Dental Advice

This information page was developed after feedback identified a lack of online information to inform patients when they are diagnosed with head and neck cancer. The information leaflet was developed through collaboration between Oracle Head and Neck Cancer UK, a specialist in Restorative Dentistry, and our patient and carers group, Oracle Voices.

Prehabilitation

A pre-treatment assessment appointment with a specialist in restorative dentistry is important if the cancer or its treatment could affect your oral health.

Dental extractions before cancer treatment

The restorative dentist may recommend removal of teeth prior to cancer treatment. This is to remove infected/decayed teeth and reduce the chance of dental complications in the future. Keeping healthy teeth and supporting your oral health is the priority, however in some cases many or all your teeth may require removal, especially if they are very decayed or wobbly. Current recommendations advise 2-3 weeks of gum healing between dental extractions and the start of radiotherapy.

Radiotherapy affects the ability of your jaw bone to heal. Keeping decayed teeth or delaying dental extractions increases your chance of developing a non-healing or infected jaw bone (osteoradionecrosis). Osteoradionecrosis develops in 7-10% of people who have extractions following radiotherapy. This is a condition which is difficult to treat, and can result in significant pain, infection, and limitation to your mouth opening.

Dental rehabilitation

Some patients will experience a significant deterioration in their oral health following cancer treatment. This can be a direct consequence of cancer treatments, or a result of dental decay and gum disease occurring after cancer treatment.

Long-term prevention of this is particularly important and typically involves a combination of:

All tooth replacement options require very good attention to oral hygiene. It is important to consider your ability to achieve this when considering which option is right for you. It is also important to note that you may not require tooth replacement options if you are missing no teeth, or only a small number of back teeth. Many people find that they can eat, speak, and smile without any difficulty if this is the case.

Dentures

Dentures are a useful way to replace teeth, particularly if you are missing many teeth. They can also be useful as a temporary replacement for your missing teeth. They often have a good appearance as they can replace both teeth and gum, and can in some cases provide support to your face if surgery has affected this.

Dentures are a removable replacement for tooth. This means that you typically remove dentures to clean them, and keep them out overnight or for a few hours each day. This helps to maintain the health of your gum. Dentures rely on health gum to help keep them stable and comfortable. This also means that if your mouth is sore, dry, or unhealthy then denture wearing may be uncomfortable or impossible. The extent and type of surgery you have had, and the area of radiotherapy you have had will also affect this.

Bridges

Dental implants

1. Implant/prosthetic planning with a CT scan of the jaw
2. Implant placement (possibly with bone grafting)
   • In some cases bone grafting may need to be performed four-nine months before implant placement
   • Three months of bone healing after implant placement is needed to ensure predictable healing of jaw bone up to the implants.
3. Implant restoration (making and fitting a bridge or denture to fit onto the implants)
   • This process required 6-7 appointments spaced two-three weeks apart

Figure 2 shows examples of tooth replacement with implants.

Tooth replacement options are personal to you. Your cancer team, including your restorative dentist, will discuss the risks and benefits of each option as well as what the potential treatment will involve. The aim of this process is to guide you through your oral rehabilitation decision making process. It is important to note that smoking and oral hygiene both affect the success of tooth replacement options. You must quit smoking and ensure that you have good oral hygiene before implant treatment can be provided.

Contact your restorative dentistry specialist for guidance on the options that are available to you.

Osteoradionecrosis (ORN)

Osteoradionecrosis is a complication of radiotherapy. This typically develops in the months or years following completion of radiotherapy. It is the necrosis (death) of jaw bone due to the body’s impaired ability to heal and maintain tissues after irradiation. The condition affects 7-10% of people who have had radiotherapy and is more likely to occur if you:

1. Have had dental extractions after radiotherapy
2. Needed a large number of dental extractions before radiotherapy
3. Smoked, especially during or after radiotherapy
4. Have poor oral hygiene during or after radiotherapy
5. Receive a high radiotherapy dose to the lower jaw bone

Prevention

Prevention is the best management of osteoradionecrosis. A restorative dentistry assessment involving “prehabilitation” and dental extractions (if required) is crucial to reducing the risk for osteoradionecrosis. Please see the oral rehabilitation section for more information. Long-term recall (dental check-ups) is also important to maintaining your oral health and, therefore, preventing dental infections and the need for dental extractions, which may increase the chances of osteoradionecrosis.

If dental extractions are required, it is important to re-evaluate the dose of radiotherapy given to the patient to determine the risk of osteoradionecrosis. Dental extractions may be undertaken in stages and combined with other treatments such as antibiotics, mouthwashes, and certain medications. There is no clear evidence on the best way to prevent osteoradionecrosis if dental extractions are required.

Treatment

Most cases of radiotherapy affect the lower jaw (approximately 90% of all cases), and can start with jaw pain or aching. In some cases, there may be no symptoms in the early stages of necrosis. Osteoradionecrosis is caused by a combination of changes to the strength of your jaw bone (which becomes more scarred/fibrous) and a reduced blood supply to the jaw bone. It is difficult to treat osteoradionecrosis, and there is not an effective cure for this.

In some cases, when the area of necrosis is very small, it may heal over time. Your doctor may prescribe antibiotics or a mouthwash to treat an infection and help you clean the area effectively.

It is common for loose fragments of bone to either be removed by a healthcare professional, or for these to come out by themselves. In some cases, the maxillofacial surgeon will clean the area surgically and remove larger areas of bone.

In addition, certain medications may help the tissues heal after osteoradionecrosis. There is no clear evidence whether any of these help; however, there is ongoing research in this area. One clinical trial (the RAPTOR trial) is investigating the use of three different medications in combination to treat osteoradionecrosis.

Osteoradionecrosis can progress, often at a slow rate. This can lead to infection coming out from the jaw bone or face. If left untreated, the condition can be life-threatening. In rare cases, the maxillofacial surgery team may remove a large portion of jaw bone in a similar manner to a cancer resection. They may then leave the remaining jaw bone to heal, using a plate to join separated fragments. Alternatively, the area may be reconstructed with a free flap, typically from your leg, hip, or shoulder. This surgery is difficult for the surgeon for the reasons outlined above: your tissues will be altered by radiotherapy and will, therefore, be more scarred and have less of a blood supply. Note – “Free flap surgery” involves the transfer of a patient’s own tissue from a donor site to a recipient site, which is typically the site of a defect. The donor site usually has a distant location with respect to the recipient site.

Contact your restorative dentistry specialist for guidance on the options that are available to you.