xerostomia

Dental oncology: Meeting a growing need

Source: Dr.Biscuspid.com

The good news is more cancer patients are surviving than ever before.

The bad news is it creates new challenges for the medical community to provide adequate and appropriate aftercare and treat the many short- and long-term side effects of cancer treatment.

For example, chemotherapy and radiation often cause oral problems such as mucositis, xerostomia, oral and systemic infections, and accelerated caries development. But many dentists refuse to treat cancer patients with these conditions due to the increased risk of osteonecrosis from radiation treatment or bisphosphonate use.

Enter Ryan Lee, DDS, MPH, MHA, who is finishing a postgraduate clinical fellowship in dental oncology at Memorial Sloan-Kettering Cancer Center in New York City. He hopes to help solve the shortage of dentists with the training to treat the growing number of cancer patients who need specialized oral care.

Ryan Lee, DDS, is one of a handful of dentists specializing in dental oncology.

Dr. Lee is one of two fellows in Sloan-Kettering’s dental oncology fellowship program, which has been offering the specialty training for at least a decade.

“All along I’ve liked working on medically complex cases with dental needs, so cancer fit into that niche very well,” he told DrBicuspid.com. “I’ve come to realize how much of a growing need it is and how little is available to meet that need,” he explained.

Currently, only two cancer hospitals offer fellowship training programs for dental oncology: the Memorial Sloan-Kettering Cancer Center and the University of Texas MD Anderson Cancer Center.

“Oncology training in the dental setting is a new and growing field, kind of a cottage industry,” Dr. Lee said. “When I went to dental school, cancer instruction was just a couple of lectures, and we learned mostly about oral cancer. We didn’t learn about the oral manifestations of systemic cancer that can be anywhere in the body.”

In fact, most of his patients don’t have oral cancers; most have breast or prostate cancer. And yet he sees hundreds of patients each month who present with cancer-related dental sequelae, including radiation-induced xerostomia, osteoradionecrosis, bisphosphonate-related osteonecrosis of the jaw, chemotherapy-related manifestations, oral (pre)cancerous lesions, and surgically resected jaws.

Dr. Lee also prescreens patients prior to bone marrow and stem cell transplants, head and neck radiation, and other cancer treatments.

“But we, as a dental profession, need to see these patients even when they’re outside the hospital setting,” he said. “The buzzword is oral systemic condition.”

An emotional toll

Some of Dr. Lee’s most difficult cases involve pediatric patients who have liquid tumors such as myeloma and often need chemotherapy and stem cell or bone marrow transplants.

“The effects of that are pretty severe in the mouth,” he said. “A lot of the children are missing teeth, and their adult teeth never fully develop so managing them throughout the course of their growth is a big issue — not only in clinical terms like chewing, eating, and smiling, but also the psychological impact.”

Treating cancer-stricken youngsters takes an emotional toll. “There’s nothing like seeing a bunch of kids with alopecia, and you know they’re going through cancer treatment,” Dr. Lee said. “It just breaks your heart.”

“Oncology training in the dental setting is a new and growing field, kind of a cottage industry.”
— Ryan Lee, DDS, Memorial
Sloan-Kettering Cancer Center

There are many physical challenges as well, he noted; for one, many patients must get a dental clearance before they start radiation therapy.

“When you get radiation to the jaw, it affects the blood vessels in such a way that you have nonhealing, so any dental extractions or oral surgery cannot be done after radiation to the mouth because of the risk of osteoradionecrosis,” Dr. Lee explained. “So we see a lot of those folks.”

Cancer patients also often need extensive oral surgery before they can be cleared for transplants.

“We often have patients that need 12 to 15 teeth extracted before they can go in for a transplant,” Dr. Lee said. Although the protocol calls for allowing three to four weeks for proper healing, sometimes they can’t wait due to the patient’s deteriorating condition and the urgent need for the transplant, he explained.

And during cancer treatment, a patient’s immunity is greatly diminished, which can result in abscesses and gingival inflammation, Dr. Lee said.

“You’ve got to manage these types of patients carefully, and these are the types of patients dentists on the outside really don’t want to deal with,” he noted.

Creative solutions

One of his most difficult cases involved a 29-year-old woman with fanconi anemia, an inherited blood disorder that leads to bone marrow failure. She subsequently developed squamous cell cancer in her mouth and has had multiple cycles of radiation, which puts her at a very high risk of osteoradionecrosis. She also has trismus (a contraction of the muscles of mastication), leaving her with limited ability to open her mouth because of the fibrosis, Dr. Lee explained.

“Because of her radiation history she has bursitis, and she’s full of mouth sores,” he said.

The woman is now missing a couple of front teeth and because of her fanconi anemia, she never developed adult teeth and now wants implants.

“Imagine performing oral surgery to place implants on someone who’s had that much radiation, who cannot open her mouth,” Dr. Lee said. “We can’t even take impressions because we can’t fit the tray into her mouth. That alone is an incredible challenge.”

He was forced to come up with creative solutions, including making customized smaller trays and using unusual materials.

“We’ve actually used butter just to be able to put a small impression tray in her mouth,” Dr. Lee said. “Having the tray in her mouth just hurts her so much because her gums are so inflamed.”

He is now focusing on dentures so she can stabilize the woman’s occlusion, but he must specifically measure how much radiation was given in the areas where the implants will be placed.

Fortunately, her illness is now in remission.

“She’s an incredibly smart person with such a great outlook, and she encourages me when I’m having a long day,” Dr. Lee said.

Influencing policymakers

Dr. Lee is encouraged by the work of Texas dentist Dennis Abbott, DDS, who specializes in oncology and has seen his practice grow quickly. Drs. Lee and Abbott met at a dental conference, and the two discussed the growing need for dentists who can treat cancer patients with specialized needs.

