal disease, pulpal disease and traumatic occlusion. Caries were managed either by an attempt at remineralization with stannous fluoride gel or by restorations; fixed partial dentures are preferable to removable partial dentures. Progressive peridontal disease was uncommon among our patients. Pulpal disease can be managed by root canal therapy or extraction (Table 3). Early intervention is emphasized to avoid acute periapical abscess. Non-restorable caries does occur and extractions are best carried out before acute periapical abscess develops. Clinical experience has taught US that the longer we can delay oral surgical procedures after radiation the more efficient is the healing process. With careful and meticulous surgical technique, attention to adequate alveoplasty, generous wound irrigation, watertight soft tissue closure, and proper antibiotic coverage, we have had no significant complications following surgical removal of teeth and alveoplasties in irradiated patients. Smal1 areas of exposed bone occurred more often in patients who required pre-radiation extractions. They were best treated conservatively by maintaining excellent oral hygiene. Spicules of bone were removed gently when loosened during the
862
Radiation Oncology 0 Biology 0 Physics Table 3. Dental management
September-October 1976, Vol. 1, Number 9 and Number
program Phase 111-Post sive care Radiation before 1970
Teeth at risk Extractions
twithout
significant
Radiation 197&74
Surgery 1%9-74
56.5
1489
843
36t
1t
(in 6 patients) 153 10 5 48
7 2 0 18
complications.
healing process. Copious irrigation with normal saline was helpful. Presently, we are testing an intermittent pressure water lavage device that seems promising in maintaining oral cleanliness. This device also is being used to control candidiasis in lieu of antifungal agents. RESULTS When the protocol group was compared to the patients who were treated prior to 1970, al1 aspects of dental condition were improved. Table 1 represents the patient population in terms of dental status and treatment. During the protocol period, only 6% of the patients to be irradiated had whole mouth extractions, compared to 36% before 1970. Table 2 shows that while the average number of teeth per patient was similar (21 and 19, respectively), only 22% of the protocol
100
comprehen-
79t
(in 13 patients) 183 10 1 54
Restorations Endodontics Fixed partial dentures Removable prostheses
treatment
patient’s teeth was extracted VS 4% prior to 1970, The salvage is greater in the surgeryonly group. Despite retaining a great many more teeth, the caries incidence was signifìcantly lower (12% VS 46%) in the protocol group (Fig. 1). Some improvement was seen in all groups when patients were divided according to treatment technique as seen in Fig. 2. The surgical salvage and external plus implant groups represent small numbers of teeth. Figure 3 shows the comparative caries incidence as a function of time after treatment for the protocol and non-protocol groups. Of interest is the late rise in caries, indicating the necessity for long term follow up and lifelong attention to oral health in the post irradiated patient. Through careful follow up, the best possible dental condition was maintained, and recog-
RESULTS OF DENTAL MANAGEMENT PROGRAM IN IRRADIATED PATIENTS (WRAMC)
75
0
10
TEETH SAVED
TEETH RESTORATIONS CARIES EDENTULOUS INCIDENCE ARCHES* EXTRACTED POST R, POST R,
Fig. 1. Comparison of dental management and results in irradiated patients prior to instituting comprehensive dental programs (before 1970) and after its institution (1970-74). *Refers to per cent of edentulous arches successfully treated.
Dentalcare programin headand neck patients 0 H.M. KEYS and J.P. MCCASLAND CARIES INCIDENCE (WRAMC) 175
1
IN IRRADIATED
PATIENTS’
'CARIESINCIDENCE.~~~.lM)
%
Fig. 2. Comparison of incidence of dental caries in “control groups” (before 1970) and study groups (1970-74) as a function of method of treatment. Surgical salvage refers to previously irradiated patients operated for recurrence. Preoperative radiation therapy refers to planned preoperative irradiation followed by surgery. CARIES INCIDENCE
VI TIME AFTER TREATMENT (WRAMC) Q
151
u
12
3
4
5
6
>8
863
responsible for the deleterious dental effects of oral radiation has been widely appreciated. The program presented here is one of several attempts to deal with the dental condition of those patients who are treated for malignant disease of the head and neck area. A schema of the pathophysiological mechanisms that lead to dental problems following such a treatment is presented in Fig. 4. The results of our program clearly demonstrate the superior dental condition achieved by our patients compared with results for patients who were given the same irradiation prior to the dental management program. Unfortunately, hard data on the influence of Phase 11 are not available. Aside from the dental concept of the importante of adequate prophylaxis and training in the self care in these patients, it was the impression of a number of the medical team that patients receiving regular dental hygienic care had less severe mucositis, less oral moniliasis, less discomfort and less weight loss during treatment. This may result, in part, from a pulsating water debridemebt and cleansing technique; a more scientific study of this technique is currently underway. Osteoradionecrosis of the mandible is a predictable complication after radiation therapy to head and neck cancer patients. However, the frequency with which this complication is reported varies considerably, probably partly due to treatment techniques,
YEARS AFTER TREATMENT Radiotian
Fig. 3. Comparison of temporal incidence of dental caries after irradiation in the “control groups” (before 1970) and protocol groups (1970-74).
