**3. Protocol for management before RTP**

In literature of this subject area, there are articles published on the management of complica‐ tions in patients with head and neck cancer. These mainly focus on mucositis, radiodermatitis and osterradionecrosis. However, in order for this to be prevented, we must monitor the patient before, during and after radiotherapy. In this chapter, therefore, we will focus on the management of the radiated patient, mainly before radiotherapy. This is because there are few protocols and we believe that these are necessary in order to minimize the risks during treatment.

Figure 26 and 27: Orthopantomography of a patient before beginning the RTP and two years after finishing the RTP.

**Figure 26.** Before RTP.

**Figure 22.** ORN two months after finishing the RTP, without previous extractions.

of motivation also influences this (Figure 25).

gressed favourably.

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**Figure 24.** Dental wear during RTP.

**Figure 23.** After seven months of good oral hygiene and rinses with chlorhexidine and chlorhexidine gel, it has pro‐

**d.** Dental caries are very frequent in post-radiation starting three months after RTP has ended. There is a collapse and detachment of the enamel prisms that mainly affect the incisal edges, cuspids and cervical region of the teeth [10] (Figure 24). This is the result of a quantitative and qualitative alteration in the saliva, with a decrease of its stopping capacity. This favours the development of an acidogenic-cariogenic bacterial flora. A change towards a soft carbohydrate-rich diet, poor dental hygiene and the deterioration

For irradiated patients, dietary changes - a softer or liquid diet with a higher concentration of carbohydrates - combined with a decrease in saliva, results in a change in the microbiota. This becomes increasingly cariogenic. This, in addition to poor dental hygiene, results in a demin‐ eralization of the enamel and the destruction of crowns and the cervical area. Here, the cement and dentin is exposed to the oral environment, producing increased dental sensitivity [48].

**Figure 27.** After RTP.

#### **3.1. First visit**

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, medica‐ tion, allergies and harmful habits. All patients are referred with an oncological report, including their medical history: tumour diagnosis, tumour stage and tumour treatment. A mouth X-ray is also included to evaluate the dental status. A bucodental exploration is developed to assess the oral situation of the patient and evaluate different therapeutic needs, covering the RTP protocol.

#### *3.1.1. RTP protocol*


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 easily be seen.

Grade 3: Abundance of plaque in the same region, possibly covering the neighbouring teeth.


retrieved from the mouth and the wet charted strip is immediately read. Subsequently, the stimulation test is carried out by depositing some drops of citric acid at 4% in the oral cavity and repeating the same process.

Figures 28-39: Radiographical series from the patient going to treatment with RTP.

**Figure 28.** Mouth closed.

**3.1. First visit**

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covering the RTP protocol.

**2.** Medical history is covered.

shown in Figures 28-38.

Grade 0: Absence of dental plaque.

opening of less than 40 mm).

the probe.

*3.1.1. RTP 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, medica‐ tion, allergies and harmful habits. All patients are referred with an oncological report, including their medical history: tumour diagnosis, tumour stage and tumour treatment. A mouth X-ray is also included to evaluate the dental status. A bucodental exploration is developed to assess the oral situation of the patient and evaluate different therapeutic needs,

**1.** All patients must bring orthopantomography and report your oncological data.

**3.** On each visit, a radiographical series from the patient is necessary - extraoral (mouth closed, neck and maximum opening of the mouth) and intraoral (maxima intercuspida‐ tion, lateral intercuspidation, top and lower arcades, buccal mucosa and tongue), as is

**4.** An exploration of the mucosa is developed (yugal mucosa, lips, tongue, gums, bottom of the vestibule, floor of the mouth, palate, etc.), in order to discard any pre-existing lesion.

**5.** A dental and periodontal exploration is developed with the assistance of a probe and mirror. The degree of dental hygiene is determined using the Silnesloe index [49].

Grade 1: Plaque not visible but could be extracted from the gingival third of the tooth using

Grade 3: Abundance of plaque in the same region, possibly covering the neighbouring teeth. **6.** The maximum interincisal distance is measured with callipers (a trismus is a bucal

**7.** A culture is carried out. The sample is taken from the back of the tongue and the readings are at 24-48-72 hours. The sample is taken from the back of the tongue using a cotton swab, depositing it in an agar-sabourand plate and placing it in the furnace for 72 hours.

**8.** The status of the saliva function is assessed using a chart paper strip (1 cm thick by 17 cm length, with 1 cm not charted), introduced in a polyethylene bag. This is called a Global Saliva Test, in rest and stimulated [50]. The section of non-charted strip is extracted from the bag for testing. The end is then folded in a right angle and 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 vallecule during the five minutes of the test's duration. During this time, the strip slowly soaks. Once this time has ended, it is

Grade 2: Moderate build-up of plaque in the gingival region that could easily be seen.

**Figure 29.** Neck.

**Figure 30.** Maximum opening of the mouth.

**Figure 31.** Maximum intercuspidation.

**Figure 32.** Right lateral intercuspidation.

**Figure 33.** Left lateral intercuspidation.

**Figure 34.** Top arcade.

**Figure 35.** Lower arcade.

Radiotherapy and Chemotherapy Treatments in Head and Neck Cancer Patients — Protocol for Management… http://dx.doi.org/10.5772/60397 181

**Figure 36.** Right buccal mucosa.

**Figure 32.** Right lateral intercuspidation.

180 Updates on Cancer Treatment

**Figure 33.** Left lateral intercuspidation.

**Figure 34.** Top arcade.

**Figure 35.** Lower arcade.

**Figure 37.** Left buccal mucosa.

**Figure 38.** Tongue.

	- **•** Extraction (if this is necessary, all patients will sign an informed consent explaining all the possible complications).
	- **•** Seals/endodontics.
	- **•** Treatment for oral candidiasis (mycostatin mouth wash three times a day for three minutes for four weeks).
	- **•** Tartar removal, scaling and root planning.
	- **•** Remove irritants that graze (traumatic prosthesis and sharp teeth).
	- **•** Motivation in oral hygiene strongly recommend a daily teeth brushing for at least three times a day with toothpaste with high fluoride content. Apart from Fluoridation

plan in patients with teeth - preparation of individual trays for the daily application of sodium fluoride gel at 1.24%, five minutes/day, indefinitely and mouth wash with chlorhexidine.

	- **•** Caries (non-restorable).
	- **•** Active periodontal disease (symptomatic teeth).
	- **•** Moderate and severe periodontal disease (≥ 5 mm bags) especially with advanced bone loss, mobility and furcation involvement.
	- **•** Partial impaction or incomplete eruption, especially of third molars, which are not fully covered by the alveolar bone or in contact with the oral cavity.
	- **•** Extensive periapical lesions (if not chronic or well localized).
	- **•** Root fragments that are not completely covered by alveolar bone or show radiolucency.
	- **•** Teeth near the tumour or in the tumour.
	- **•** Lack of opposing teeth.
	- **•** Compromised hygiene.

When developing extractions, patients should be handled as follows [52-54].


Most authors agree that the minimum delay time for RTP treatment is 15-20 days [39, 44, 52, 55]. While others indicate that, in the case of complex surgical procedures, patients must wait four to six weeks [10, 54].
