Dental Issues and hyperbaric oxygen therapy

Dental issues can be challenging for laryngectomees, mainly because of the long term effects of radiation therapy. Maintenance of good dental hygiene can prevent many problems.


Dental Issues

Dental problems are common after exposure of the head and neck to radiation therapy.

Radiation affects include:

• Reduced blood supply to the maxillary and mandibular bones.
• Reduced production and changes in the chemical composition of saliva.
• Changes in the bacteria that colonize the mouth.

Because of these changes dental caries, soreness, and gingival and periodontal inflammation can be particularly problematic. These can be lessened by good mouth and teeth care, i.e., by cleaning, flushing, and using fluorinated toothpaste after each meal when possible. Using a special fluorinated preparation with which to gargle or apply on the gum helps in preventing dental carries. Keeping well hydrated and using saliva substitute when needed are also important.

It is advisable that patients receiving radiation therapy to the head and neck visit their dentist for a thorough oral examination several weeks prior to initiation of the treatment and be examined at a regular annual or semiannual basis throughout life. Getting regular dental cleaning by a dental hygienist or a dentist are also important.

Because radiation treatment alters the blood supply to the maxillary and mandibular bones patients may be at risk of developing bone necrosis ( osteoradionecrosis) at those sites. Tooth extraction and dental disease in irradiated areas can to the development of osteoradionecrosis. Patients should inform their dentist about their radiation treatment prior to understanding these procedures. Osteoradionecrosis may be prevented by administration of a series of hyperbaric oxygen therapy (see below) before and after extraction or dental surgery. This is recommended if the involved tooth is in an area that had been exposed to a high dose of radiation. Consulting the radiation oncologist who delivered the radiation treatment can be helpful in determining if this is necessary. 

Dental prophylaxis can reduce the risk of developing dental problems leading to bone necrosis. Special fluoride treatments may help to prevent dental problems, along with brushing, flossing, and having one's teeth cleaned regularly.

A home care dental lifelong routine is recommended:

•  Flossing each tooth and brushing with toothpaste after each meal
•  Brushing the tongue with a tongue brush or a soft bristled toothbrush once a day
• Rinsing with a baking soda rinse daily. Baking soda helps neutralize the mouth. The rinse is made of one teaspoon ob baking soda added to 12 oz. of water. The baking soda rinse can be used throughout the day.
• Using fluoride in fluoride carriers once a day. These preparation are commercially available and are also custom made by dentists. They are applied over the teeth for 10 minutes. One should not rinse, drink, or eat for 30 minutes after fluoride application.

Stomach acid reflux is also very common after head and neck surgery, especially in individuals who have had partial or complete laryngectomy. (see page on eating, swallowing and smelling) This can also cause dental erosion (especially of the lower jaw) and, ultimately teeth loss. 

These ill effects can be reduced by:

• Taking acid reducing medication
• Eating small amounts of food and liquid each time
• Not lying down right after eating
• When lying down, elevate the upper part of the body with a pillow to 45 degrees.

Hyperbaric oxygen therapy

Hyperbaric oxygen (HBO) therapy involves breathing pure oxygen in a pressurized room. HBO is a well-established treatment for decompression sickness (a hazard of scuba diving) and can be used to prevent osteoradionecrosis. 

HBO is used to treat a wide range of medical conditions including: bubbles of air in the blood vessels (arterial gas embolism), decompression sickness, carbon monoxide poisoning, a wound that won't heal, a crush injury, gangrene, skin or bone infection causing tissue death (such as osteoradionecrosis), radiation injuries, burns, skin grafts or skin flaps at risk of tissue death, and severe anemia.

In an HBO therapy chamber, the air pressure is raised up to three times higher than normal air pressure. Under these conditions, the lungs can gather much more oxygen than would be possible when breathing pure oxygen at normal air pressure.

The blood carries this oxygen throughout the body, stimulating the release of chemicals called "growth factors" and stem cells that promote healing. When tissue is injured, it requires even more oxygen to survive. HBO therapy increases the amount of oxygen in the blood and can carry temporarily restore normal levels of blood gases and tissue function. These promote healing and the ability of the tissues to fight infection.

A patient is wheeled into a hyperbaric chamber

HBO therapy is generally safe, and complications are rare. These can include: temporary nearsightedness (myopia), middle ear and inner ear injuries (including leaking fluid and eardrum rupture due to increased air pressure), organ damage caused by air pressure changes (barotrauma), and seizures as a result of oxygen toxicity.

Pure oxygen can cause a fire if there is a source of ignition, such as a spark or flame, and adequate fuel. It is therefore forbidden to take items that could ignite a fire (e.g, lighters or battery powered devices) into the HBO therapy room.

HBO therapy can be performed as outpatient procedure and does not require hospitalization. Hospitalized patients may need to be transported to and from the HBO therapy site if it is an outside facility.

Treatment can be performed in one of two settings:

·        A unit designed for one person in an individual (monoplace) unit, the patient lies down on a padded table that slides into a clear plastic tube.

           A HBO chamber designed for one person

·        A chamber designed to accommodate several people in a multiperson HBO room  where the patient may sit or lie down. A hood or mask delivers the oxygen.

             

              A HBO chamber designed to accommodate several people

During HBO therapy the increased air pressure creates a temporary feeling of fullness in the ears - similar to the one felt in an airplane or at a high altitude  that can be relieved by yawning.

A therapy session may last from one to two hours. Members of the health care team monitor the patient throughout the session. Following HBO therapy the patient may feel lightheaded. Typically, this feeling dissipates within a few minutes.

To be effective, HBO therapy requires more than one session. The number of sessions required depends on the medical condition. Some conditions, such as carbon monoxide poisoning, can be treated in as few as three visits. Others, such as osteoradionecrosis, and non-healing wounds, may require 25 to 30 treatments.

HBO therapy alone can often effectively treat decompression sickness, arterial gas embolism and severe carbon monoxide poisoning. To effectively treat other conditions, HBO therapy is used as part of a comprehensive treatment plan and is administered in conjunction with additional therapies and medications that fit  individual needs.