I ,Xerasromio Hlghcr carbhydr&
nized problems
were managed early. Table 3 shows the post radiation dental treatment in the non-protocol and protocol groups. Significantly fewer extractions and restorations were required in the 1970-74 group, despite retention of many more marginal teeth. Overall, considerably less post irradiation dental care is required. Only 1 patient developed osteoradionecrosis. DISCUSSION
The recognition
that irradiating
tions of the salivary
major por-
gland tissue is largely
theropy
dlet
A
\
Lawcr ,I,,
’\
Bacterial @agi on teeth
pH-
aries
111
Periiontol ,disease
1 Fulpal Periopical
disease (
infection
/
(abrctr) Osteamdianscrask
Fig. 4. Proposed mechanism for the interaction of radiation and oral cavity-dental processes leading to pathology of radiation injury.
864
Radiation Oncology 0 Biology 0 Physics
September-October
extensiveness of tumors, patient selection and dental condition. In the study of dental condition of head and neck patients conducted at the M.D. Anderson Hospital,’ there were 304 patients evaluated over a 6.5 year period from 1%6 to 1972. These patients, among other parameters, had their incidence and apparent cause of necrosis studied. Sixty-seven of the 304 patients or 22% had a total of 74 episodes of necrosis. This may be considered on the high side, as even very minor episodes of necrosis are included, but provides a basis for comparison with our own results. Osteoradionecrosis of the mandible of significant extent has never been a common occurrence at Walter Reed Army Medical Center. Only 13 patients demonstrated this complication during the interval from 1950 to 1970 by historical review. We have had only one case in the 115 patients treated in the current program over a 5 year period. It is conceivable that additional cases may develop in the future among the same patient population but the early indication is that the incidence is going to be much lower than that noted above. The program of pretreatment preparation (restoration, endodontics, selective extraction, etc.) required considerable increased effort to care adequately for the protocol group, as shown in Table 4. However, the overall tost-benefit analysis is much more complicated. At apparently tremendous tost in time, effort and money, patients were given the finest dental care available anywhere; the net result was significant improvement in dental status, reduction in an already rare complication, and probably no change in survival. In a civilian institution, the total tost Table 4. Dental management Teeth at risk
Radiation before 1970 Radiation 1970-74 Surgery 1%9-74
1976, Vol. 1, Number 9 and Number 10
of such a program could be estimated fairly accurately from the charges for the care given. In a military hospital, it is more difficult to measure the expense involved. However, one simple analysis is of interest (Table 5). The dental clinic visits (in-patient and out-patient) were totaled for each irradiated series, and the surprising result is that the patients managed under the comprehensive program, on the average, had six fewer dental visits than those treated as their condition demanded. A second analysis is presented in Table 6. Here, the total dental procedures for the study and control groups are presented and compared as percentages of the total teeth present prior to therapy. It is obvious that considerably more pretreatment restorations were done in the protocol group, but that this was offset by the excessive extractions and more frequent posttreatment dental problems in the control series. On the benefit side of the ledger is the fact that the patients managed under the protocol Table 5. Total dental clinic visits in irradiated patients (Walter Reed Army Medical Center) 74 patients before 1970 Pretreatment
visits
Posttreatment
Endodontics
918 (8.O)t
1014 (13.7)t
Total visits
program Phase I-Pretreatment
Restorations
693 (9.4)?
