Dental Management of Patients Who Have Undergone Oral Cancer Therapy

Radiomorphometric indices for measuring mandibular bone quality in oncologic patients

OBJECTIVE

This retrospective study compared the thickness and degree of resorption of the mandibular cortex in patients with head and neck cancer (AG), patients with cancer at sites other than the head and neck (BG), and patients with no cancer (CG) to describe and compare the changes in the mandible after antineoplastic therapy and their possible clinical implications.

MATERIALS AND METHODS

A total of 287 panoramic radiographs were examined. The following radiomorphometric indices were analyzed: mental index (MI), panoramic mandibular index (PMI), and mandibular cortical index (MCI). Analysis of variance (ANOVA) and the Kruskal‒Wallis test, with p < 0.05 considered significant, were performed.

RESULTS

Males predominated in the AG (83%), while females predominated in the BG and CG (78.6 and 62%, respectively). In the AG, tongue carcinoma (22.1%) was prevalent, while in the BG, breast carcinoma was predominant (53.8%). All parameters measured in the AG and BG patients were significantly lower than those in the CG patients: MI (p < 0.001), right PMIc/a (p < 0.001), left PMIc/a (p < 0.001), right PMIc/b (p = 0.004), left PMIc/b (p < 0.001), and MCI (p < 0.001).

CONCLUSIONS

Radiomorphometric indices MI, PMI, and MCI were significantly lower in panoramic radiographs of patients with head and neck cancer and patients with cancer in other regions of the body than in those of nononcological patients.

Is cone-beam computed tomography (CBCT) an alternative to plain radiography in assessments of dental disease? A study of method agreement in a medically compromised patient population

OBJECTIVES

Poor oral health and dental infections can jeopardize medical treatment and be life-threatening. Due to this, patients with head and neck malignancies, generalized tumor spread, organ transplant, or severe infection are referred for a clinical oral and radiographic examination. The aim of this study was to compare the diagnostic agreement of three radiographic modalities: intraoral radiographs (IO), panoramic radiographs (PX), and cone beam computed tomography (CBCT) for diagnosis of dental diseases.

MATERIALS AND METHODS

Three hundred patients were examined with IO, PX, and CBCT. Periapical lesions, marginal bone level, and caries lesions were diagnosed separately by four oral radiologists. All observers also assessed six teeth in 30 randomly selected patients at two different occasions. Kappa values and percent agreement were calculated.

RESULTS

The highest Kappa value and percent agreement were for diagnosing periapical lesions (0.76, 97.7%), and for the assessment of marginal bone level, it varied between 0.58 and 0.60 (87.8-89.3%). In CBCT, only 44.4% of all teeth were assessable for caries (Kappa 0.68, 93.4%). The intra-observer agreement, for all modalities and diagnoses, showed Kappa values between 0.5 and 0.93 and inter-observer agreement varied from 0.51 to 0.87.

CONCLUSIONS

CBCT was an alternative to IO in diagnosing periapical lesions. Both modalities found the same healthy teeth in 93.8%. All modalities were performed equally regarding marginal bone level. In caries diagnosis, artifacts were the major cause of fallout for CBCT.

CLINICAL RELEVANCE

Intraoral radiography is the first-hand choice for diagnosing dental disease. For some rare cases where intraoral imaging is not possible, a dedicated panoramic image and/or CBCT examination is an alternative.

Evaluation of the Effects of Radiation Therapy on Muscle Contractibility and Skin Healing: An Experimental Study of the Cancer Treatment Implications

BACKGROUND

Radiotherapy can affect healthy cells, resulting in side effects. This study aimed to assess the impact of radiotherapy on soft tissue in surgical wounds in rats.

METHODS

The animals were divided into four groups: control (S) group without irradiation, immediate irradiation (S-IIr) group receiving irradiation right after surgery, late irradiation (S-LIr) group receiving irradiation four weeks after surgery, and early irradiation (Ir-S) group receiving irradiation before surgery. The irradiated groups underwent two fractional stages of 15 Gy. Muscle contractibility (EMG) was evaluated at two different time points, and after 2 and 7 weeks, the animals were euthanized for histological analysis of the muscles and skin.

RESULTS

There was no significant difference between the EMG1 and EMG2 values of the S and S-LIr groups, but both S-IIr and Ir-S groups exhibited a statistically significant difference. The S group demonstrated a larger diameter of muscle fiber compared to other groups, showing a significant difference. In terms of skin analysis, the S-IIr group had the least inflammatory infiltrate and the highest amount of red fibers, differing significantly from the other groups.

