Patients with head and neck cancer treated with radiotherapy: Their experiences after 6 months of prophylactic tooth extractions and temporary removable dentures

Prophylactic Use of Pentoxifylline and Tocopherol for Prevention of Osteoradionecrosis of the Jaw after Dental Extraction in Post-Radiated Oral and Oropharyngeal Cancer Patients: An Initial Case Series

Osteoradionecrosis of the jaw is a morbid complication of radiotherapy in patients with oral and oropharyngeal cancers that may be precipitated by dental extractions. Pentoxifylline and tocopherol (PENTO) has been utilized in the management of osteoradionecrosis and as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. This observational study aims to report the outcome of the prophylactic use of PENTO in the prevention of osteoradionecrosis of the jaw after dental extractions in post-radiated oral and oropharyngeal cancer patients and to review the current literature on this topic. Four post-radiated oral and oropharyngeal oncology patients were referred to the dental oncology clinic of the University Dental Practice, University of Tennessee Health Sciences Center for dental extractions. All four patients were prescribed pentoxifylline 400 mg BID (twice a day) and tocopherol 400 IU BID (oral tablets) for 2 weeks before extraction(s) and for 6 weeks after extraction(s). All patients were followed up every week after the second week post-extraction if feasible until the extraction site(s) healed (covered by mucosa). The assessment endpoint was defined as 6 weeks post-extraction with the outcomes assessed as using four categories determined by the area of exposed bone: complete healing (complete mucosal coverage of extraction site); partial healing (reduction in size of extraction site); no change; and progression (increase in size of the extraction site). At the assessment endpoint, all patients had complete healing of all extraction sites. The ORN rate at the patient level (0/4) and individual tooth level (0/8) was 0%. All patients tolerated the PENTO medications and no adverse effects from the use of these medications were reported. This limited study in addition to the other reviewed studies estimates the rate of ORN at the patient level as 3.2% (14/436) for post-radiated head and neck oncology patients after dental extractions/invasive oral procedures. In conclusion, this PENTO regimen can reduce/prevent the incidence of ORN in post-radiated head and neck oncology patients. This safe and cost-effective protocol (PENTO regimen) should be further evaluated as prophylaxis for post-radiated head and neck oncology patients requiring an invasive dental procedure. We recommend large prospective studies to be carried out to further validate these findings.

Psychosocial needs of post-radiotherapy cancer survivors and their direct caregivers - a systematic review

Radiotherapy is an important modality for cancer treatment. About 50% of cancer patients receive radiotherapy, and one-third of radiotherapy recipients were identified as having unmet psychosocial needs. The unmet psychosocial needs worsen the patient's quality of life and treatment effectiveness. This review aims to identify the psychosocial needs of post-radiotherapy cancer survivors and their direct caregivers. Systematic research of Embase, Scopus and PubMed was done and 17 studies were selected for analysis. The results show that patients encounter distress and fear due to treatment immobilization and unfamiliarity with procedures respectively. Information provision is a common need raised by patients and caregivers. Patients and caregivers report relationship problems due to affected sexual functions. To facilitate future studies, solutions to each identified psychosocial need are proposed in the discussion based on the 17 selected papers and other supporting literature. This review proposes art therapy to alleviate psychological distress, and pre-treatment information sessions to reinforce information delivery. Creative interventions such as a sexual rehabilitation program are recommended. Future studies are warranted to examine the interventions and thus improve the patients' and caregivers' well-being.

The extent of unnecessary tooth loss due to extractions prior to radiotherapy based on radiation field and dose in patients with head and neck cancer

BACKGROUND AND PURPOSE

Prior to radiotherapy (RT), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. To allow enough time for adequate wound healing prior to RT, decisions are made based on the estimated radiation dose. This study aimed to gain insight into (1) the overall number of teeth extracted and (2) the patient and tumor characteristics associated with the number of redundantly extracted teeth.

MATERIALS AND METHODS

Patients with head and neck cancer (HNC), treated with RT between 2015 and 2019, were included in this cross-sectional study. For each extracted tooth the radiation dose was calculated retrospectively. The cut-off point for valid extraction was set at ≥ 40 Gy in accordance with the national protocol. Potential factors for doses ≥ 40 Gy were identified, including age, sex, tumor location, tumor (T) and nodal stage (N), overall tumor stage and number of teeth extracted.

RESULTS

A total of 1759 teeth were removed from 358 patients. Of these 1759 teeth, 1274 (74%) appeared to have been removed redundantly, based on the mean dose (Dmean) of < 40 Gy. Using the maximum dose (Dmax) of < 40 Gy, 1080 teeth (61%) appeared to have been removed redundantly. Tumor location and N-classification emerged as the most important associative variables in the multivariable regression analysis.

CONCLUSION

To our knowledge this is the first study to provide insight into the amount of teeth redundantly extracted prior to RT and represents a step forward in de-escalating the damage to the masticatory system prior to RT.

Backscatter from therapeutic doses of ionizing irradiation does not impair cell migration on titanium implants in vitro

OBJECTIVE

The influence of radiation backscatter from titanium on DNA damage and migration capacity of human osteoblasts (OBs) and mesenchymal stem cells (MSCs) may be critical for the osseointegration of dental implants placed prior to radiotherapy. In order to evaluate effects of radiation backscatter, the immediate DNA damage and migration capacity of OBs and MSCs cultured on titanium or plastic were compared after exposure to ionizing irradiation.

MATERIALS AND METHODS

Human OBs and MSCs were seeded on machined titanium, moderately rough fluoride-modified titanium, or tissue culture polystyrene, and irradiated with nominal doses of 2, 6, 10, or 14 Gy. Comet assay was performed immediately after irradiation, while a scratch wound healing assay was initiated 24 h post-irradiation. Fluorescent live cell imaging documented the migration.

