|Year : 2018 | Volume
| Issue : 3 | Page : 251-256
Dental management prior to radiation therapy in patients with head and neck cancer
Paula Bonar Alvarez1, Mario Perez-Sayáns2, Mônica Ghislaine Oliveira Alves3, Mercedes Gallas Torreira1, María Elena Padín Iruegas4, Andrés Blanco Carrión1, Abel García-García5
1 Oral Medicine, Oral Surgery and Implantology Unit, Faculty of Medicine and Dentistry, Santiago de Compostela, Spain
2 Oral Medicine, Oral Surgery and Implantology Unit, Faculty of Medicine and Dentistry, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
3 Faculdade de Odontologia de São José dos Campos, Universidade Estadual Paulista, “Júlio de Mesquita Filho”, Brazil
4 Human Anatomy and Embryology Area, Faculty of Physiotherapy, Department of Functional Biology and Health Sciences, Pontevedra, Spain
5 Maxillofacial Surgery, Oral Medicine, Oral Surgery and Implantology Unit, Department of Maxillofacial Surgery, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
|Date of Web Publication||28-Jan-2019|
Dr. Paula Bonar Alvarez
Oral Medicine, Oral Surgery and Implantology Unit, Faculty of Medicine and Dentistry, Santiago de Compostela
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Patients diagnosed with head and neck tumors, are treated by surgery, radiation therapy (RT), chemotherapy (CT) or a combination thereof. The goal is to describe the management protocol for patients subjected to radiation therapy (RT) and to study their long-term oral health status. MATERIALS AND METHODS: A retrospective study was performed in a sample of 50 patients. We analyzed the oral health status and all the variables included applying the adapted protocol of pre-RT. RESULTS: Prior to RT, 84% of patients required scaling and 32% conservative treatment. Around 74% of patients required at least one exodontia. The mean of exodontias for patients presenting Grade 3 of oral hygiene was 6.50 per person (p<0.0001). The pre-RT study of possible candida infection showed that 78% of patients were negative for this infection. The mean resting saliva production was 39.10 (SD: 23.30; range: 13-145), with a stimulated value of 64.78 (SD: 33.92; range: 16-200). CONCLUSIONS: All patients should be protocoled to ensure that they present optimal oral conditions prior to initiating RT treatment.
Keywords: Head and neck tumors, oral health status, oral hygiene, radiotherapy, saliva
|How to cite this article:|
Alvarez PB, Perez-Sayáns M, Alves MG, Torreira MG, Iruegas ME, Carrión AB, García-García A. Dental management prior to radiation therapy in patients with head and neck cancer. Indian J Cancer 2018;55:251-6
|How to cite this URL:|
Alvarez PB, Perez-Sayáns M, Alves MG, Torreira MG, Iruegas ME, Carrión AB, García-García A. Dental management prior to radiation therapy in patients with head and neck cancer. Indian J Cancer [serial online] 2018 [cited 2020 Nov 30];55:251-6. Available from: https://www.indianjcancer.com/text.asp?2018/55/3/251/250883
| » Introduction|| |
Oral squamous cell carcinoma (OSCC) represents 90% of all head and neck cancers and 3–4% of malignant neoplasms., Head and neck cancer incidences have increased significantly in the past 20 years., The clinical diagnosis must be very thorough, exploring locations such as floor of the mouth, and tongue; in short, should include all the locations where OSCC can often settle, as well as exploring the lymph node chain to rule out the presence of metastasis. The etiology of cancer is unknown, although it is known that it is a pathology with a multifactorial origin. The risk factors are tobacco and alcohol, which, although independent risk factors, have a synergistic effect.,, Patients diagnosed with this type of cancer are treated by surgery, radiation therapy (RTP), chemotherapy (CTP) alone, or in combination. RTP causes numerous sequelae that have a significant effect on the patient's quality of life. The complications caused in the orofacial sphere can be classified as acute (mucositis, risk of infection, radiation dermatitis, salivary gland disorders, altered sense of taste) or late-onset (soft tissue necrosis, trismus, osteoradionecrosis, postirradiation caries and dental hypersensitivity).,,,
The goals of this study are to describe the management protocol for patients subjected to RTP of the head and neck, to assess the need for oral treatment prior to RTP in patients with head and neck cancer, and to study their long-term oral health status.