CONCLUSIONS

Regardless of the duration, radiotherapy was found to have effects on the surrounding soft tissues, as concluded by this study.

Dental management before radiotherapy of the head and neck region: 4-year single-center experience

OBJECTIVE

To review our experience with a standardized dental management approach in patients with planned radiotherapy of the head and neck region based on preradiation and follow-up data.

MATERIAL AND METHODS

Records of patients who underwent radiotherapy between June 2016 and November 2020 were reviewed. Data on dental findings and therapeutic recommendations were extracted from a prospectively managed database. Hospital records were used to obtain follow-up data.

RESULTS

Two hundred eighty-one patient records were identified. After the exclusion of 81 patients because of incomplete data, 200 patients were included in the study. Dental findings relevant to radiotherapy were found in 144 cases (72.0%). Teeth extractions were recommended in 112 (56.0%) patients. Follow-up data were available for 172 (86.0%) patients (mean follow-up: 16.8 ± 10.7 months). Radiodermatitis was the most frequently observed sequela of radiotherapy (42.4%), followed by dysphagia (38.4%) and stomatitis (36.6%). Osteoradionecrosis was observed in only 2.3% of the patients.

CONCLUSION

Dental findings relevant to planned radiotherapy were frequent and in many cases resulted in recommendations for teeth extraction. Based on our standardized dental management protocol, we observed low rates of late oral complications after radiotherapy of the head and neck region.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

Health-related quality of life in cancer immunotherapy: a systematic perspective, using causal loop diagrams

Purpose

System science offers a unique set of tools, including causal loop diagrams (CLDs), for stakeholders to better grasp the complexity of factors surrounding quality of life. Because the health-related quality of life (HRQoL) of cancer immunotherapy patients exists within an intricate system affected by and affecting many factors across multiple dimensions, the development of a systems-level model can provide a powerful framework to aid the understanding of this complexity. We developed a CLD for HRQoL of cancer immunotherapy patients.

Methods

We first applied a literature-based approach to construct a CLD for patients following immunotherapy. We then iteratively reviewed and enhanced the CLD through interviews with subject matter experts.

Results

Based on the reviewed literature and subject matter expert input, we produced a CLD representing the system surrounding cancer immunotherapy patients’ HRQoL. Several feedback loops are identified that span clinical experiences, oncology teams’ perceptions about immunotherapy, social support structures, and further research and development in cancer immunotherapy, in addition to other components. The CLD enables visualization of thought experiments regarding how a change anywhere in the system can ultimately worsen or improve patients’ HRQoL.

Conclusion

The CLD illustrates the valuable contribution of a systems perspective to quality-of-life research. This systems-based qualitative representation gives insight on strategies to inhibit harmful effects, enhance beneficial effects, and inherent tradeoffs within the system. The CLD identifies gaps in the literature and offers a communication tool for diverse stakeholders. Our research method provides an example for studying the complexities of quality of life in other health domains.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03110-5.

Anticancer effects of picrasidine I on oral squamous cell carcinoma

Picrasidine I is a dimeric alkaloid derived from a Southern Asian plant Picrasma quassioides and demonstrated to possess pharmacological activities, such as anti-inflammatory and anti-osteoclastogenic effects. However, its potential anticancer effect remains unclear. In the present study, anticancer activity of picrasidine I was assessed by treating oral squamous cell carcinoma cells with different concentrations of picrasidine I (20, 30, and 40 μM) for 24, 48, and 72 h. The findings revealed that picrasidine I reduced the cell viability in a dose-dependent manner. Picrasidine I exerted its cytotoxic effect through arresting cell cycle at G2/M phase by downregulating cyclin A, cyclin B, CDK4, and CDK6, and inducing apoptosis in oral cancer cells. The induction of apoptosis was evidenced by increasing expression of death receptors, disruption of mitochondrial membrane potential, increased activation of PARP and caspases 3, 8, and 9, enhanced expression of proapoptotic mediators (Bak and Bim L/S), and reduced expression of antiapoptotic mediators (Bcl-2 and Bcl-xL). Moreover, analysis of MAPK signaling pathway revealed that picrasidine I-mediated proapoptotic activities by downregulating JNK phosphorylation. Taken together, the study identifies picrasidine I as a potent anticancer agent that can be used as a therapeutic intervention against oral squamous cell carcinoma.

Leaf extract of Osbeckia octandra induces apoptosis in oral squamous cell carcinoma cells

Background

Osbeckia octandra is a plant endemic to Sri Lanka and is used in ethnomedicine for treating various diseases. However, the anti-cancer properties of O. octandra are yet to be fully investigated. In the present study, we evaluated the anti-cancer effects of O. octandra on oral cancer cells.