“It’s such a small, relatively unknown field,” Dr. Lee observed.

But Dr. Lee, who is working toward another doctorate in health policy, hopes to change that. In addition to becoming an academic-level dental oncologist, he would also like to practice part time treating the cancer-specific needs of patients.

“It would be nice to be able to influence policymakers and show them that dental oncology treatment is a medically necessary condition, that the effects on the mouth are severe,” Dr. Lee said.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

June, 2012|Oral Cancer News|

Pig mucus effective at blocking viruses associated with cervical and oral cancer

Source: American Chemical Society

Scientists are reporting that the mucus lining the stomachs of pigs could be a long-sought, abundant source of “mucins” being considered for use as broad-spectrum anti-viral agents to supplement baby formula and for use in personal hygiene and other consumer products to protect against a range of viral infections. Their study appears in ACS’ journal Biomacromolecules.

In the report, Katharina Ribbeck and colleagues point out that mucus, which coats the inside of the nose, mouth and vagina, is the immune system’s first line of defense. The slimy secretion traps disease-causing microbes, ranging from influenza virus to HIV (which causes AIDS) before they can cause infection. That has led to consideration of mucin, the main component of mucus, for use as an anti-viral agent in a variety of products. However, existing sources of mucins, such as breast milk, cannot provide industrial-sized quantities. Large amounts of mucus exist in the lining of pigs’ stomachs, and the authors set out to determine if pig mucus – already used as a component of artificial saliva to treat patients with “dry mouth,” or xerostomia – has the same anti-viral activity.

They found that pig mucus is effective at blocking a range of viruses, from strains of influenza to the human papilloma virus, which is associated with cervical and oral cancer. They report that pig mucins could be added to toothpastes, mouthwashes, wound ointments and genital lubricants to protect against viral infections. “We envision porcine gastric mucins to be promising antiviral components for future biomedical applications,” the report says.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

April, 2012|Oral Cancer News|

Oral Complications After Head/Neck Radiation ‘Underreported’

Source: Elsevier Global Medical News

Late oral effects of head and neck cancer therapy are “multiple, underreported, and under-appreciated. “That is the perspective of Joel Epstein, D.M.D., who has worked extensively with head and neck cancer patients experiencing severe dental and other oral problems following radiation therapy.

“The acute complications of head and neck cancer therapy are pretty well known, but the late complications are underappreciated,” Dr.  Epstein, director of oral medicine at City of Hope National Medical Center, Duarte, Calif., told attendees at the symposium. As head and neck cancer treatments have advanced and patients are living longer, the spectrum of treatment complications has shifted, he explained. In a 5-year, prospective longitudinal study of 122 patients with oral carcinoma, dry mouth, sticky saliva, speech changes, dental problems, and sleep disturbance were reported by all patients except those treated only with surgery. These complications persisted at 1 and 5 years and affected quality of life (Head Neck 2008;30:461-70).

According to Dr. Epstein, the data illustrate the need for better collaboration between oncologists and dentists. “While people discuss  the concept of multidisciplinary [and] interdisciplinary teams for the benefit of our patients, it is unfortunate that dentistry developed  separately from physicians and surgeons. So while we need to interact, we’re not really well prepared to do so, particularly in the  community,” he said.

Clinically, it’s important to evaluate oral care, including brushing, flossing, fluoride, and tobacco abstinence, at all head and neck cancer treatment follow-up visits. Patients should be assessed for xerostomia, speech, swallowing, mucosal sensitivity, and taste. Head and neck and oral exams should include assessments for saliva (wet mucosa), exposed bone, infection, and new lesions or recurrent cancer, and a dental exam (for plaque, caries, and periodontal health), Dr. Epstein recommended.

Dry mouth, in particular, can lead to a host of other chronic problems related to swallowing, eating, sleeping, and dental health. When the 50-item Vanderbilt Head and Neck Symptom Survey was administered to a total of 70 patients, 67 reported having dry mouth at more than 6 months’ follow up (Head Neck 2011 Aug. 24 [doi:10.1002/hed.21816]).

The majority reported that dry mouth makes chewing/swallowing difficult (65) and that it affects their ability to sleep (67) and  talk (64). With regard to eating and swallowing, similar majorities reported trouble eating solids (67) and drinking liquids (68), with food getting stuck in their mouth (66) and throat (67).

And, of concern, the same numbers of patients reported the sensation of choking or strangling on solids (66) and liquids (68). “The impact on function from the lack of saliva and the change in quality of saliva are issues we need to be more ready and willing to address,”  Dr. Epstein commented.

Taste and smell may also be profoundly altered. In the Vanderbilt survey, most patients reported altered taste (68), a decreased desire to eat (68), altered food choices (66), and a decrease in food eaten (66). A change in sense of smell was reported by 69 patients.

Such alterations often result in changes in diet, including decreased consumption of high-fiber food and of vitamins and other nutrients,  along with increased consumption of fats, caffeine, and sugar. All of these factors increase the risk for dietary deficiencies, as well as  dental caries.

Yet, altered taste sensation is not something patients might think to mention. “Half of patients experience altered taste sensation. But if  they think you’re not interested or you don’t ask, you may not know,”  Dr. Epstein commented.

Periodontal health is often compromised by hyposalivation, which can lead to inflammation, bone/attachment loss, oral infection, and necrosis. Dental demineralization and cavitation may develop as early as 2-3 months after cancer treatment and progress rapidly, leading to fractures of the gum line, tooth loss, and necrosis.

Demineralization appears as a change to white, which may not be recognized as a problem because of the belief that white teeth are  healthy. However, recognition at this stage is critical in order to prevent further dental damage, he said.

“The white change near the gum line and the tips of the teeth represent demineralization, and [in] time reversal can be accomplished  prior to structural breakdown. Once cavitation has occurred, fillings are needed and prevention must be instituted or the cavities will  recur and progress,” Dr. Epstein said in an interview.