visits
*Average number
115 patients 197&74
1707 (23.l)t
1075 (9.3)t
1993 (17.3)t
of visits per patient. preparation Fixed partial restorations
565
7
0
0
1489
358
10
0
843
30
3
2
Dental care program in head and neck patients 0 H.M. KEYS and J.P. MCCASLAND
Table 6. Comparison of dental effort devoted to protocol (1970-74) and non-protocol patients ( < 1970)
Total teeth Extraction Restoration Extraction Restoration Othert Total TProstheses,
Before 1970
1970-74
1113 548 (4%) 7 (1%) Radiation therapy 79 (7%) 183 (16%) 65 (6%)
1915 426 (22%) 3.58 (10%)
882 (79%) endodontics,
36 (2%) 153 (8%) 73 (4%) 1046 (55%)
etc.
dental comprogram had fewer posttreatment plications, required less dental intervention, had improved natural and restored and prosthetic dental status, and hence were less bothered by the deleterious effects of radiation therapy to the head and neck area. Such treatment results have broad implications to other groups of patients whose irradiation unavoidably exposes the salivary gland apparatus to significant radiation doses; recently, we have included all such patients in the comprehensive dental program.
865
CONCLUSIONS 1. A comprehensive dental program for head and neck patients is feasible at a large medical center, but requires the coordinated efforts of a broad range of interested dental specialists. 2. The program has been successful in its major objectives by reducing the incidence of radiation caries, preserving more teeth, having fewer edentulous patients and improving speech, deglutition, mastication and cosmesis. 3. Significant osteoradionecrosis essentially has been prevented. 4. Postirradiation extractions can be performed with care as necessary without significant sequelae. 5. The patient education part of the program has resulted in better understanding of oral health problems, prevention of progressive periodontal disease; along with periodic follow up this has resulted in earlier recognition of dental disease, thus decreasing the loss of teeth after treatment. 6. Significant improvement in dental management also was obtained for patients who were treated surgically. 7. The overall tost appears reasonable as judged by decrease in the average number of clinic visits per patient.
REFERENCES Daley, T.E., Diane, J.B.: Managerneut of Dental Problems in hadiated
Patients.
The University
of Texas at Houston, M.D. Anderson Hospita1 and Tumor Institute, Houston, Texas, 1972, pp. 1-43. McCasland. J.P.: Dental considerations in head
and neck patients: Management of dental and jaw problems. In Proceedings of the International Symposium
Weck, Montreux, press.
on Cancer of the Head and
Switzerland,
2-4 April 1975, in
Oncol~
Biel. Phys.,
1976, Vol. 1, pp. 859-865.
Pergamon
hss.
Printal
in tk
U.S.A.
TECHNIQUES AND RESULTS OF A COMPREHENSIVE DENTAL CARE PROGRAM IN HEAD AND NECK CANCER PATIENTSt HENRY
M. KEYS, M.D.* and JOHN P. MCCASLAND, D.D.S.0 Walter Reed Army Medical Center, Washington, DC 20012, U.S.A.
Since 1969, alI patients witb cancer of the head and neck at Waker Reed Amy Medical Center have been enrolkd in a comprehensive program of dentaf evaluation and care. Thii program consists of three phases: Phase I-These cuagnostk and treatment procedures carried out prior to treatment for the prhnary disease; Phase II- Adjunctive and supportive procedures during and hmnediate.fy after primary treatmenti and Phase III-Al1 subsequent defìnitive dentaf and prosthetk care rendered along with the essenti periodic follow-up examinations. Comparison of the 172 pat&& entered in the program with the last 74 patients treated before instftution of the program reveals that the treatment group had fewer extractions, fewer clhdc visits, 75% fewer caries. Oniy 1 patient developed osteoradionecrosis and improved tolerante to treatment. Radiation
caries, Head and neuk cancer.