Methods

Human oral cancer cell lines (HSC2, YD10B, YD38, YD9, and YD32) were used in this study. BrdU incorporation, cell cycle and annexin-V/PI staining were all evaluated using flow cytometry to determine the extent to which O. octandra leaf extract inhibits cell proliferation and induces apoptosis. Cell viability and reactive oxygen species (ROS) were also measured in order to investigate the anti-cancer effects of O. octandra extracts. Western blotting was performed to detect cell cycle related protein such as cyclin d1 and cdk4, and to detect apoptosis-related proteins such as Bcl-2, Bcl-X_L, Bax, Caspase-9, Cleaved caspase-3, Fas, Caspase-8, and Bid.

Results

Leaf extract of O. octandra reduced oral squamous cell carcinoma (OSCC) cell viability in a dose-dependent manner. Leaf extract of O. octandra has non-toxic in normal keratinocytes. Also, O. octandra extract interrupted the DNA replication via G1 phase arrests, and this effect was independent of ROS generation. In the apoptosis-related experiments, the population of annexin V-positive cells increased upon treatment with O. octandra extract. Furthermore, the expression of anti-apoptotic protein (Bcl-2 and Bcl-xL) was decreased, whereas the expression of cleaved caspase-3 protein was increased in O. octandra-treated OSCC cells.

Conclusions

The results suggest that a leaf extract of O. octandra inhibited the proliferation of OSCC cells through G₁ phase arrest and interrupting DNA replication. The leaf extract of O. octandra could trigger the apoptotic response via caspase 3 activation in OSCC cells. These results suggest that O. octandra has the potential to be developed as an alternative medicine for treating OSCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03505-4.

Addressing oral health barriers to care in head and neck cancer patients using a novel collaborative care approach

With appropriate interprofessional collaboration, dental schools have the capacity to facilitate the dental management of patients with head and neck cancer who are facing multiple barriers to care.

Ibero-American Expert Consensus on Squamous Cell Carcinoma of the Head and Neck Treatment in Patients Unable to Receive Cisplatin: Recommendations for Clinical Practice

Cisplatin is the standard of treatment for squamous cell carcinoma of the head and neck (SCCHN) that has demonstrated efficacy, either in locally advanced disease when combined with radiotherapy at high doses, or in metastatic/recurrent disease when combined with other agents. However, the usual toxicities related to cisplatin, such as neurotoxicity, nephrotoxicity, ototoxicity, and hematologic toxicities, especially when high doses have been administered, have important implications in the patients' quality of life. The decision to administer cisplatin depends on several patient factors, such as age, performance status, weight loss, comorbidities, previous toxicities, chronic viral infection, or even the current SARS-CoV-2 pandemic. In order to establish recommendations for the management of patients with SCCHN, a group of experts in medical and radiation oncology from Spain and Latin-American discussed how to identify patients who are not candidates for cisplatin to offer them the most suitable therapeutic alternative.

Primary Cilia Enhance Osteogenic Response of Jaw Mesenchymal Stem Cells to Hypoxia and Bisphosphonate

PURPOSE

Primary cilia play a significant role in mesenchymal stem cell (MSC) lineage commitment, skeletal development, and bone homeostasis. MSC responsiveness to metabolic stress is associated with radiation and drug-induced jaw osteonecrosis. Therefore, we hypothesize that orofacial MSCs (OFMSCs) osteogenic commitment in response to cellular stressors hypoxia and bisphosphonates is a survival response coupled to primary cilia biogenesis.

MATERIALS AND METHODS

Human OFMSCs were subjected to cellular stress using severe hypoxia, nitrogen-containing bisphosphonate (pamidronate) and low serum starvation. OFMSC primary cilia formation, as well as cell survival and proliferation, were detected using immunofluorescence, CellTitre-Glo, and WST-1 assays respectively. OFMSC differentiation was tested using Alizarin Red S staining. OFMSCs survival and osteogenic markers were assessed by western blotting relative to primary cilia number and associated acetylated tubulin levels.

RESULTS

Baseline OFMSC proliferation was stable under short-term severe hypoxia and pamidronate treatments whether combined with or without serum starvation. Hypoxia and pamidronate decreased the number of OFMSCs positive for primary cilia that was consistent with increased HIF-1α and caspase 3 but decreased cyclin D1. Combined effects of hypoxia and pamidronate on OFMSCs significantly reduced ciliation but did not completely abrogate it. Combination of serum deprivation, hypoxia, and pamidronate promoted OFMSCs osteogenic differentiation that was consistent with upregulated HIF-1α levels.