In the Vanderbilt survey, reported dental problems included difficulty chewing because of teeth/dentures (54 of the 70 patients); tooth  sensitivity to hot, cold, or sweet foods (52); teeth feeling looser (51); teeth cracking/chipping (50); and trouble with dentures (24).

Oral candidiasis is another common problem, affecting approximately 39% of head and neck cancer patients during treatment and 33% afterward. One common clinical mistake is prescribing these patients antifungals that contain sugar, such as nystatin. “Nystatin is very high in sugar, and one of the [most commonly] used antifungals. The message is to avoid sugar-sweetened products in dry mouth patients and utilize alternatives,” Dr. Epstein said in the interview.

Mucosal sensitivity and pain is also frequent. In a meta-analysis of 22 studies published between 1990 and 2008, the prevalence of trismus was 25.4% in patients who received conventional radiotherapy and 5% for the few intensity-modulated radiation therapy studies that were included, suggesting that the newer radiation modality might diminish the problem (Support. Care Cancer 2010;18:1033-8).

Data suggest that the radiation effect on mandibular movement correlates with the radiation dose to the mastication muscles, with a  steep dose-response curve. Onset is typically 2-6 months post treatment and is ongoing. Concurrent chemotherapy may increase the  incidence and/or severity of mandibular immobility (Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1999;88:365-73).

In the Vanderbilt survey, most patients reported burning in the throat or mouth (69); sensitivity to hot, spicy, or acid food (67);  sensitivity to dryness (69); and changes in food intake because of mucosal sensitivity (67); most patients also reported that mucosal  sensitivity prevents tooth brushing (63). “Mucosal sensitivity is a quality of life issue,” Dr. Epstein said.

The Vanderbilt survey was particularly illuminating, Dr. Epstein commented. Studies that utilize claims data probably underrepresent  the problem of long-term oral complications because dental and medical insurance are separate and the data are not easily combined, he added.

“Late oral effects are best diagnosed [and] managed in a multidisciplinary team with close communication between medical and  dental providers. … We really need to come together.”

The Multinational Association of Supportive Care in Cancer is developing tools to improve communication between dentistry and  medicine. These could be available for beta testing as early as this fall.

Dr. Epstein said he had no relevant financial disclosures.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

 

March, 2012|Oral Cancer News|

IMRT provides better QOL in head and neck cancers

Source: www.oncologyreport.com/
AUthor: Miriam E. Tucker

Intensity-modulated radiotherapy is more expensive than 3-D–conformal radiotherapy is and has not been shown to improve standard outcomes in patients with head and neck cancer. But it results in better quality of life. These findings from two studies presented at the Multidisciplinary Head and Neck Cancer Symposium raise the question: Does improved quality of life justify the greater expense of intensity modulated radiotherapy (IMRT), which has been rapidly adopted for the treatment of head and neck cancer?

Because IMRT spares surrounding tissues, it reduces the likelihood of developing xerostomia, noted Dr. Nathan C. Sheets, who presented data on billing charges associated with IMRT, compared with 3-D–conformal radiotherapy (CRT). IMRT is reimbursed at a substantially higher level than CRT, however, and it is unclear how to assess this cost relative to other aspects of care in this population, said Dr. Sheets, a radiation oncology resident at the University of North Carolina, Chapel Hill.

A separate study presented by Dr. Allen M. Chen compared quality of life in patients who received IMRT vs. CRT. “There’s very little data to suggest IMRT is better than non-IMRT using traditional end points. But the question is: How do you define ‘better’?” said Dr. Chen, director of the radiation oncology residency training program at the University of California, Davis in Sacramento.

“IMRT might not particularly involve better cure rates, but it could make a difference in terms of other end points, such as quality of life, which we all know is very important to patients,” he said.

Gap Ranges from $5,000 to $6,000
The cost study analyzed data for 184 patients who had received definitive radiation therapy for head and neck squamous cell cancer at the University of North Carolina at Chapel Hill during 2000-2009 and for whom billing records were available.

The median year of treatment was 2004 for 89 patients treated with CRT, and 2007 for 95 IMRT patients, reflecting the shift to use of IMRT over time. The majority of patients – 87% of CRT and 94% of IMRT – received concurrent chemotherapy. More IMRT patients received positron emission tomography (PET) scans at any point (69% vs. 37%).

Over 36 months’ follow-up, locoregional control was nearly identical for the two patient groups (P = .73). Mean total costs, from the time of diagnosis through the first year of follow-up, were considerably higher for IMRT, at $50,502 vs. $38,977 for CRT. Outpatient costs accounted for the bulk of the difference ($35,418 IMRT vs. $22,696 CRT), whereas inpatient costs were similar, Dr. Sheets reported.

Multivariate analysis showed that factors associated with increased cost of radiotherapy included IMRT, recurrent disease, comorbidities, non-white race, and use of positron-emission scanning. After adjustment for inflation, each of these factors, including IMRT, independently increased the total cost by approximately $5,000-$6000. (Treatment failure was much more expensive, contributing about $14,274 to the total cost.)

Dr. Sheets ended his presentation with the question, “Do the benefits of IMRT outweigh the costs?”

QOL Improves Over 2 Years’ Follow-up
Dr. Chen’s quality of life study addressed that question. The study used the University of Washington Quality of Life instrument (UW-QOL), a previously validated, self-administered questionnaire given to patients returning for follow-up after completion of radiation therapy for head and neck cancer. The University of California, Davis, routinely uses the measure in clinical practice.

Scores on the UW-QOL were retrospectively reviewed for 155 patients with squamous cell carcinomas of the head and neck requiring bilateral neck irradiation for locally advanced disease. Only patients who were clinically without evidence of recurrent disease and with at least 2 years of follow-up were included in the analysis. Definitive radiation therapy was given to 82 patients (53%), while 73 (47%) underwent postoperative treatment.