| » Materials and Methods|| |
A retrospective study was performed in a sample of 50 patients referred to the Oral Medicine Teaching Unit between January 2011 and January 2013. This study received the assent of the Ethics Committee investigation of CHUS. This sample was obtained from those patients referred for oral assessment prior to commencing RTP of the head and neck in the Radiation Therapy Department at the Hospital Clínico Universitario del Complejo Hospitalario Universitario de Santiago de Compostela.
The inclusion criteria were patients diagnosed with head and neck cancer and patients who were to receive RTP of the head and neck. The exclusion criteria were patients who had previously received RTP of the head and neck and patients subjected to full-body irradiation.
The variables studied included age, sex, use of CTP, tumor-node-metastasis stage, RTP sessions, histological tumor type, location, comprehensive initial and resting saliva test, candida culture, level of hygiene, toxic habits (smoking and alcohol), exodontias (location, number and reason), need for conservative, prophylactic, or surgical treatment.
Radiation therapy protocol
During the first visit, we collect the clinical history including the patients' personal data: age, gender, family medical history, personal medical history, current medical problems, medication, allergies, and harmful habits. All the patients are referred with an oncological report, including the oncological medical history of the patient: tumor diagnosis, tumor stage, and tumor treatment and a mouth X-ray to evaluate the dental status. A bucodental exploration is developed to assess the oral situation of the patient and evaluate different therapeutic needs and cover the RTP protocol.
The first step is the oral examination, including mucosa (buccal mucosa, lips, tongue, gums, base of the vestibule, floor of the mouth, palate, etc.), to rule out any preexisting lesion [Figure 1]. Next, the odontogram is done, where a dental and periodontal examination was undertaken with the help of a probe and mirror. In addition, oral hygiene is evaluated in all patients using the Silness-Loe index. Oral hygiene instructions were emphasized. Dental prophylaxis and the application of flour diary during treatment are essential to prevent the extensive dental caries suffered by these patients, caused by poor motivation and decreased saliva flow, and the high level of cariogenic flora.,,,, Fluoride application must be continued on a daily basis as long as dry mouth persists. The vestibular and palatine/lingual regions of both arches were examined using a no. 5 dental mirror and a no. 23 dental explorer and the different degrees are written down (Grade 0: Absence of dental plaque; Grade 1: Plaque not visible but could be extracted from the gingival third of the tooth using the probe; Grade 2: Moderate build-up of plaque in the gingival region that could be easily seen; Grade 3: Abundant plaque in the same region, possibly covering the neighboring tooth).
|Figure 1: Images of oral health status in patients with head and neck tumors before RT|
Click here to view
The status of the salival function is assessed, using a millimeter paper strip (1 cm wide, 17 cm long, with 1 cm unmarked) introduced in a polyethylene bag, which is called a global saliva test, in rest and stimulated. The section of noncharted strip is extracted from the bag for testing. The end is then folded in a right angle and is inserted in the oral cavity, below the tongue. When closing the lips, these will slightly touch the polyethylene bag. The saliva produced is accumulated in the lingual vallecula during the 5 minutes of duration of the test, during which the strip will soak slowly. Once this time has ended, it is retrieved from the mouth and the wet charted strip is read immediately. Subsequently, the stimulation test is developed by depositing some drops of citric acid at 4% in the oral cavity and repeating the same process.
It is important to know if there is candidiasis before treatment then it is done to culture. A sample taken from the dorsal surface of the tongue was cultured and the results are read at 24, 48, and 72 hours. This sample was obtained using a cotton swab and placed on a Sabouraud agar plate (Biomérieux, Marcy l´Etoite, France) which was kept in an oven for up to 72 hours.
