Nutritional Implications of Dental and Swallowing Issues in Head and Neck Cancer

Management of patients who have head and neck cancer necessitates a multidisciplinary approach.[1,2] Comprehensive care must be initiated prior to therapy, maintained throughout course of treatment, and systematically coordinated for the rest of the patient’s life. As Dwyer and Minasian note, a multidisciplinary team that includes dental professionals, a speech/language pathologist, and a registered dietician is best suited for this complex management challenge. These individuals, working in conjunction with physicians, nurses, and other professionals, can provide patients with key preventive and therapeutic supportive care interventions.

Role of the Dental Team

The dental team typically includes a general practitioner and dental hygienist. Depending on the complexity of the patient’s oral condition, the services of other dental professionals, including a maxillofacial prosthodontist and/or an oral/maxillofacial surgeon may be needed.

The role of the dental team in the care of the head and neck cancer patient is wide-ranging, encompassing comprehensive management of dental (tooth), periodontal, oral mucosal, and salivary gland lesions. Among the many injuries to oral tissues, the lifetime compromise of salivary glands and the mandibular vasculature in many of these patients dictates an all-inclusive, protocol-driven approach to the prevention of diseases of the hard and soft oral tissues. The patient must comply with this preventive-oriented health care approach to maximize outcome because, despite best efforts, professional interventions will not fully succeed if the patient is oncompliant.

Oropharyngeal Mucositis

The authors appropriately describe the range of oropharyngeal lesions that may develop in these patients. Of particular concern is oropharyngeal mucositis caused by ionizing radiation. This complication can be serious, resulting in interruptions in the administration of cancer therapy.

The lesion, which typically emerges 2 weeks after the initiation of high-dose upper mantle irradiation, results primarily, but not exclusively, from impaired basal epithelial cell repli-cation.[3] As Dwyer and Minasian indicate, several regimens can be used to palliate this lesion, including utilization of salivary stimulants or replacement products, as well as topical/systemic pain medications. These approaches can enhance the patients’ quality of life while allowing cancer therapy to continue.

Important insights into the mechanisms of cancer chemotherapy- and radiation-induced mucositis are emerging. Although the direct injury caused by cytotoxic agents to basal epithelial cell metabolism is still thought to be a pivotal component, new evidence has come to light in the 1990s about the role of the overall inflammatory response and colonizing microflora in etiopathogenesis of mucositis. For example, a better understanding of the deleterious or protective roles of select cytokines may lead to a new standard of care in which mucosal immune systems are manipulated, to the patient’s benefit.[4]

Issues Related to Swallowing

The authors also address critical issues associated with the compromised swallowing that occurs in many head and neck cancer patients. Swallowing can be affected during both the acute and chronic phases of cancer management.

For example, acute mucositis due to chemotherapy and/or radiation or chronic functional abnormalities due to surgical intervention to the head and neck can collectively impair swallowing and, thus, dietary and nutritional intake. Chronic quantitative and qualitative alterations in salivary function, also a common occurrence in patients undergoing head and neck irradiation, can contribute to dysgeusia and, thus, also induce dietary and nutritional alterations. These effects, in turn, can contribute to clinically significant sequelae, including delayed wound healing and malnutrition. As discussed by Minasian and Dwyer, management of swallowing and nutritional components should thus be implemented for each patient as indicated by the clinical condition.

Two Final Points

Two final points should be made about the issues of access to care and prevention. Although not discussed in the article, these concepts have a major impact on the overall problem of managing patients with head and neck cancer.

First, unfortunately, numerous barriers compromise the ability of many head and neck cancer patients to receive comprehensive management by a multidisciplinary health care team. These patient-based barriers include insufficient insurance coverage and limited access to treatment facilities that specialize in management of complex cancer patients.

Second, it is essential to reemphasize that many oropharyngeal squamous cell carcinomas are preventable. Most of these cancers are caused by tobacco use, and many are associated with excessive alcohol consumption. Society rarely has the opportunity to prevent a malignancy on an international, public health level; prevention of oropharyngeal squamous cell carcinoma by advocating avoidance of both tobacco use and alcohol abuse represents one such opportunity.

The devastating treatments, which can so fundamentally compromise the lives of patients and their families for many years, can be avoided altogether if patient education results in abstinence from tobacco. In addition to the obvious effects of preventive strategies on patients’ quality of life, the economic impact of preventing the primary malignancy, as opposed to treating head and neck cancer and its complications, is enormous.[5]

References:

1. Singer MI, Phillips TL, Kramer AM, et al: Treatment, in Silverman S Jr (ed): Oral Cancer, 4th ed, pp 75-89. Hamilton, BC Decker., 1998.

2. Silverman S, Jr: Complications of treatment, in Silverman S Jr (ed): Oral Cancer, 4th ed, pp 91-102. Hamilton, BC Decker, 1998.

3. Squier CA: Mucosal alterations. Consensus Development Conference on Oral Complications of Cancer Therapies: Diagnosis, prevention, and treatment. NCI Monogr 9:169-172, 1990.

4. Sonis ST, Lindquist L, Van Vugt A, et al: Prevention of chemotherapy-induced ulcerative mucositis by transforming growth factor beta 3. Cancer Res 54:1135-1138, 1994.

5. Peterson DE: Prevention of oral complications in cancer patients. Prev Med 23:763-765, 1994.