IMRT was used in 84 patients (54%), with inclusion of the low neck in an extended field. The remaining 71 patients (46%) were treated with 3-D–CRT using opposed lateral fields matched to a low anterior neck field. Concurrent chemotherapy was administered with radiation therapy for 73 patients (47%).

The mean global quality of life scores for the IMRT patients were 67.5 at 1 year and 80.1 at 2 years, compared with 55.4 and 57.0, respectively, for the CRT patients (P less than .001). At 1 year after completion of radiation therapy, the proportion of patients who rated their global quality of life as “very good” or “outstanding” 51% of the IMRT patients, compared with 41% of those treated with CRT (P = .11).

Those numbers became statistically significant at 2 years, with “very good” or “outstanding” quality of life reported by 73% of the IMRT patients and 49% of the CRT group (P less than .001). At last follow-up, 80% of patients treated by IMRT reported that their health-related quality of life was “much better” or “somewhat better,” compared with the month before developing cancer, compared with 61% among patients treated by 3-D–CRT (P less than .001).

On multivariate analysis accounting for gender, age, radiation intent (definitive vs. postoperative), radiation dose, T stage, primary site, use of concurrent chemotherapy, and neck dissection, the use of IMRT was the only variable independently associated with improved quality of life (P = .01).

In 1- and 2-year analyses of factors contributing to the difference in UW-QOL score, only “saliva” was found to be significantly different between IMRT and CRT (P less than .001) for both time points. Other examined factors that did not affect the score included pain, appearance, activity, recreation, chewing, swallowing, speech, mood, and anxiety.

“Treatments for dry mouth are fairly primitive and ineffective at present, so preventing dry mouth is so critical. It’s a huge problem. Imagine not being able to make any saliva. And, there are health consequences with respect to things like oral hygiene and dental caries. There’s a cost associated with chronic dry mouth,” Dr. Chen said in the interview.

Increased Cost Not That Big
The increase in cost with IMRT isn’t that big, Dr. Bhisham Chera, the principal investigator for the cost study and a radiation oncologist at the University of North Carolina said in an interview.

“On average, it was about $5,000-$6,000 more total,” he said. “It is more expensive, but what was shocking to me is that it wasn’t much more expensive as some therapies – like newer chemotherapy drugs, compared to older ones, where there’s a hundred thousand dollar difference in cost and the survival improvement is only a few months.”

“We think the incremental increase in cost is justified because of the improvement in dry mouth. If you really compare it to other therapies such as using transperineal prostatectomy vs. robotic prostatectomy or cisplatin vs. cetuximab chemotherapy, the cost difference is vastly greater,” he added. “Here, the incremental difference is not that much. It is more expensive, but it’s not astronomically more expensive.”

Note: Dr. Sheets, Dr. Chen, and Dr. Chera all stated that they had no disclosures.

February, 2012|Oral Cancer News|

Review Finds Evidence Lacking for Dry Mouth Remedies

Source: Medscape Today

December 28, 2011 — There is not enough evidence to recommend any topical therapies for dry mouth, but that does not mean that they do not work, according to investigators who published a review of research on the therapies online December 4 in the Cochrane Library.

“There was very little evidence,” said Helen Worthington, PhD, a professor of evidence-based care at the University of Manchester, United Kingdom.

Dr. Worthington and colleagues scoured the literature for randomized controlled trials of topical therapies for dry mouth, or xerostomia. They found 36 studies of treatments such as lozenges, sprays, mouth rinses, gels, oils, chewing gum, and toothpaste.

Xerostomia often results from treatments for head and neck cancer that damage the salivary glands, as well as from Sjögren’s syndrome, an autoimmune disorder that also damages these glands. It is also a common adverse effect of many medications.

The authors cite an estimated prevalence of dry mouth of about 20% in the general population. This percentage may be increasing because people are living longer and suffering from more chronic illnesses for which the treatments can have xerostomia as an adverse effect.

It is possible to feel the sensation of dry mouth without having a clinically reduced saliva flow, the researchers point out.

The treatments in the review broke down into 2 broad categories: saliva substitutes, in which some other substance is intended to perform the role of the patient’s own saliva, and saliva stimulants, which are intended to activate the patient’s own mechanism for producing saliva.

Two of the trials compared saliva stimulants with placebos, 9 compared saliva substitutes with placebos, 5 compared saliva stimulants with saliva substitutes, 18 compared 2 or more saliva substitutes with each other, and 2 compared 2 or more saliva stimulants with each other.

The researchers found convincing evidence that 1 saliva substitute, oxygenated glycerol triester saliva spray, was more effective than another, an electrolyte spray (standardized mean difference, 0.77; 95% confidence interval, 0.38 – 1.15). This corresponded to an approximate mean difference of 2 points on a 10-point visual analog scale in which patients rate their mouth dryness.

However, this evidence did not actually prove that either substitute was useful for treating dry mouth, Dr. Worthington said.

The researchers concluded that an integrated mouth care system (toothpaste, gel, and mouthwash) looked promising, as did oral reservoir devices. Here again, however, the evidence was not quite strong enough to recommend either one.

Asked to comment on the review, Joel Napeñas, DDS, a specialist in saliva disorders at Carolinas Medical Center in Charlotte, North Carolina, told Medscape Medical News that it is still possible to treat dry mouth despite the lack of evidence for a particular therapy.

“There are a lot of nonrandomized controlled trials that do show variable results,” said Dr. Napeñas, who was not involved in the Cochrane review. “Since there is no strong evidence for any individual agent, we are left with trial and error on an individualized basis.”

Dr. Napeñas begins by measuring saliva flow: He has the patient spit into a cup and then asks the patient to suck on something like a piece of wax and spit again to see whether the sucking action increases the patient’s saliva flow.