If extractions were recommended, it is should consider the prognosis of the tooth itself, the patient's motivation, and the ability to follow oral hygiene instructions. All teeth with a questionable prognosis should be extracted before RTP:, caries (not restorable), active periodontal disease (symptomatic teeth), moderate and severe periodontal disease (pockets ≥5 mm), especially with advanced bone loss, mobility, and furcal involvement, partial impaction or incomplete eruption, especially of third molars, which are not completely covered by the alveolar bone, or are in contact with the oral cavity, extensive periapical lesions (if not chronic or well localized), root remnants not fully covered by alveolar bone or which exhibit radiolucency, teeth close to, or in, the tumor, absence of antagonist teeth and poor hygiene.
When developing extractions, patients should be handled as follows:,,, Antibiotic prophylaxis for patients who need it, as recommended by the ADA, rinse with antiseptic mouthwash such as 0.12% chlorhexidine digluconate, 1 minute, and use an anesthetic technique. Anesthesia with vasoconstrictor [4% Articaine with epinephrine 1:200,000 (Ultracain®, Inibsa®) and truncal block, infiltrative anesthesia, and/or intraligamentary anesthesia] should be done with minimum trauma and also regularization of the alveolar process by approximation of margins. Also, nonabsorbable suture must be used with 4.0 silk and antibiotic coverage was prescribed: Amoxicillin 750 mg 1/8 hours/7 days. If necessary we give a postoperative treatment: analgesic/antiinflammatory (ibuprofen 600 mg) and antiseptic mouthwash with 0.12% chlorhexidine digluconate. Finally, always make the minimum number of sessions, starting with mandibular exodontias.
All data obtained were analyzed using the statistical system SPSS, version 20.0, for Windows. The discontinuous or discrete variables were analyzed using descriptive statistics, with the results being expressed as mean, standard deviation, and as frequency tables and percentages for qualitative variables.
The Chi-squared test, Student's t-test, or a one-way analysis of variance were used during intervariable relationship studies, depending on the application conditions. P values of 0.0001 or lower (P ≤ 0.0001) were considered to be statistically significant.
| » Results|| |
A total of 50 patients [8 women (16%) and 42 men (84%)] were analyzed. The mean age of the patients studied was 61.12 (SD: 10.08), with a range of 45–88. In [Table 1], we can observe a resume of the clinical and pathological characteristics of the sample.
58% of patients studied had toxic habits. Thus, 54% of patients were ex-smokers, 12% smoked more than 20 cigarettes a day, 8% smoked between 10 and 20 cigarettes, and 4% between 1 and 10; only 22% are nonsmokers. As regards alcohol consumption, 12% of patients were ex-alcoholics, 8% were alcoholics, 4% drunk high alcohol spirits, 34% drunk low alcohol spirits, and 42% did not drink alcohol.
In most cases the histological study revealed OSCC (96%), with the remaining 4% having another histological type. Around 20% of lesions were located in the pharynx, whereas 16% were located on the tongue, 14% in the larynx, 12% the supraglottis, 6% the parotid, 4% were cervical or present in the nasopharynx, pyriform sinus, soft palate, unknown, or floor of the mouth, and the remaining 2% were found in the laryngopharynx, retromolar trigone, epiglottis, or hard palate. The most common tumor stage was stage IV (70% of patients), with stage III being identified in 22% of patients and stages I and II in 4% each; these differences were statistically significant (χ2 = 58.24, P < 0.0001).
All patients received RTP, with a mean number of sessions of 33.86 (SD: 2.85) and a range of 20–37. In 36% of patients RTP was combined with CTP, and 66% underwent prior surgery.