INTRODUCTION The deleterious eff ects of radiation therapy on dental condition have long been known. There was a period of time when prevention of these effects was attempted by whole mouth extraction, or at least extraction of teeth within the field of irradiation. The emphasis of this type of program in previous decades was to prevent the development of osteoradionecrosis of the mandible, felt to be the most serious problem developing from the use of radiation therapy in the oral cavity area. The development of radiation induced dental caries is a second problem, and the rapid onset and progression of such caries formation gave further impetus to the desire to extract teeth prior to the institution of radiation therapy. However, osteoradionecrosis still occurred in patients with whole mouth extraction prior to treatment and a sizable proportion of patients were unable to successfully use whole mouth
dentures after their course of radiation therapy. In the light of the experience in the past decade or more at several institutions, the practice of routine whole mouth extraction seems unwarranted. Several observations increased enthusiasm for establishing a new dental program for head and neck cancer patients. First, the prosthetic treatment of edentulous cancer patients was successful in only about half of the patients despite the considerable care given to this task by the prosthodontic services. Second, a sizable number of post radiation dental extractions had been performed without significant sequelae. Third, a randomized trial at M.D. Anderson Hospital was demonstrating the efficacy of the fluoride treatment in preventing radiation caries.’ Recognizing the role which an active dental program could play in the management of
tpresented in part at the American Society of Therapeutic Radiologists’ Armual Meeting, 8-12 October 1975, San Francisco, Califomia. SFormerly Chief, Radiation Therapy Service, Walter Reed Army Medical Center. Present address: Division of Radiation Oncology, Strong Memorial Hospital, University of Rochester Cancer Center, 601 Ehnwood Avenue, Rochester, NY 14642, U.S.A.
§Chief, Removable Prosthedontic Service, Dental Department. Reprint requests to: Henry M. Keys, M.D. at his present address. Acknowledgements-These fine results are a tribute to the skill and dedication of the dental specialists involved, and to the committment to the program made by the Department of Dentistry and by Walter Reed Army Medical Center. 859
860
Radiation Oncology ?? Biology 0 Physics
September-October
head and neck cancer patients, a comprehensive program of dental management was organized in 1%9 at Walter Reed Army Medical Center (WRAMC). The objectives of the program were: To reduce the incidence of radiation caries. To preserve as many useful teeth as possible for optimal dental function and avoid creating edentulous arches for which prosthodontic alternatives are limited. To prevent significant osteoradionecrosis. To provide a mechanism for continuing maintenance of optimal dental health during and after cancer therapy. Conceptually, the program can be divided into three phases: Phase 1 consists of those diagnostic and treatment procedures carried out prior to institution of medical treatment for the primary disease. Phase 11 consists of adjunctive and supportive procedures which are carried out during, and imrnediately following prirnary treatment of the tumor. They are performed by an Oral Hygienist, in conjunction with whatever dental specialty care is required. Phase 111 consists of all subsequent definitive dental and prosthetic care rendered along with the essential periodic follow-up examinations.
1976, Vol. 1, Number 9 and Number 10
METHODS AND MATERIALS Patient material From 1969 to 1974, 172 patients with cancer of the head and neck were entered into this program; 115 received irradiation as part of al1 of their treatment while the remaining 57 were treated only by surgery. The only patients excluded were those with early laryngeal carcinoma. These 172 patients are compared to the last 74 patients treated with radiation prior to the institution of this program (Table 1). The records of all 246 patients were carefully reviewed. The treatment policy, the treatment techniques, and dose levels remained fairly constant during the time interval under study. A 4 MV accelerator was added to the Cobalt teletherapy unit in 1971 and the head and neck cancer patients were treated almost interchangeably on the two units, thereafter.
Methods Phase 1. All patients were referred to the Dental Department prior to treatment and a careful clinical and radiographic examination was performed by trained specialists in oral endodontics, periodontal, oral diagnosis, surgery, fixed prosthodontics and removable prosthodontics. Joint treatment planning conferences were held to explore all dental problems in depth. The location, size and
Table 1. Head and neck cancer: patients’ dental status (Waker Reed Army Medical Center) Number of patients (%) Whole mouth extractions No. % Radiation before 1970
Edentulous No. %
Dentulous % No.
