Monday, February 14, 2011

Head and Neck Radiation Therapy

Patients receiving radiation therapy to the head and neck are at risk for developing oral complications. Because of the risk of osteonecrosis in irradiated fields, oral surgery should be performed before radiation treatment begins.

Before Head and Neck Radiation Therapy:

# Conduct a pretreatment oral health examination and prophylaxis.
# Schedule dental treatment in consultation with the radiation oncologist.
# Extract teeth in the proposed radiation field that may be a problem in the future.
# Prevent tooth demineralization and radiation caries:
         * Fabricate custom gel-applicator trays for the patient.
         * Prescribe a 1.1% neutral pH sodium fluoride gel or a 0.4% stannous, unflavored fluoride gel (not fluoride rinses).
        * Use a neutral fluoride for patients with porcelain crowns or resin or glass ionomer restorations.
        * Be sure that the trays cover all tooth structures without irritating the gingival or mucosal tissues.
        * Instruct the patient in home application of fluoride gel. Several days before radiation therapy begins, the patient should start a daily 10-minute application.
       * Have patients brush with a fluoride gel if using trays is difficult.

# Allow at least 14 days of healing for any oral surgical procedures.
# Conduct prosthetic surgery before treatment, since elective surgical procedures are contraindicated on irradiated bone.

During Radiation Therapy:

    * Monitor the patient's oral hygiene.
    * Watch for mucositis and infection.
    * Advise against wearing removable appliances during treatment.

After Radiation Therapy:
    * Recall the patient for prophylaxis and home care evaluation every 4 to 8 weeks or as needed for the first 6 months after cancer treatment.
    * Reinforce the importance of optimal oral hygiene.
    * Monitor the patient for trismus: check for pain or weakness in masticating muscles in the radiation field. Instruct the patient to exercise three times a day, opening and closing the mouth as far as possible without pain; repeat 20 times.
    * Consult with the oncology team about use of dentures and other appliances after mucositis subsides. Patients with friable tissues and xerostomia may not be able to wear them again.
    * Watch for demineralization and caries. Lifelong, daily applications of fluoride gel are needed for patients with xerostomia.
    * Advise against elective oral surgery on irradiated bone because of the risk of osteonecrosis. Tooth extraction, if unavoidable, should be conservative, using antibiotic coverage and possibly hyperbaric oxygen therapy.


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