As regards the need for oral treatment prior to RTP treatment, 84% of patients required scaling, 32% conservative treatment, and 4% required canal treatment. Around 74% of patients required at least one exodontia (mean: 3.74; SD: 3.516; range: 0-13), whereas the remaining 26% did not require an extraction. The mean number of maxillary exodontias was 1.9 (SD: 2.618; range: 0–10) and the mean number of mandibular exodontias was 1.92 (SD: 2.069; range: 0–8). The main causes of these extractions were as follows: 42.2% due to periodontal disease, 21.9% due to caries, 31.5% due to root remnants, and 2.13% other causes.
The pre-RTP study of possible candida infection on the dorsal surface of the tongue showed that 78% of patients were negative for this infection and 22% positive.
The need for a pre-RTP extraction was not related to smoking habit in a statistically significant manner (F = 1.244, P = 0.306). Similarly, positivity for candida infection was also not statistically significantly related to TSG-I (T = 0.381, P = 0.705), although negative patients (38) presented a higher mean baseline salivation (39.79) than those who tested positive for candida. Likewise, we have found no relationship between degree of oral hygiene and candida positivity (χ2 = 2.348, P = 0.503). Those patients with poor and insufficient hygiene (n = 21) required more pre-RTP surgery than those with a good and normal hygiene (n = 12), although the differences were not statistically significant (χ2 = 5.622, P = 0.131).
The mean resting saliva production was 39.10 (SD: 23.30; range: 13–145), with a stimulated value of 64.78 (SD: 33.92; range: 16–200). With respect to TSG-I and TSG-II, TSG-I mean was 39.41 and 38.94 for groups without surgery and previous surgery before radiotherapy, respectively (P = 0.90). Regarding TSG-II was 74.65 and 59.53 for the same groups. However, no statistically significant differences in stimulated salivary flow (TSG-II) were found between the groups (P = 0.630).
As regards oral hygiene, 8% of patients presented Grade 3, 64% Grade 2, 16% Grade 1, and 12% Grade 0. It is well known that a worse degree of oral hygiene leads to a higher mean number of exodontias [Figure 2]. Thus, in our study, the mean for patients presenting Grade 3 was 6.50 per person (range: 2–13), 4.53 (0–11) for Grade 2, 1.25 (0–6) for Grade 1, and 1 (0–2) for Grade 0. These differences were statistically significant (χ2 = 41.200; P < 0.0001) [Figure 1].
| » Discussion|| |
This study has allowed us to determine the oral requirements presented by cancer patients prior to RTP of the head and neck. Previous literature findings suggest the need for a comprehensive dental evaluation of patients prior to commencing RTP treatment, mainly as regards the exodontias required to prevent such a procedure from being performed after RTP in order to minimize the risk of osteoradionecrosis.,,,,,,,,
In agreement with the literature,,,, 96% of patients in this study presented OSCC, which is the most common histological type. Similarly, both the mean age of patients ,, and their distribution by sex [8 women (16%) and 42 men (84%)] coincided with the values reported by other authors.,, As regards the location distribution, we found some variation with respect to previous literature reports, with the most common location being the pharynx (20%), followed by the tongue (16%) and larynx (14%).,,
The patients who attend our unit arrive at an advanced stage (70% stage IV), a value that is also in agreement with the literature.,,,,,
As regards the risk factors, we found that 54% of patients were ex-smokers, a value somewhat higher than reported in the literature, whereas 24% were usual smokers, a lower value than found by other authors.,, As regards alcohol consumption, 12% of patients were ex-alcoholics, 8% were alcoholics, 4% drunk high alcohol spirits, 34% drunk low alcohol spirits, and 42% did not drink alcohol. These values are very similar to those found in the literature. Our findings confirm that the presence of risk factors predisposes a person to development of this disease.