Total No. %
21
28
16
22
37
50
74 100
Radiation 1970-74
5
4
25
22
85
74
115 100
Surgery 1%9-74
0
0
12
21
45
79
57 100 246
Dental care program in head and neck patients 0 H.M. KEYS and J.P. MCCASLAND
histopathology of the tumor were considered, as well as the anticipated mode of therapy. After al1 the altematives were considered, a treatment plan was developed to combine predictability of results with the lowest possible risk. A maximum of 14 days was allowed for the completion of the recommended treatment procedures so that initiation of radiation therapy was not delayed unduly. Sequelae that could require long term management were anticipated and plans made to treat or avoid them without reducing rehabilitation alternatives. The treatment was presented to the medical team responsible for cancer management for approval. This plan consisted of al1 therapeutic and restorative procedures required and and preprosthetic included extractions surgery , periodontal therapy, endodontic therapy, dental restorations and removable prostheses when necessary. A most important step is the institution of a preventative dentistry program. Patients who are judged unwilling or unable to follow the prescribed preventative measures should not be considered for retention of teeth. The details of management have been presented elsewhere.’ Essentially, Phase 1 consists of evaluation followed by a caries control program (Table 2). This program emphasizes the establishment of an oral and dental environment that is easily maintained by the patient along with education of the patient in his responsibilities in the control of radiation caries and periodontal disease. A follow up mechanism for reinforcement of home care responsibility and the timely recognition of deteriorating dental conditions requiring early intervention was built into the third phase of the overall program. Base 11. Phase 11 dental management Table 2. Caries control program 1. 11.
111. IV. V.
Control active caries (restorations) Control of dental placque A. Thorough dental prophylaxis B. Oral hygiene instructions C. Follow up reinforcement Daily application of stannous fluoride gel Dietary counseling Extractions
861
consists of adjunctive and supportive procedures carried out during radiation therapy. This involves maintaining a high degree of oral hygiene and monitoring the effect of prostheses on the soft tissues. Surgical and radiation patients were followed by an Oral Hygienist who assisted in the maintenance of oral hygiene on the ward. The oral hygiene program was designed to decrease the quantity of oral microflora, which could decrease the severity of mucositis in the irradiated patient. Exercises to prevent trismus and deviation were prescribed. Temporary obturators may be fabricated during this phase; immediate obturators and extraoral prostheses were modified as the healing process occurred. Phuse 111. Phase 111 management consists of al1 subsequent definitive dental and prosthetic care rendered. Any procedures deferred during Phase 1 were carried out at this time. Periodic examinations permitted early recognition of caries, periodontal disease, pulpal disease and traumatic occlusion. Caries were managed either by an attempt at remineralization with stannous fluoride gel or by restorations; fixed partial dentures are preferable to removable partial dentures. Progressive peridontal disease was uncommon among our patients. Pulpal disease can be managed by root canal therapy or extraction (Table 3). Early intervention is emphasized to avoid acute periapical abscess. Non-restorable caries does occur and extractions are best carried out before acute periapical abscess develops. Clinical experience has taught US that the longer we can delay oral surgical procedures after radiation the more efficient is the healing process. With careful and meticulous surgical technique, attention to adequate alveoplasty, generous wound irrigation, watertight soft tissue closure, and proper antibiotic coverage, we have had no significant complications following surgical removal of teeth and alveoplasties in irradiated patients. Smal1 areas of exposed bone occurred more often in patients who required pre-radiation extractions. They were best treated conservatively by maintaining excellent oral hygiene. Spicules of bone were removed gently when loosened during the
862
Radiation Oncology 0 Biology 0 Physics Table 3. Dental management
September-October 1976, Vol. 1, Number 9 and Number
program Phase 111-Post sive care Radiation before 1970
Teeth at risk Extractions
twithout
significant
Radiation 197&74
Surgery 1%9-74
56.5
1489
843
36t
1t
(in 6 patients) 153 10 5 48
7 2 0 18
complications.
healing process. Copious irrigation with normal saline was helpful. Presently, we are testing an intermittent pressure water lavage device that seems promising in maintaining oral cleanliness. This device also is being used to control candidiasis in lieu of antifungal agents. RESULTS When the protocol group was compared to the patients who were treated prior to 1970, al1 aspects of dental condition were improved. Table 1 represents the patient population in terms of dental status and treatment. During the protocol period, only 6% of the patients to be irradiated had whole mouth extractions, compared to 36% before 1970. Table 2 shows that while the average number of teeth per patient was similar (21 and 19, respectively), only 22% of the protocol
100
comprehen-
79t
(in 13 patients) 183 10 1 54
Restorations Endodontics Fixed partial dentures Removable prostheses
treatment
patient’s teeth was extracted VS 4% prior to 1970, The salvage is greater in the surgeryonly group. Despite retaining a great many more teeth, the caries incidence was signifìcantly lower (12% VS 46%) in the protocol group (Fig. 1). Some improvement was seen in all groups when patients were divided according to treatment technique as seen in Fig. 2. The surgical salvage and external plus implant groups represent small numbers of teeth. Figure 3 shows the comparative caries incidence as a function of time after treatment for the protocol and non-protocol groups. Of interest is the late rise in caries, indicating the necessity for long term follow up and lifelong attention to oral health in the post irradiated patient. Through careful follow up, the best possible dental condition was maintained, and recog-
RESULTS OF DENTAL MANAGEMENT PROGRAM IN IRRADIATED PATIENTS (WRAMC)
75
0
10
TEETH SAVED
TEETH RESTORATIONS CARIES EDENTULOUS INCIDENCE ARCHES* EXTRACTED POST R, POST R,
Fig. 1. Comparison of dental management and results in irradiated patients prior to instituting comprehensive dental programs (before 1970) and after its institution (1970-74). *Refers to per cent of edentulous arches successfully treated.