CONCLUSIONS

Partial rather than complete loss of OFMSC ciliation and enhanced osteogenic commitment represent adaptive survival response of OFMSCs to severe hypoxia and pamidronate-induced metabolic stress. Hypoxia and drug-induced OFMSC stress may be significant events governing the pathogenesis and clinical outcomes of jaw osteonecrosis.

Anethole induces anti-oral cancer activity by triggering apoptosis, autophagy and oxidative stress and by modulation of multiple signaling pathways

Oral cancer is one of the major public health problems. The aim of this study was to evaluate the effects of anethole, 1-methoxy-4-[(E)-1-propenyl]-benzene, on growth and apoptosis of oral tumor cells, and to identify the signaling pathways involved in its interaction with these cancer cells. Cancer gingival cells (Ca9-22) were treated with different concentrations of anethole. Cell proliferation and cytotoxic effects were measured by MTT and LDH assays. Cell death, autophagy and oxidative stress markers were assessed by flow cytometry while cell migration was determined by a healing capacity assay. The effect of anethole on apoptotic and pro-carcinogenic signaling pathways proteins was assessed by immunoblotting. Our results showed that anethole selectively and in a dose-dependent manner decreases the cell proliferation rate, and conversely induces toxicity and apoptosis in oral cancer cells. This killing effect was mediated mainly through NF-κB, MAPKinases, Wnt, caspase 3, 9 and PARP1 pathways. Anethole showed an ability to induce autophagy, decrease reactive oxygen species (ROS) production and increased intracellular glutathione (GSH) activity. Finally, anethole treatment inhibits the expression of oncogenes (cyclin D1) and up-regulated cyclin-dependent kinase inhibitor (p21^WAF1), increases the expression of p53 gene, but inhibits the epithelial-mesenchymal transition markers. These results indicate that anethole could be a potential molecule for the therapy of oral cancer.

Analysis of referrals to the stomatology service in a Southern Brazilian hospital: a retrospective study

This paper intends to describe the demand for referrals to the stomatology service requested by the medical teams for inpatients in a reference hospital in the south of Brazil. This research is a retrospective cross-sectional descriptive study focusing on data collection and assessment of information about referrals to the stomatology unit carried out from January 2008 to December 2018. All information was obtained from the hospital management software database, then transferred and analyzed individually for descriptive statistics. A total of 4433 cases were referred to the stomatology team, with an average of 403 cases by year. Hematology/hemato-oncology (37.3%) was the specialty asking for the majority of the referrals, followed by Oncology (20.4%) and Pneumology (8.2%). The mean patients' profile was males (55.5%), receiving a diagnosis of oral mucositis (43.5%), and with the first and second decades of life being the most prevalent ones (34.9%), with a mean age of 34.8±22.3 years. The most common treatment performed by the stomatology team was the photobiomodulation therapy (44.8%). This retrospective study demonstrated the important profile of the stomatological care in hospitalized patients from a specific hospital, especially referred by the hematology/hemato-oncology team. These results evidenced the importance of the stomatology specialty in the hospital environment.

Effects of fractionation and ionizing radiation dose on the chemical composition and microhardness of enamel

OBJECTIVE

To evaluate the chemical and mechanical properties of enamel submitted to different in vitro radiation protocols.

DESIGN

Third molars were divided into seven groups (n = 8): non-irradiated (NI); a single dose of 30 Gy (SD30), 50 Gy (SD50), or 70 Gy (SD70) of radiation; or fractional radiation doses of up to 30 Gy (FD30), 50 Gy (FD50), or 70 Gy (FD70). Hemisections were analysed by Fourier transform infrared spectroscopy (FTIR), energy dispersive X-ray spectroscopy (EDS) and Knoop microhardness (KHN) test. One-way ANOVA followed by Bonferroni's post-hoc test compared the test groups with the NI. Two-way ANOVA was performed for the fractionation and radiation dose, followed by Bonferroni's test (α = 0.05).

RESULTS

FTIR revealed differences for the amide I band between the NI and FD50 and NI and FD70 groups (p < 0.001). For the organic matrix/mineral ratio, the FD70 group presented a lower ratio compared to NI (p = 0.009). Excluding the NI group, there were differences between the FD30 and FD50 (p = 0.045) and the FD30 and FD70 groups (p < 0.001). For EDS, there were differences for Ca (p = 0.011) and Ca/P (p < 0.001), with the FD70 group presenting lower values compared to NI (p = 0.015; p < 0.001). For KHN, the FD70 group presented lower values than the NI (p = 0.002). Two-way ANOVA showed difference for the dose (p < 0.001), with the 70 Gy group presenting a lower KHN value within the fractionated groups.