If the saliva flow increases, this suggests that saliva stimulants may work. Barring contraindications, therefore, Dr. Napeñas prescribes systemic saliva stimulants, usually pilocarpine or cevimeline, often in combination with topical stimulants.

If the experiment does not increase saliva flow, Dr. Napeñas instead recommends various saliva substitutes. He also typically recommends that patients try a variety of topical therapies to see what works best. “Biotene-type products are some of the first we would go to,” he said.

Frequently sipping water and sucking on ice can help many patients, he said. He advises patients to avoid caffeine and alcohol, which can worsen symptoms, and he pointed out that patients with xerostomia should avoid many commercial mouth rinses because they contain alcohol.

Dr. Napeñas also initiates preventive measures to prevent caries, including topical fluoride, prescription fluoride products, and frequent recalls, because patients with low saliva flow are at high risk for caries.

“It’s a very difficult condition to treat,” he said. “The way I approach it is to throw everything I can at it.”

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

December, 2011|Oral Cancer News|

Consider dental issues before beginning cancer treatment

Soure: www.curetoday.com/
Author: Lacey Meyer

Dentists advise resolving tooth and gum issues before starting cancer treatment.

Bettye Davis admits she has never had very good teeth. But when she received a diagnosis of salivary gland cancer, she was surprised that her oncologist recommended she visit a dentist before beginning radiation treatments to her jaw.

“When we first saw her, she still had quite a few teeth, but she had severe periodontal disease and severe bone loss,” says Dennis Abbott, DDS, Davis’ dentist. Knowing radiation would do more damage, he recommended removing the remainder of her teeth and allowing time to heal before she began 33 radiation treatments.

“We knew that if we took the teeth out after radiation, we risked the bone not healing well, which would have meant osteonecrosis, dead bone in her mouth, and lots of systemic problems.”

According to the National Cancer Institute, eliminating pre-existing dental and mucosal infections and instituting a comprehensive oral hygiene protocol before and throughout therapy can reduce the severity and frequency of oral complications from cancer therapy. Abbott says the NCI recommendations, as well as an increasing number of studies, are bringing more recognition to the importance of dental issues before, during and after cancer treatment.

A Proactive Approach
Abbott’s goal is to help patients maintain healthy teeth and reduce the risk of future infection with an oral care plan that eliminates or stabilizes disease that could produce complications during or following therapy. These complications can range from irradiated bone and gums not healing properly to an oral bacterial infection spreading throughout the body due to chemotherapy-induced immunosuppression.

Radiation to the head and neck area can also cause severe dry mouth (xerostomia) and loss of the protective effects of saliva, which accelerates existing tooth decay and can damage tiny blood vessels in the bone that deliver nutrients and oxygen that allow the bone to grow. So any tooth extractions or invasive dental procedures in irradiated bone are likely to result in slow healing, leading to pain and infection.

Oral complications may be acute (developing during therapy) or chronic (developing or continuing long after therapy), with the most common and significant being oral mucositis (inflammation and ulcers in the lining of the mouth), salivary gland dysfunction, taste dysfunction, pain and dry mouth. Limited or no saliva can lead to increased risk of infections in the mouth, gum disease and dental disease, which can progress rapidly and be difficult to control.

Available medications to stimulate saliva production rely on residual salivary gland function, if enough function remains. Mouth gels, rinses and sprays can moisturize the mouth, but unlike natural saliva, they don’t contain antibodies; growth and repair factors; fluoride; and calcium phosphates that help keep teeth healthy and strong.

Abbott says this means patients must be proactive in caring for their teeth to prevent cavities. Topical antimicrobials or antiseptics can also help control infections, including dental decay related to acid-producing bacteria.

Oral Health and Overall Health
With radiation therapy directed at her salivary glands, Davis, 73, experienced extreme dry mouth, especially at night. But, she says, a mint-flavored antioxidant topical gel Abbott prescribed, AO ProVantage, effectively relieved this symptom. “It has really helped because it keeps your mouth refreshed, plus it helps you have more moisture in your mouth,” Davis says.

The decision to extract teeth prior to radiation, Abbott says, is based on the health of the tooth, the condition of the gums and bone around the tooth, the amount of radiation the bone around the tooth is scheduled to receive and the area that will be radiated. Gum disease is a cause for tooth extraction prior to therapy. Other causes include problems with previous root canals, tooth fractures and broken fillings that can’t be adequately restored.

“You can’t dismiss oral health because it affects systemic health,” Abbott says. “The mouth has a huge amount of bacteria, and if it’s not taken care of, there is the risk of that bacteria getting into the bloodstream.”

Catching Up to Get Ahead
The American Dental Association recommends all cancer patients schedule a dental exam at least two weeks before beginning treatment. This should involve a full comprehensive exam, gum probing around every tooth and X-rays. It may also include removal of local sites of irritation, such as broken teeth, or identifying chronic infections, such as gum disease.

“Those conditions need to be managed up front because we are very limited after treatment and the complication risk is so significant that not doing it before can lead to significant difficulties after,” says Joel Epstein, DMD, MSD, director of oral medicine services at City of Hope Cancer Center in Duarte, Calif.

Appropriate healing time for dental care prior to treatment is imperative, Epstein adds, because a surgically treated area in the mouth becomes vulnerable to bacteria. Patients with suppressed immune systems can develop infection, which could result in a treatment delay or dose reduction, ultimately affecting the treatment outcome and survival.

Epstein says two weeks of healing time is ideal, but the overall goal is to have the right dental treatment coordinated with medical therapy to avoid those types of risks. Therefore communication between the dentist and oncology team is key.

Dental Care During Treatment
Treating dental issues during cancer therapy is possible but can be difficult and can also lead to complications, such as infection in patients on immunosuppressing chemotherapy and delayed healing of affected oral tissue in patients receiving high-dose radiation.