Treatment needs were high, with 74% of the patients in this study requiring at least one exodontia (mean: 3.74 teeth). This percentage is higher than those reported by authors such as Epstein (68%), Sulaiman (41.18%), and Jham (50.2%), whereas other authors, such as Bonan (82%), have reported higher values, thus giving a range of 68–82%.,,,
The main reasons for extraction were periodontal disease (42.2%), followed by root remnants (31.5%), caries (21.9%), and other causes (2.13%). The value found in this study for periodontal disease is similar to those reported by other authors, whereas the values for root remnants and caries were much higher than those found in the literature., A statistically significant relationship was found between oral hygiene and number of exodontias.
The patient must wait a minimum of 2 weeks between tooth extraction and the commencement of RTP in order to reduce the likelihood of ORN,,,, although other authors state that this period should be 4–6 weeks for complex surgical procedures., In agreement with the latter, we believe that, irrespective of whether the patient has undergone a simple exodontia or a more complex procedure, the optimal period is 4–6 weeks, as this decreases the probability of complications arising during RTP treatment.
Only 32% of the patients in this study underwent conservative treatment as the majority presented poor oral hygiene, thus meaning that this treatment alternative was ruled out due to the increased likelihood of failure in the medium to long term, which would increase the probability of complications. This value is higher than those reported in previous studies (Jham: 15%, Jaume Escoda: 16%). In these patients, it is also important to provide a topical calcium source for the teeth in addition to fluoride. On the contrary, chlorhexidine gel has also been shown to clinically reduce caries risk.,,,
The percentage of fungal superinfection prior to initiating RTP treatment was 22%. This value is higher than that reported by Jham (15%), probably due to the fact that the majority of such studies only perform cultures during and after RTP. However, we have found that other authors find prevalences around 50–60%., Although candida superinfections must be eliminated prior to commencing RTP treatment, none of the protocols available in the literature include such a step.
We were able to compare the production of saliva at rest and stimulated before the start of the RTP in patients who have received prior surgery with the study developed by Jacob et al., in which the mean salivary flow was significantly reduced in the groups that had received previous surgery versus a control group without cancer (P < 0.001). Furthermore, these authors showed that the difference in salivary flow rate between the groups was greater for unstimulated (TSG-I) than for the stimulated (TSG- I) which corresponds to our results. Furthermore, Jaguar et al., consistent with our results, the mean of stimulated salivary flow (TSG-II) and unstimulated (TSG-I) were lower in the group after surgery, compared to the group without surgery. Although like our results found no statistically significant differences in stimulated salivary flow between groups (P = 0.26), however, Jaguar et al. observed a significant difference between the groups only in unstimulated saliva (P = 0.008); we found the same results although without statistical significance (P = 0.903).
We were unable to compare resting and stimulated saliva production prior to the commencement of RTP with literature values as similar studies have not assessed this variable. However, we consider it vital to quantify this, as any previously existing xerostomia must be treated to prevent complications during RTP.
| » Conclusions|| |
All patients should be protocoled to ensure that they present optimal oral conditions prior to initiating RTP treatment so that local and systemic complications can be minimized during and after treatment and establish the measures that can be adopted to reduce adverse effects. Around 74% of the patients in this study required at least one exodontia prior to treatment. Similarly, as 84% of patients required prophylactic treatment, this should be included in the treatment protocol. We consider it vital to quantify resting and stimulated saliva production prior to the commencement of RTP, as any preexisting xerostomia must be treated to prevent complications during RTP. The utility of an oral assessment should be explained and the importance of maintaining good oral health should be stressed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours; 2005.
Bagan J, Sarrion G, Jimenez Y. Oral cancer: Clinical features. Oral Oncol 2010;46:414-7.
Ord RA, Blanchaert RH. Oral cancer: the dentist's role in diagnosis, management, rehabilitation, and prevention. Chicago: Quintessence Pub.; 2000.
Little JW, Falace D, Miller C, Rhodus NL. Dental Management of the Medically Compromised Patient. Elsevier Health Sciences; 2017.
Scully C, Bagan J. Oral squamous cell carcinoma: Overview of current understanding of aetiopathogenesis and clinical implications. Oral Dis 2009;15:388-99.