Dentalcare programin headand neck patients 0 H.M. KEYS and J.P. MCCASLAND CARIES INCIDENCE (WRAMC) 175
1
IN IRRADIATED
PATIENTS’
'CARIESINCIDENCE.~~~.lM)
%
Fig. 2. Comparison of incidence of dental caries in “control groups” (before 1970) and study groups (1970-74) as a function of method of treatment. Surgical salvage refers to previously irradiated patients operated for recurrence. Preoperative radiation therapy refers to planned preoperative irradiation followed by surgery. CARIES INCIDENCE
VI TIME AFTER TREATMENT (WRAMC) Q
151
u
12
3
4
5
6
>8
863
responsible for the deleterious dental effects of oral radiation has been widely appreciated. The program presented here is one of several attempts to deal with the dental condition of those patients who are treated for malignant disease of the head and neck area. A schema of the pathophysiological mechanisms that lead to dental problems following such a treatment is presented in Fig. 4. The results of our program clearly demonstrate the superior dental condition achieved by our patients compared with results for patients who were given the same irradiation prior to the dental management program. Unfortunately, hard data on the influence of Phase 11 are not available. Aside from the dental concept of the importante of adequate prophylaxis and training in the self care in these patients, it was the impression of a number of the medical team that patients receiving regular dental hygienic care had less severe mucositis, less oral moniliasis, less discomfort and less weight loss during treatment. This may result, in part, from a pulsating water debridemebt and cleansing technique; a more scientific study of this technique is currently underway. Osteoradionecrosis of the mandible is a predictable complication after radiation therapy to head and neck cancer patients. However, the frequency with which this complication is reported varies considerably, probably partly due to treatment techniques,
YEARS AFTER TREATMENT Radiotian
Fig. 3. Comparison of temporal incidence of dental caries after irradiation in the “control groups” (before 1970) and protocol groups (1970-74).
I ,Xerasromio Hlghcr carbhydr&
nized problems
were managed early. Table 3 shows the post radiation dental treatment in the non-protocol and protocol groups. Significantly fewer extractions and restorations were required in the 1970-74 group, despite retention of many more marginal teeth. Overall, considerably less post irradiation dental care is required. Only 1 patient developed osteoradionecrosis. DISCUSSION
The recognition
that irradiating
tions of the salivary
major por-
gland tissue is largely
theropy
dlet
A
\
Lawcr ,I,,
’\
Bacterial @agi on teeth
pH-
aries
111
Periiontol ,disease
1 Fulpal Periopical
disease (
infection
/
(abrctr) Osteamdianscrask
Fig. 4. Proposed mechanism for the interaction of radiation and oral cavity-dental processes leading to pathology of radiation injury.