If dental treatment is needed during a cycled chemotherapy, it must be coordinated between cycles and at a time when white cell counts are high, Epstein says.

For patients receiving radiation for head and neck cancers, the dentist needs to understand the risks for healing and communicate with the oncologist to understand which regions are involved in the radiation fields, Epstein says. The dentist should also be aware of any previous or ongoing bisphosphonate use and understand the associated risks.

“We function as a part of the oncology team for all of our patients,” Abbott says. “I understand the blood work that I get back, and I understand what it is that I need to look for in order to keep the patient safe and then develop my treatment plan around that.”

Preparation and Coordination
A less common but significant oral complication involves bone healing, or lack thereof. Because radiation can damage bone cells, limiting their ability to heal, any future trauma or surgery to irradiated bone can cause osteonecrosis, or bone death.

Bisphosphonates and the RANK ligand inhibitor Xgeva (denosumab)—used to maintain bone density and prevent fractures in people with bone metastases—have also been associated with increased risk for osteonecrosis of the jaw (ONJ), which can occur in 1 to 2 percent of patients on these therapies, according to a 2010 study published in the Journal of Clinical Oncology.

A study published in 2009 in Annals of Oncology showed that preventive dental measures can significantly decrease the risk of developing ONJ. In 2003 and 2004, the FDA updated inserts for the intravenous bisphosphonates Aredia (pamidronate) and Zometa (zoledronic acid) recommending a dental exam with preventive dentistry prior to cancer treatment.

“The main prevention is treatment of the at-risk dental conditions before you’ve had a long-term effect on the bone,” Epstein says. The FDA also warns against invasive dental procedures if possible during or following bisphosphonate use, noting that the majority of reported cases of ONJ have been associated with dental procedures, such as tooth extraction, and many had signs of local infection.

Whether a tooth is extracted from an irradiated area or following bisphosphonate use, Epstein says it must be done carefully. “You want a specialist surgeon to do that with coordination with the cancer center and with people who have supported this need before.”

Therapies Making “A Huge Difference”
After her diagnosis of metastatic renal cell carcinoma in 2009, Linda Morris had two extractions before starting Zometa. When an exposed jaw area wouldn’t heal, she developed osteonecrosis. After visiting six dentists over two years, the 67-year-old saw Abbott.

To prevent infection, Abbott had her apply AO ProVantage twice daily and rinse her mouth with non-alcoholic antibacterial chlorhexidine, as well as clean her teeth with a water flosser. To promote healing, Abbott removed necrotic tissue and performed a comprehensive cleaning every two weeks. For the first time, Morris began to see progress.

“The biggest problem I had was not being able to find the dental care I needed,” Morris says.

“The topically applied gel has made a huge difference in how we can treat this problem,” Abbott says. “We’ve had two cases where the necrotic bone has been totally resolved.”

December, 2011|Oral Cancer News|

Acupuncture can prevent radiation-induced chronic dry mouth

Source: http://www.virtualmedicalcentre.com
Author: staff

When given alongside radiation therapy for head and neck cancer, acupuncture has shown for the first time to reduce the debilitating side effect of xerostomia, according to new research from The University of Texas MD Anderson Cancer Center and Fudan University Shanghai Cancer Center.

The study, published in the journal Cancer, reported findings from the first randomised controlled trial of acupuncture for the prevention of xerostomia.

Xerostomia, or severe dry mouth, is characterised by reduced salivary flow, which commonly affects patients receiving radiotherapy for head and neck cancer. Most current treatments are palliative and offer limited benefit, according to Lorenzo Cohen, Ph.D., professor in MD Anderson’s Departments of General Oncology and Behavioral Science and director of the Integrative Medicine Program.

The condition impairs quality of life for patients, as it creates difficulties eating, speaking and sleeping, while also increasing the risk for oral infections.

“There have been a number of small studies examining the benefits of acupuncture after xerostomia develops, but no one previously examined if it could prevent xerostomia,” said Cohen, who is also the study’s principal investigator. “We found incorporating acupuncture alongside radiotherapy diminished the incidence and severity of this side effect.”

Cohen and his colleagues examined 86 patients with nasopharyngeal carcinoma, treated at Fudan University Shanghai Cancer Center. Forty patients were randomised to acupuncture and 46 to the standard of care. Those in the treatment arm received acupuncture therapy three times per week during the seven-week course of radiotherapy. Patients were evaluated before radiotherapy, weekly during radiotherapy, and then again one and six months later.

The results were based on data derived from two self-report questionnaires and measuring actual saliva flow. Patients completed the Xerostomia Questionnaire (XQ), an eight-item survey which assessed symptoms consistent with the condition. XQ scores under 30 corresponded to mild or no symptoms of xerostomia.

The second measure, MD Anderson Symptom Inventory Head and Neck (MDASI-HN), ranked the severity of cancer-related symptoms, other than xerostomia, and their interference with quality of life. The team also measured saliva flow rates using standardised sialometry collection techniques.

Benefits Noticed Quickly

“What was quite remarkable was that we started to see group differences as early as three weeks into radiotherapy for the development of xerostomia, cancer-related symptoms that interfere with quality of life, and saliva flow rates – an important objective measure,” said Zhiqiang Meng, M.D., Ph.D., co-principle investigator of the study and deputy chair of the Department of Integrative Oncology, Fudan University Shanghai Cancer Center.

The largest group differences in XQ scores were seen by the end of radiotherapy, but the differences persisted over time. By one month after the end of radiotherapy, 54.3 percent of the acupuncture group reported XQ scores greater than 30, compared to the control group at 86.1 percent. By six months after radiotherapy, the numbers dropped to 24.1 percent in the acupuncture group and 63.6 percent of the control group still reporting symptoms of xerostomia. Saliva flow rates were also greater in the acupuncture group, starting at three weeks into radiotherapy and persisting through the one and six month follow-up.