Castellsagué X, Quintana MJ, Martínez MC, Nieto A, Sanchez MJ, Juan A, et al
. The role of type of tobacco and type of alcoholic beverage in oral carcinogenesis. Int J Cancer 2004;108:741-9.
Andre K, Schraub S, Mercier M, Bontemps P. Role of alcohol and tobacco in the aetiology of head and neck cancer: A case-control study in the Doubs region of France. Eur J Cancer B Oral Oncol 1995;31:301-9.
Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S, et al
. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7.
Gomes F, Kustner E, López J, Zubeldia FF, Melcior BG. Manejo odontológico de las complicaciones de la radioterapia y quimioterapia en el cáncer oral. Med Oral 2003;8:178-87.
Cox JD, Stetz J, Pajak TF. Toxicity criteria of the radiation therapy oncology group (RTOG) and the European organization for research and treatment of cancer (EORTC). Int J Radiat Oncol Biol Phys 1995;31:1341-6.
Jawad H, Hodson NA, Nixon P. A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: Part 1. Br Dent J 2015;218:65.
Cullen L, Baumler S, Farrington M, Dawson C, Folkmann P, Brenner L. CE: Oral care for head and neck cancer symptom management. Am J Nurs 2018;118:24-34.
Kufta K, Forman M, Swisher-McClure S, Sollecito TP, Panchal N. Pre-Radiation dental considerations and management for head and neck cancer patients. Oral Oncol 2018;76:42-51.
Silness J, Löe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and periodontal condition. Acta Odontol 1964;22:121-35.
Beech N, Robinson S, Porceddu S, Batstone M. Dental management of patients irradiated for head and neck cancer. Aust Dent J 2014;59:20-8.
Rothwell BR. Prevention and treatment of the orofacial complications of radiotherapy. J Am Dent Assoc 1987;114:316-22.
Brown LR, Dreizen S, Handler S, Johnston DA. Effect of radiation-induced xerostomia on human oral microflora. J Dent Res 1975;54:740-50.
Deng J, Jackson L, Epstein JB, Migliorati CA, Murphy BA. Dental demineralization and caries in patients with head and neck cancer. Oral Oncol 2015;51:824-31.
López-Jornet P, Camacho-Alonso F, Bermejo-Fenoll A. A simple test for salivary gland hypofunction using Oral Schirmer's test. J Oral Pathol Med 2006;35:244-8.
Epstein J, Stevenson-Moore P. Periodontal disease and periodontal management in patients with cancer. Oral Oncol 2001;37:613-9.
Jansma J, Vissink A, Spijkervet FK, Roodenburg JL, Panders AK, Vermey A, et al
. Protocol for the prevention and treatment of oral sequelae resulting from head and neck radiation therapy. Cancer 1992;70:2171-80.
Sulaiman F, Huryn JM, Zlotolow IM. Dental extractions in the irradiated head and neck patient: A retrospective analysis of Memorial Sloan-Kettering Cancer Center protocols, criteria, and end results. J Oral Maxillofac Surg 2003;61:1123-31.
Silvestre-Donat F, Plaza A, Serrano M. Revisiones. Prevención y tratamiento de las complicaciones derivadas de la radioterapia en pacientes con tumores de cabeza y cuello. Med Oral 1998;3:136-47.
Devi S, Singh N. Dental care during and after radiotherapy in head and neck cancer. Natl J Maxillofac Surg 2014;5:117-25.
] [Full text]
Scully C, Epstein JB. Oral health care for the cancer patient. Eur J Cancer B Oral Oncol 1996;32:281-92.
Makkonen T, Kiminki A, Makkonen T, Nordman E. Dental extractions in relation to radiation therapy of 224 patients. Int J Oral Maxillofac Surg 1987;16:56-64.
Bruins HH, Koole R, Jolly DE. Pretherapy dental decisions in patients with head and neck cancer: A proposed model for dental decision support. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 1998;86:256-67.
