Should oral foci of infection be removed before the onset of radiotherapy or chemotherapy?

Pretreatment dental screening aims to locate and eliminate oral foci of infection in order to eliminate local, loco-regional, or systemic complications during and after oncologic treatment. An oral focus of infection is a pathologic process in the oral cavity that does not cause major infectious problems in healthy individuals, but may lead to severe local or systemic inflammation in patients subjected to oncologic treatment. As head and neck radiotherapy patients bear a lifelong risk on oral sequelae resulting from this therapy, the effects of chemotherapy on healthy oral tissues are essentially temporary and reversible. This has a large impact on what to consider as an oral focus of infection when patients are subjected to, for example, head and neck radiotherapy for cancer or intensive chemotherapy for hematological disorders. While in patients subjected to head and neck radiotherapy oral foci of infection have to be removed before therapy that may cause problems ultimately, in patients that will receive chemotherapy such, so-called chronic, foci of infection are not in need of removal of teeth but can be treated during a remission phase. Acute foci of infection always have to be removed before or early after the onset of any oncologic treatment.

Patients with advanced periodontal disease before intensity-modulated radiation therapy are prone to develop bone healing problems: a 2-year prospective follow-up study.

PURPOSE: Intensity-modulated radiation therapy (IMRT) has changed radiation treatment of head and neck cancer (HNC). However, it is still unclear if and how IMRT changes oral morbidity outcomes. In this prospective study, we assessed the outcome of reducing post-IMRT sequelae by means of pre-radiation dental screening and eliminating oral foci. METHODS: All consecutive dentate patients > 18 years, diagnosed with primary oral or oropharyngeal carcinoma, referred for pre-treatment dental screening between May 2011 and May 2013, were included and followed for 2 years. Patients were treated with IMRT or IMRT with chemotherapy (CHIMRT). Dental screening data, demographic data, and data on oral sequelae during follow-up were recorded. Diagnosed oral foci were treated before start of the radiation therapy. RESULTS: Oral foci were found in 44/56 (79%) patients, consisting predominantly of periodontal breakdown. Bone healing problems after radiotherapy occurred more often in patients with periodontal pockets ≥ 6 mm at baseline (19 vs. 4% in patients with pockets < 6 mm). Osteoradionecrosis developed in 4/56 patients (7%) during follow-up. In line with this observation, multiple logistic regression analysis showed that the periodontal inflamed surface area, which is higher in patients with more severe periodontal disease, predicted that a patient has a higher risk on developing osteoradionecrosis or bone healing problems (p = 0.028). CONCLUSIONS: Patients with severe periodontal disease before IMRT/CHIMRT are more prone to develop bone healing problems post-radiotherapy.

Head and neck intensity modulated radiation therapy leads to an increase of opportunistic oral pathogens.

OBJECTIVES: The introduction of intensity modulated radiation therapy (IMRT) has led to new possibilities in the treatment of head and neck cancer (HNC). Limited information is available on how this more advanced radiation technique affects the oral microflora. In a prospective study we assessed the effects of various advanced treatments for HNC on the oral microflora, as well as the effects of elimination of oral foci of infection. MATERIALS AND METHODS: All consecutive dentate patients >18years, diagnosed with a primary oral or oropharynx carcinoma and seen for a pre-treatment dental screening (May 2011-May 2013) were included. Patients were grouped by oncologic treatment: surgery (SURG), IMRT (IMRT) or IMRT+chemotherapy (CHIMRT). Dental screening data, demographic data, subgingival biofilm samples, oral lavages and whole saliva samples were obtained to microbiologically analyze the effects of cancer treatments (1-year follow-up). RESULTS: This study included 82 patients (29 SURG, 26 IMRT and 27 CHIMRT). The trends in changes in prevalence and proportions of microorganisms were comparable in the IMRT and CHIMRT group. However, relative to the SURG group, increased prevalence of enteric rods, staphylococci and Candida species was observed in the IMRT and CHIMRT groups. In these groups, elimination of oral foci decreased the frequency of detection of pathogens such as Porphyromonas gingivalis, Tannerella forsythia and Streptococcus mutans. CONCLUSION: Different treatments in HNC patients result in different changes in the oral microflora. Opportunistic pathogens such as staphylococci, enteric rods and Candida sp. tend to increase in prevalence after IMRT with or without chemotherapy, but not after surgical intervention.