Acupuncture also helped cancer-related symptoms, other than xerostomia, as measured by the MDASI-HN questionnaire, with differences that emerged in week three and continued through six months.

“The medical implications are quite profound in terms of quality of life, because while chronic dry mouth may sound benign, it has a significant impact on sleeping, eating and speaking,” Cohen said. “Without saliva, there can be an increase in microbial growth, possible bone infection and irreversible nutritional deficits.”

Additional studies are needed to determine the mechanisms for the benefits of acupuncture, and while the study didn’t examine this issue, Cohen said it may have an impact on local blood flux, specifically at the parotid gland.

Further research is planned, including a large trial conducted at MD Anderson in collaboration with Fudan University Shanghai Cancer Center. Both centers will enroll 150 patients undergoing radiotherapy for head and neck cancer: 50 will receive acupuncture, 50 sham acupuncture and 50 will be enrolled in a control group. Researchers will also examine saliva constituents and a number of other measures to better determine the mechanisms of acupuncture.

Source: MD Andersen Cancer Center: Cancer

November, 2011|Oral Cancer News|

Proper dental care for cancer patients: why it is important

Source: newcanaan.patch.com
Author: Alan B. Sheiner DDS

Common side effects from radiation therapy are not stressed enough in dental schools, but they can be managed and even prevented.

A few weeks ago, I was contacted by a retired physician with whom I had not spoken for a number of years since he retired from practice to become a “gentleman farmer” in the country. While I was happy to hear from him, his news was not so good. He was calling because he had been treated for base of tongue cancer and his teeth were “coming apart”. His cancer treatment consisted of chemotherapy and radiation therapy. Unfortunately, he somehow “slipped through the cracks” and his oral cavity was now suffering from some of the side effects of the cancer therapy – fortunately he is currently cancer free.

The oral cavity, one of the most complex and visible organ systems in the body, is invariably compromised as a result of treatment for head and neck cancer. Whether the malignancy is to be treated by surgery, radiation therapy, chemotherapy or a combination of these modalities, the function, if not also the form, of the oral cavity will be impacted. Aside from the obvious physical changes after cancer surgery to the head and neck region, there are issues which usually accompany radiation therapy to the head and neck region.

There may be side effects from cancer therapy, some of which can be devastating, but preventable or manageable with proper precautions and care. The most common side effects for head and neck cancer patients who undergo radiation therapy are:

Dry Mouth (xerostomia)
Post Radiation Tooth Decay
Inability to open the mouth wide (Trismus)
Necrosis of soft tissue and bone (osteoradionecrosis)
Impaired ability to heal from wounds in the oral cavity

Prior to commencement of active treatment, each patient should be thoroughly evaluated by a dentist well versed in the management and care of the irradiated head and neck cancer patient. Unfortunately, this subject has not been stressed in dental school. Even if a dentist has had some instruction, his or her clinical experience might be quite limited. A real life example of this is a lady irradiated for a parotid gland tumor. The parotid gland (we have two) is a major salivary gland. Her general dentist provided her with fluoride applicators, but unfortunately this practitioner did not appreciate the importance of using a neutral pH fluoride gel. The acidulated fluoride gel, normally used when a dentist or hygienist gives a fluoride treatment, literally ate into the surfaces of this woman’s porcelain crowns. Now, in addition to having a dry mouth from radiation, she also has multiple crowns with surfaces like sandpaper. These expensive restorations could not be salvaged and required replacement. In short, the dentist remembered that radiated patients should have daily fluoride treatment. He just did not have a genuine understanding of how to accomplish the task properly.

The most common and profound side effects of irradiation to the head and neck region are: dry mouth (since the major salivary glands are almost always damaged by the therapy), post-irradiation dental caries (a preventable situation), the risk of osteoradionecrosis (non-healing chronic bone death in irradiated bone which has a compromised blood supply) and trismus (an inability to open the mouth fully).

As always, your dentist is the best resource and first person you should see for consultation.

October, 2011|Oral Cancer News|

New Guidelines for Reirradiation of Head and Neck Cancer

Source: Medscape News Today

When head and neck cancer recurs and surgery is not an option, reirradiation provides the only potentially curative option. However, because the tumor often recurs in the same place or very close to tissue that has already been irradiated, this treatment approach represents a “significant challenge.”

For this reason, it should be handled at a tertiary-care center, according to a new guideline issued by the American College of Radiology. Specifically, it stipulates that the tertiary center should have a head and neck oncology team that is equipped with the resources and the experience to manage the complexities and toxicities of retreatment.

In the guideline, published in the International Journal of Radiation Oncology, Biology and Physics, a panel of experts outline appropriateness criteria for various clinical scenarios that arise with such patients.

It provides a consensus on how patients should be managed.

“This is an important document because it is the first set of guidelines for the potentially curative treatment of patients who have regrowth of head and neck tumors. It provides a consensus on how patients should be managed,” coauthor Madhur Kumar Garg, MD, said in a statement. Dr. Garg is from the Department of Radiation Oncology at Montefiore Medical Center, in the Bronx, New York, where about a dozen reirradiation procedures are performed annually.

Commitment to Retreatment

Retreatment is justified because clinical trial results have shown that local treatment improves overall survival, the panel of experts notes.

However, they emphasize that, before a commitment to retreatment is made, patients presenting with recurrent or second primary tumors need to undergo careful restaging evaluation. In addition to computed tomography (CT) or magnetic resonance imaging to evaluate the extent of the recurrent tumor, the panel urges that strong consideration be given to positron emission tomography with CT to evaluate for metastatic disease, or “at a minimum, a CT scan of the chest should be performed.”