864
Radiation Oncology 0 Biology 0 Physics
September-October
extensiveness of tumors, patient selection and dental condition. In the study of dental condition of head and neck patients conducted at the M.D. Anderson Hospital,’ there were 304 patients evaluated over a 6.5 year period from 1%6 to 1972. These patients, among other parameters, had their incidence and apparent cause of necrosis studied. Sixty-seven of the 304 patients or 22% had a total of 74 episodes of necrosis. This may be considered on the high side, as even very minor episodes of necrosis are included, but provides a basis for comparison with our own results. Osteoradionecrosis of the mandible of significant extent has never been a common occurrence at Walter Reed Army Medical Center. Only 13 patients demonstrated this complication during the interval from 1950 to 1970 by historical review. We have had only one case in the 115 patients treated in the current program over a 5 year period. It is conceivable that additional cases may develop in the future among the same patient population but the early indication is that the incidence is going to be much lower than that noted above. The program of pretreatment preparation (restoration, endodontics, selective extraction, etc.) required considerable increased effort to care adequately for the protocol group, as shown in Table 4. However, the overall tost-benefit analysis is much more complicated. At apparently tremendous tost in time, effort and money, patients were given the finest dental care available anywhere; the net result was significant improvement in dental status, reduction in an already rare complication, and probably no change in survival. In a civilian institution, the total tost Table 4. Dental management Teeth at risk
Radiation before 1970 Radiation 1970-74 Surgery 1%9-74
1976, Vol. 1, Number 9 and Number 10
of such a program could be estimated fairly accurately from the charges for the care given. In a military hospital, it is more difficult to measure the expense involved. However, one simple analysis is of interest (Table 5). The dental clinic visits (in-patient and out-patient) were totaled for each irradiated series, and the surprising result is that the patients managed under the comprehensive program, on the average, had six fewer dental visits than those treated as their condition demanded. A second analysis is presented in Table 6. Here, the total dental procedures for the study and control groups are presented and compared as percentages of the total teeth present prior to therapy. It is obvious that considerably more pretreatment restorations were done in the protocol group, but that this was offset by the excessive extractions and more frequent posttreatment dental problems in the control series. On the benefit side of the ledger is the fact that the patients managed under the protocol Table 5. Total dental clinic visits in irradiated patients (Walter Reed Army Medical Center) 74 patients before 1970 Pretreatment
visits
Posttreatment
Endodontics
918 (8.O)t
1014 (13.7)t
Total visits
program Phase I-Pretreatment
Restorations
693 (9.4)?
visits
*Average number
115 patients 197&74
1707 (23.l)t
1075 (9.3)t
1993 (17.3)t
of visits per patient. preparation Fixed partial restorations
565
7
0
0
1489
358
10
0
843
30
3
2
Dental care program in head and neck patients 0 H.M. KEYS and J.P. MCCASLAND
Table 6. Comparison of dental effort devoted to protocol (1970-74) and non-protocol patients ( < 1970)
Total teeth Extraction Restoration Extraction Restoration Othert Total TProstheses,
Before 1970
1970-74
1113 548 (4%) 7 (1%) Radiation therapy 79 (7%) 183 (16%) 65 (6%)
1915 426 (22%) 3.58 (10%)
882 (79%) endodontics,
36 (2%) 153 (8%) 73 (4%) 1046 (55%)
etc.
dental comprogram had fewer posttreatment plications, required less dental intervention, had improved natural and restored and prosthetic dental status, and hence were less bothered by the deleterious effects of radiation therapy to the head and neck area. Such treatment results have broad implications to other groups of patients whose irradiation unavoidably exposes the salivary gland apparatus to significant radiation doses; recently, we have included all such patients in the comprehensive dental program.
865
CONCLUSIONS 1. A comprehensive dental program for head and neck patients is feasible at a large medical center, but requires the coordinated efforts of a broad range of interested dental specialists. 2. The program has been successful in its major objectives by reducing the incidence of radiation caries, preserving more teeth, having fewer edentulous patients and improving speech, deglutition, mastication and cosmesis. 3. Significant osteoradionecrosis essentially has been prevented. 4. Postirradiation extractions can be performed with care as necessary without significant sequelae. 5. The patient education part of the program has resulted in better understanding of oral health problems, prevention of progressive periodontal disease; along with periodic follow up this has resulted in earlier recognition of dental disease, thus decreasing the loss of teeth after treatment. 6. Significant improvement in dental management also was obtained for patients who were treated surgically. 7. The overall tost appears reasonable as judged by decrease in the average number of clinic visits per patient.
REFERENCES Daley, T.E., Diane, J.B.: Managerneut of Dental Problems in hadiated
Patients.
The University
of Texas at Houston, M.D. Anderson Hospita1 and Tumor Institute, Houston, Texas, 1972, pp. 1-43. McCasland. J.P.: Dental considerations in head
and neck patients: Management of dental and jaw problems. In Proceedings of the International Symposium
Weck, Montreux, press.
on Cancer of the Head and
Switzerland,
2-4 April 1975, in