Evidence supporting pre-radiation elimination of oral foci of infection in head and neck cancer patients to prevent oral sequelae. A systematic review.

Pre-radiation dental screening of head-neck cancer patients aims to identify and eliminate oral foci of infection to prevent post-radiation oral problems. The evidence for the efficacy of dental screening is unclear. In this systematic review, we analyzed available evidence on the efficacy of pre-radiation elimination of oral foci of infection in preventing oral sequelae. A search was conducted (MEDLINE/EMBASE) for papers published up to May 2014. Papers on head-neck cancer patients subjected to pre-radiation dental screening, (chemo)radiation and oral follow-up were included. Of the 1770 identified papers, 20 studies fulfilled the inclusion criteria of which 17 were retrospective. A great heterogeneity in patient groups, dental screening techniques, definitions of oral foci of infection and techniques for eliminating foci was found. Most papers lacked essential details on how dental screening was performed and a clear definition of an oral focus of infection. The evidence for efficacy of elimination of oral foci of infection to prevent post-radiotherapy oral sequelae was inconclusive. Consequently, the efficacy of pre-radiation elimination of oral foci of infection remains unclear. No conclusions can be drawn about a definition of an oral focus of infection and whether pre-radiation elimination of these foci should be mandatory. We therefore suggest prospective studies with well-defined criteria for oral foci of infection, a clear description of which foci were eliminated and how, a detailed description of pre-radiation dental screening, clearly described patient and tumor characteristics, and a detailed dental history and dental status. Subsequently, oral problems that occur post-radiation should be systematically recorded.

Groningen temporomandibular total joint prosthesis: an 8-year longitudinal follow-up on function and pain.

Total temporomandibular joint replacement is a surgical procedure for patients with severe temporomandibular joint afflictions affecting quality of life, which have not responded beneficially to previous conventional surgery. The aim of this study was to assess the long-term outcome of the Groningen temporomandibular joint (TMJ) prosthesis in patients with chronic pain and mutilated temporomandibular joints following multiple surgical procedures, with respect to prosthesis failure, the patient's postoperative level of satisfaction and longitudinal changes in maximum mouth opening, functional mandibular impairment and pain. Eight female patients were studied in whom Groningen TMJ prostheses were inserted, two unilaterally and six bilaterally. The Groningen TMJ prosthesis was mechanically successful during 8 years of follow-up in seven out of eight patients with a disc dislocation being seen in one patient (7%). Patients were satisfied, despite the limited improvement of the maximum mouth opening, and pain scores. Although the decline of MFIQ scores during 8 years of follow-up was significant compared to baseline (p=0.027), the effects of the prosthesis on maximum mouth opening, function and pain were limited. This may be due to persistent chronic pain and the adverse effects of multiple previous surgical procedures.

Efficacy of routine pre-radiation dental screening and dental follow-up in head and neck oncology patients on intermediate and late radiation effects. A retrospective evaluation.

BACKGROUND AND PURPOSE: Head-neck radiotherapy is accompanied by a life-long risk of developing severe oral problems. This study retrospectively assessed oral foci detected during pre-radiation dental screening and follow-up in order to assess risk factors for developing oral problems after radiotherapy. MATERIALS AND METHODS: Charts of 185 consecutive head-neck cancer patients, subjected to a pre-radiation dental screening in the University Medical Center Groningen, the Netherlands, between January 2004 and December 2008 were reviewed. Eighty (partially) dentulous patients scheduled for curative head-neck radiotherapy met the inclusion criteria. RESULTS: Oral foci were found in 76% of patients, predominantly periodontal disease. Osteoradionecrosis had developed in 9 out of 80 patients (11%). Overall, patients presenting with periodontal pockets ≥ 6mm at dental screening had an increased risk (19%) of developing osteoradionecrosis compared to the total group of patients. Patients in whom periodontal disease treatment was composed of initial periodontal in stead of removal of the affected teeth, the risk of developing osteoradionecrosis was even higher, viz. 33%. CONCLUSIONS: A worse periodontal condition at dental screening and initial periodontal therapy to safeguard these patients to develop severe oral sequelae after radiotherapy were shown to be major risk factors of developing osteoradionecrosis.