In addition, a detailed history and assessment is needed, which includes documentation of the sequelae of previous treatment, such as fibrosis, carotid stenosis, dysphagia, xerostomia, and osteoradionecrosis.

Retreatment options include surgical resection and palliative chemotherapy — both are regarded as standard of care, the panel writes. But for patients with unresectable disease, reirradiation is the “only potentially curative treatment,” they add.

Two phase 2 clinical trials conducted by the Radiation Therapy Oncology Group (RTOG) have shown survival outcomes with reirradiation plus chemotherapy that appear to be superior to those seen with chemotherapy alone in other studies. However, “whether this apparent improvement is the result of selection bias is uncertain,” the panel explains. A larger phase 3 comparing reirradiation plus chemotherapy with chemotherapy alone was closed because of poor accrual.

In terms of the dose of radiation delivered in the second treatment course, it appears that at least 50 to 60 Gy is needed, the experts report. Both of the phase 2 studies conducted by the RTOG delivered a total dose of 60 Gy, using an accelerated hyperfractionated regimen delivering 1.4 Gy twice daily in 4 week-on/week-off cycles. Multiple single-institution reports of reirradiation have used once-daily standard fractionation in a planned continuous treatment course with less toxicity, they note. However, differences in study designs and in the chemotherapy regimens make it difficult to discern what independent effect, if any, differences in radiation fractionation had on the toxicity that was seen.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

October, 2011|Oral Cancer News|

Palifermin Decreases Severe Oral Mucositis of Patients Undergoing Postoperative Radiochemotherapy for Head and Neck Cancer: A Randomized, Placebo-Controlled Trial

Source: OncologyStat.com

TAKE-HOME MESSAGE

This randomized, placebo-controlled trial found that weekly palifermin was associated with decreased incidence and duration of severe oral mucositis in patients undergoing postoperative chemoradiotherapy for head and neck cancer.

SUMMARY

OncologySTAT Editorial Team

Combined chemoradiotherapy (CRT) offers improved outcomes after resection of locally advanced head and neck cancer but also increases the risk of oral mucositis, a debilitating and potentially dose-limiting toxicity of locoregional treatment. Palifermin, an analogue of keratinocyte growth factor, is FDA approved to prevent and treat mucositis in patients undergoing high-dose myelotoxic therapy for hematologic malignancies. In this multicenter, randomized, placebo-controlled trial, Henke et al evaluated whether palifermin reduces severe oral mucositis in patients undergoing CRT after surgical resection of locally advanced head and neck cancer.

Adult patients receiving postoperative CRT for high-risk stage II to IVB head and neck squamous cell carcinoma and with an ECOG performance status of 0 to 2 were enrolled from 38 centers in Europe, Australia, and Canada. Eligible study patients were stratified by tumor location (oral cavity/oropharynx or hypopharynx/larynx) and residual tumor (R0 [complete resection] or R1 [incomplete resection]). Study patients received a radiation dose of 60 Gy (R0 group) or 66 Gy (R1 group) plus cisplatin 100 mg/m2 on days 1 and 22, with the study drug administered 3 days prior to starting CRT and then weekly for 6 weeks. Patients who underwent radiotherapy after 6 weeks received an additional 100 mg/m2 of cisplatin and study drug. Oral saline rinses, topical anesthetics, feeding tubes, and hematopoietic growth factors were permitted; oral anti-inflammatory, antifungal, or antibiotic solutions were not permitted.

Patients initially were randomized to three treatment arms: weekly palifermin 180 µg/kg throughout CRT, weekly palifermin 180 µg/kg for 4 doses followed by weekly placebo through the remainder of CRT, or weekly placebo throughout CRT. However, adverse event monitoring led to a restart of the study after enrollment of the first 17 patients, with subsequently enrolled patients randomized to receive weekly palifermin 120 µg/kg (n = 92) or weekly placebo (n = 94) throughout CRT (for a minimum of 7 weeks); efficacy analyses were based on these 186 patients. The primary endpoint was the incidence of severe oral mucositis (WHO grade 3 or 4). Oral mucosa assessments occurred twice weekly throughout CRT and until resolution of oral mucositis to WHO grade ≤ 2 or week 15, whichever occurred first. Among secondary endpoints were duration of and time to onset of severe oral mucositis, incidence of grade ≥ 2 xerostomia at month 4, and incidence of treatment breaks (≥ 5 missed consecutive radiation fractions; chemotherapy delays or discontinuation). Time to disease progression and overall survival (OS) also were assessed.

Of 186 patients randomized to weekly palifermin 120 µg/kg or placebo, 79 in the palifermin arm (86%) and 82 in the placebo arm (87%) completed all oral evaluations. Patients in the palifermin group received a mean radiation dose of 59.7 Gy in a mean of 43.5 days and a mean cumulative cisplatin dose of 217.1 mg/m2. Patients in the placebo group received a mean radiation dose of 59.8 Gy in a mean of 43.2 days and a mean cumulative cisplatin dose of 206.4 mg/m2. Severe oral mucositis was observed in 47 patients (51%) in the palifermin group and 63 patients (67%) in the placebo group (P = .027). The median duration of severe oral mucositis was 4.5 days in the palifermin group vs 22.0 days in the placebo group (P = .037), and the median time to develop severe oral mucositis was 45 vs 32 days (P = .022), respectively. Incidence of grade ≥ 2 xerostomia at month 4, incidence of treatment breaks, time to disease progression, and OS did not differ significantly between the two groups.

In conclusion, weekly palifermin at a dose of 120 µg/kg was associated with reduced incidence, increased time to development, and decreased duration of severe oral mucositis in patients undergoing postoperative CRT for locally advanced head and neck cancer. However, differences in other efficacy endpoints were not statistically different in patients receiving palifermin. Further study of palifermin in this patient population is needed.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

September, 2011|Oral Cancer News|