Oral Care in Head and Neck Radiotherapy: Proposal for an Oral Hygiene Protocol

Abstract

This review aims to provide a comprehensive overview of the literature on the oral side effects caused by radiotherapy for head and neck cancers. Various treatments are examined to mitigate these sequelae, and a protocol is proposed for dentists and dental hygienists to manage oncological patients. A literature search was conducted to select relevant articles addressing the effects of radiotherapy treatments on the oral cavity, with a particular focus on the development of mucositis, candidiasis, changes in salivary pH, trismus, fibrosis, and alterations in the oral biofilm. PubMed and MedLine were used as search engines, with keyword combinations including: head and neck cancer, mucositis, candida, dental care, dental hygiene, epidemiology, oral microbiome, biofilm, trismus, fibrosis, and salivary pH. A total of 226 articles were identified, spanning the period from 1998 to 2023. Articles deemed inappropriate or in languages other than English or Italian were excluded. A management protocol for oncological patients was proposed, divided into two phases: home-based and professional. Despite the advancements in intensity-modulated radiation therapy, it is impossible to completely avoid damage to healthy tissues. Preventive education and counseling in the dental chair, ongoing motivation, and education about oral hygiene are crucial to combine a good therapeutic outcome with an improved quality of life for the patient.

Keywords: head and neck cancer; hygiene; oral cavity; radiotherapy.

Figure 1

Evolution of damage caused by radiotherapy: This figure illustrates the interconnections among various complications.

Figure 2

This figure elucidates the progression of tissue damage and the subsequent healing mechanism. The initial stage (I) involves tissue radiation, leading to the generation of ROS (reactive oxygen species) and cytokines. The second and third stages (II–III) encompass the activation of inflammation genes (such as NF-κB—“nuclear factor kappa-light-chain-enhancer of activated B cells”) and cells, resulting in the production of IL-1-6 (interleukins 1-6) and TNF-α (tumor necrosis factor α). The fourth stage (IV) is characterized by tissue colonization and the formation of pseudomembrane and fibrin (N1—pro-inflammatory neutrophils). The final stage (V) culminates in the restoration of healthy tissue (N2—anti-inflammatory neutrophils).