Hancock PJ, Epstein JB, Sadler GR. Oral and dental management related to radiation therapy for head and neck cancer. J Can Dent Assoc 2003;69:585-90.
Samim F, Epstein JB, Zumsteg ZS, Ho AS, Barasch A. Oral and dental health in head and neck cancer survivors. Cancers Head Neck 2016;1:14.
Hong CH, Hu S, Haverman T, Stokman M, Napeñas JJ, Bos-den Braber J, et al
. A systematic review of dental disease management in cancer patients. Supportive Care Cancer 2018;26:155-74.
Lalla RV, Long-Simpson L, Hodges JS, Treister N, Sollecito T, Schmidt B, et al
. Clinical registry of dental outcomes in head and neck cancer patients (OraRad): Rationale, methods, and recruitment considerations. BMC Oral Health 2017;17:59.
Escoda-Francolí J, Rodríguez-Rodríguez A, Pérez-García S, Gargallo-Albiol J, Gay-Escoda C. Dental implications in oral cancer patients. Med Oral Patol Oral Cir Bucal 2011;16:e508-13.
Bonan PRF, Lopes MA, Pires FR, Almeida OP. Dental management of low socioeconomic level patients before radiotherapy of the head and neck with special emphasis on the prevention of osteoradionecrosis. Braz Dent J 2006;17:336-42.
Jham BC, Reis PM, Miranda EL, Lopes RC, Carvalho AL, Scheper MA, et al
. Oral health status of 207 head and neck cancer patients before, during and after radiotherapy. Clin Oral Investig 2008;12:19-24.
Epstein J, Emerton S, Lunn R, Le N, Wong F. Pretreatment assessment and dental management of patients with nasopharyngeal carcinoma. Oral Oncol 1999;35:33-9.
Murray CG, Herson J, Daly TE, Zimmerman S. Radiation necrosis of the mandible: A 10 year study. Part II. Dental factors; onset, duration and management of necrosis. Int J Radiat Oncol Biol Phys 1980;6:549-53.
Beumer J, Harrison R, Sanders B, Kurrasch M. Preradiation dental extractions and the incidence of bone necrosis. Head Neck Surg 1983;5:514-21.
Ceballos A, Bullón P, Gándara J, Chimenos E, Blanco A, Martínez-Sahuquillo A, et al
. Medicina bucal práctica. Santiago de Compostela: Danú 2000:1-732.
Epstein JB, Schubert MM. Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology (Williston Park) 2003;17:1767-79; discussion 1779-82, 1791-2.
Wijers OB, Levendag PC, Braaksma MM, Boonzaaijer M, Visch LL, Schmitz PI. Patients with head and neck cancer cured by radiation therapy: A survey of the dry mouth syndrome in long-term survivors. Head Neck 2002;24:737-47.
Joyston-Bechal S. Prevention of dental diseases following radiotherapy and chemotherapy. Int Dent J 1992;42:47-53.
Fayle SA, Duggal MS, Williams SA. Oral problems and the dentist's role in the management of paediatric oncology patients. Dent Update 1992;19:152-6, 158-9.
Kurnatowski P, Moqbil S, Kaczmarczyk D. Signs, symptoms and the prevalence of fungi detected from the oral cavity and pharynx of radiotherapy subjects with head and neck tumors, and their susceptibility to chemotherapeutics. Ann Parasitol 2014;60.
Azizi A, Rezaei M. Prevalence of Candida species in the oral cavity of patients undergoing head and neck radiotherapy. J Dent Res Dent Clin Dent Prospects 2009;3:78-81.
Jacob RF, Weber RS, King GE. Whole salivary flow rates following submandibular gland resection. Head Neck 1996;18:242-7.
Jaguar G, Lima E, Kowalski L, Pellizon A, Carvalho A, Alves F. Impact of submandibular gland excision on salivary gland function in head and neck cancer patients. Oral Oncol 2010;46:349-54.
[Figure 1], [Figure 2]