CONCLUSION

Fractional doses 70 Gy irradiation caused chemical and mechanical changes to enamel. Radiation applied in single or fractional doses produced different effects to enamel.

The Multidisciplinary Team (MDT) Approach and Quality of Care

The core function of a multidisciplinary team (MDT) is to bring together a group of healthcare professionals from different fields in order to determine patients' treatment plan. Most of head and neck cancer (HNC) units are currently led by MDTs that at least include ENT and maxillofacial surgeons, radiation and medical oncologists. HNC often compromise relevant structures of the upper aerodigestive tract involving functions such as speech, swallowing and breathing, among others. The impairment of these functions can significantly impact patients' quality of life and psychosocial status, and highlights the crucial role of specialized nurses, dietitians, psycho-oncologists, social workers, and onco-geriatricians, among others. Hence, these professionals should be integrated in HNC MDTs. In addition, involving translational research teams should also be considered, as it will help reducing the existing gap between basic research and the daily clinical practice. The aim of this comprehensive review is to assess the role of the different supportive disciplines integrated in an MDT and how they help providing a better care to HNC patients during diagnosis, treatment and follow up.

Therapeutic Effect of Ecdysterone Combine Paeonol Oral Cavity Direct Administered on Radiation-Induced Oral Mucositis in Rats

Radiation-induced oral mucositis represents an influential factor in cancer patients’ accepted radiation therapy, especially in head and neck cancer. This research investigates the treatment effect of Ecdysterone (a steroid derived from the dry root of Achyranthes bidentate) and Paeonol (a compound derived from Cortex Moutan) on radiation-induced oral mucositis and possible underlying mechanisms. Concisely, 20 Gy of X-rays (single-dose) irradiated the cranial localization in rats for the modeling of oral mucositis. The therapeutic effects of Ecdysterone-Paeonol oral cavity directly administered on radiation-induced oral mucositis were investigated by weight changes, direct observations, visual scoring methods, ulcer area/total area, and basic recovery days. Assessments of tumor necrosis factor α and interleukin-6 were performed to evaluate the inflammatory cytokines secretion in the damaged areas of tongues harvested post-treatment, and changes in signaling pathways were investigated by Western blotting. System Drug Target (SysDT) methods revealed the targets of Ecdysterone-Paeonol in order to support compound-target network construction. Four representative targets with different functions were chosen. The binding interactions between the compound and receptor were evaluated by molecular docking to investigate the binding affinity of the ligand to their protein targets. Ecdysterone-Paeonol, administered orally, effectively improved radiation-induced oral mucositis in rats, and the therapeutic effect was better than Ecdysterone administered orally on its own. In this study, calculational chemistry revealed that Ecdysterone-Paeonol affected 19 function targets associated with radiation-induced oral mucositis, including apoptosis, proliferation, inflammation, and wound healing. These findings position Ecdysterone-Paeonol as a potential treatment candidate for oral mucositis acting on multiple targets in the clinic.

Upregulation of MDR- and EMT-Related Molecules in Cisplatin-Resistant Human Oral Squamous Cell Carcinoma Cell Lines

Cisplatin is one of the major drugs used in oral cancer treatments, but its usage can be limited by acquired drug resistance. In this study, we established three cisplatin-resistant oral squamous cell carcinoma (OSCC) cell lines and characterized them using cell viability assays, qPCR, Western blotting, FACS, immunofluorescence, and wound healing assays. Three OSCC cell lines (YD-8, YD-9, and YD-38) underwent long-term exposure to cisplatin, eventually acquiring resistance to the drug, which was confirmed by an MTT assay. In these three newly established cell lines (YD-8/CIS, YD-9/CIS, and YD-38/CIS), overexpression of multidrug resistance (MDR)-related genes was detected by qPCR and Western blotting. The cell lines displayed an increase in the functional activities of breast cancer resistance protein (BCRP) and multidrug resistance protein1 (MDR1) by rhodamine 123 and bodipy FL prazosin accumulation assays. Moreover, the cisplatin-resistant cells underwent morphological changes, from round to spindle-shaped, increased expression of epithelial-to-mesenchymal transition (EMT)-related molecules such as N-cadherin, and showed increased cell migration when compared with the parental cell lines. These results suggest that these newly established cell lines have acquired drug resistance and EMT induction.