RESULTS

DNA damage increased with higher dose and with backscatter from titanium, and MSCs were significantly more affected than OBs. All doses of radiation accelerated the cell migration on plastic, while only the highest dose of 10 Gy inhibited the migration of both cell types on titanium.

CONCLUSIONS

High doses (10 Gy) of radiation inhibited the migration capacity of both cell types on titanium, whereas lower doses (2 and 6 Gy) did not affect the migration of either OBs or MSCs.

CLINICAL RELEVANCE

Fractionated doses of 2 Gy/day, as distributed in conventional radiotherapy, appear not to cause severe DNA damage or disturb the migration of OBs or MSCs during osseointegration of dental implants.

Removable partial prosthesis combined with swallowing training is an efficient clinical solution for oral cancer post-operation patients with palatal defect and dysphagia: a prospective study

OBJECTIVE

Dysphagia is one of the major complications of oral cancer patients, and is disturbing thousands of patients worldwide. Our study aim to evaluate the clinical efficacy of prosthesis combined with swallowing training on palatal defect and dysphagia in post-operative oral cancer patients.

MATERIALS AND METHODS

Sixteen oral cancer patients with palatal defect and dysphagia post-operation were treated with removable prosthesis and individualized swallowing function training. Swallowing function of patients before and after treatment was analyzed and compared by videofluoroscopic swallowing examination. The severity of depression and life quality were evaluated by Depression Scale (SDS) and Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) scores, respectively.

RESULTS

Oral transit time (OTT) significantly shortened after treatment (P < 0.01), and Penetration-Aspiration Scale (PAS) scores was significantly higher after treatment (P < 0.001). Different consistency bolus showed different risk of aspiration. Thickened liquids were related to lower PAS scores (P < 0.001). SDS standard score was significantly lower after treatment (P < 0.05). The total score of FACT-H&N after treatment was significantly higher (P < 0.05). No patients came back for regressed swallowing function during the follow-up period (17.06 ± 2.376 months).

CONCLUSION

Removable prosthesis and swallowing training can significantly improve swallowing function, reduce depression degree, and improve quality of life (QOL).

CLINICAL RELEVANCE

Removable prosthesis combined with swallowing training is a cheap and effective method to improve QOL in patients with palate defect and dysphagia after oral cancer.

Experiences and perceptions of social eating for patients living with and beyond head and neck cancer: a qualitative study

Purpose

Patients with head and neck cancer (HNC) describe eating as more than a physical activity for nutrition and calories. After treatment for HNC, patients report a changed social experience around food, with eating and drinking in front of family and friends depicted as a challenge. However, there is limited research exploring how patients with HNC adapt and cope with social eating difficulties. This study aims to explore patients’ experiences and perceptions of social eating and drinking following treatment for HNC.

Methods

A qualitative research design using semi-structured interviews was employed to understand the experiences of social eating of patients living with and beyond HNC. Reflexive thematic analysis was used to inductively develop key themes from the data.

Results

Fourteen interviews were conducted with patients, and two key themes were identified: (1) “Social eating became a conscious process” and (2) “Strategies to maximise social eating participation”. To maximise social eating enjoyment, patients attempted to minimise the attention on their eating function and the fuss created around food. Patients with HNC established psychological and cognitive adaptations to manage expectations and promote positive participation in social eating.

Conclusion

This paper identifies key barriers limiting or diminishing social eating for patients with HNC; including being self-conscious, lack of understanding from others and functional issues with eating and drinking. This research highlights the need to raise awareness of social eating challenges and for the social dimensions of eating to be addressed through family-centred, supportive holistic interventions implemented early in the patient’s cancer journey.

Tooth extractions prior to chemoradiation or bioradiation are associated with weight loss during treatment for locally advanced oropharyngeal cancer

PURPOSE

Prior to radiotherapy combined with chemotherapy (CRT) or biotherapy (BRT) for oropharyngeal squamous cell carcinoma (OPSCC), teeth with poor prognosis that pose a risk for post-RT osteoradionecrosis (ORN) are removed. The effect of tooth loss on body weight loss and tube feeding (TF) dependency during CRT/BRT is unknown. This study aimed to evaluate the effect of incomplete dentition, tooth extractions prior to CRT/BRT, and the subsequent loss of functional units on (1) weight loss during CRT/BRT and (2) the need for TF during CRT/BRT for OPSCC.

METHODS

OPSCC patients treated with CRT/BRT between 2013 and 2016 were included in this retrospective cohort study. Dental status was determined during the dental assessment at first visit and after tooth extractions prior to the start of CRT/BRT. Weight loss during CRT/BRT was scored dichotomously, comparing weight loss > 5% to stable or increased weight. Potential factors associated with weight loss were identified, including patient, tumor, and treatment characteristics.

RESULTS

Seventy-seven OPSCC patients were included. Forty patients (52%) experienced weight loss > 5% during CRT/BRT. Extractions were performed in 66% of the OPSCC patients. The mean number of extracted teeth was 4.1 ± 5.6 per patient. Tooth extractions prior to CRT/BRT were associated with weight loss > 5% during CRT/BRT (HR 1.130 (95% CI 1.011-1.262), p = 0.031). None of the dental status-related parameters showed any significant associative value for TF during CRT/BRT.

CONCLUSIONS

Pre-CRT/BRT tooth extractions intended to reduce the risk of ORN, are a risk factor for weight loss during CRT/BRT for OPSCC.

TRIAL REGISTRATION NUMBER

This study was approved by the medical ethics committee of the MUMC + (METC 2020-1589) on July 28, 2020.