Table 2 Oral risks and mitigation36,45
Dental consideration | Recommendation |
|---|---|
Dental caries and periodontal disease risk | Minimising frequency and exposure times of cariogenic food/drink and safe consumption of ONS is desired. In reality, this may not always be achievable due to tolerance issues. Possible strategies to mitigate the effects include: Aim to time ONS with mealtimes if/when feasible Aiming for full ONS volume in one sitting rather than sipping at regular intervals during the day and/or increasing volume taken in each sitting to reduce frequency across the day if tolerated Advocate plaque removal due to 'stickiness' of ONS Prescription of high concentration fluoridated toothpaste: Advise patients to 'spit but not rinse' after brushing teeth Use of fluoridated mouthwash other times than toothbrushing in the post treatment phase Regular reviews with the restorative dentist and dental care professionals Assessing if high cariogenic foods can be replaced with low cariogenic iso-caloric options, such as: Full-fat milk and dairy products especially those that contain probiotics which can reduce Streptococcus mutans, increase saliva pH and promote a higher plaque index48 Fortifying meals with additional fat (for example, oil/butter/cream) Consider replacing some ONS with ONS 'shots' which contain less sucrose Using a straw where possible Regular brushing and flossing Take dentures out after every meal to clean them and at night before sleep Encourage plaque removal with toothbrush before ONS consumption and then ~30 minutes after, topical application of toothpaste that contains Recaldent CP-ACP (casein phosphopeptide-amorphous calcium phosphate) or other remineralising agent for patients at risk of caries. Saliva is normally supersaturated with calcium and phosphate which facilitates repair of initial carious lesions. Patients with xerostomia have reduced buffering and remineralisation capacity Rehabilitation services and where possible, joint dietitian/SLT appointments to support patients to come off ONS if/when feasible Early identification by restorative dentist of 'high risk' patients before commencing radiotherapy considering:49 Age Sex Number of decayed, missing or filled surfaces Radiation dose, field and technique Encourage cessation and/or reduction of smoking and alcohol |
Osteoradionecrosis | Reviewing dental hygiene alongside nutritional assessment when feasible in appointments especially for high-risk patients Early identification by restorative dentist of 'high risk' patients before commencing radiotherapyconsidering the following risk factors:49,50 Smoking status Primary site in the oropharynx Bone surgery before radiotherapy Concurrent chemotherapy Xerostomia presence Dental extraction pre- radiotherapy ≤20 days between dental extraction and commencing radiotherapy (in practice, most restorative dentists aim for a minimum ten days from extractions to starting radiotherapy)51 ≥55 gy radiotherapy dose |
Xerostomia | Mouthcare Saliva replacement |
Trismus | Difficulty with oral access (liaise with SLTs for use of interventions such as jaw-stretching exercises) |
Challenges with eating, drinking and chewing caused by dentition issues | Liaise with restorative dentistry regarding the challenges in tolerating oral diet Lack of occluding pairs of teeth (real or prosthetic) Problems with prostheses Delays or lack of access to implant-based rehabilitation (often due to the need to await osseointegration) |
Dental extractions | Medications, for example, analgesia to alleviate pain/discomfort with eating and drinking after dental extractions Texture modifications to alleviate discomfort with eating and drinking and reduce chewing burden (for example, nourishing liquids and soft diet) Counselling by restorative dentists due to negative impact on QofL, as this can be detrimental in regards to speaking, eating, socialising and intimacy52 |
