Cancer Rotacion

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Peer-reviewedJOURNAL OF THE !R!SH DENTAL ASSOCIAT!ON

Sarah BrodyBDentSc BA BE PhD'

O s a m a O m e rBDS(Stat) MSc PhD FDS RCSI, FFD RCSP

Jac in ta McLough l inBDentSc MDS FDS FFPi

Leo StassenFRCS FDSRCS MA FTCD

FFSEM(UK) FFD RCSP-^

1 . Dublin Dental University Hospital,Lincoln Place,

Dublin 22. St James's Hos pital,

James's Street,Dublin 8

Address for co rrespondence:Prof. Leo Stassen

Oral and Maxillofacial DeptDublin Dental University Hospital

Lincoln Place Du blin 2

T: 01-61 2 7200F: 01-612 7296

E: [email protected]

The dentist's role within themulti-disciplinary team maintainingquality of life for oral cancer patients inlight of recent advances in radiotherapyPrcis: Mu ltidisciplinary care of the oral cancer patien t, including th erole of the general dental practitioner in maintaining the patient'soral health post radiotherapy.Abstract: Every year in Ireland over 400 people are diagnosed withhead and neck cancer. Oral cancer, a specific type of head and neckcancer, is usual ly treated with surgery and often requiresradiotherapy (RT). However, side effects of RT treatm ent, whichinclude mucosit is, xerostomia, radiat ion caries, tr ismus andosteoradionecrosis, can seriously compromise a patient's quality ofl ife. Treatment for oral cancer patients is managed in a multi-d i sc i p l i n a ry t e a m . C e n e ra l d e n ta l p ra c t i t i o n e rs (G D P s) ,cons ultant/specialist dentists and oral-maxillofacial surgeons play animp ortant role in these patients ' care.Recent advances in the delivery of RT have not only improved loco-regional control and survival rates, but have also reduced theincidence and severity of RT-associated side effects; however, nomode of RT delivery has successfully e liminated side effects. The roleof dentists is essential in maintaining oral health and all patientsshould be dentally screened prior to commencing RT.Recent reports have attem pted to standardise the qua lity o f care forthe oral cancer patient and have highlighted the significance of therole of the GDP. Despite the advancements in RT delivery, the dentalteam is still faced with a number of challenges, including the highnumber of patients lost to follow-up dental care, lack of an effectivetreatment for xerostomia, poor patient compliance, and a lack ofstandardised guidelines and fund ing .Addressing these challenges will involve increased communicationbetween all members of the multidisciplinary team and increasedinvolvement of the GDP, thereby ensuring tha t den tal care continuesto evolve concurrently w ith new methods of RT delivery.journal of the Irish Dental Association 201 3; 59 (3): 1 37-146.

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Peer-reviewedJOURNAL OF THE IRISH DENTAL ASSOCIATION

Mucositis/stomatitisLim ited m outh opening Dental dminralisation

Trismus/tissue fibrosis Radiation caries

OsteoradionecrosisPeriodontal disease

Oral and dentalcomplications

of radiotherapyDysphagia

Salivary gland dysfunction/xerostomiaTaste andsmell alterations

Oral cancer inductionNutrit ional compromise/weight loss

Difficulty with denturesAbnormal dental and facial developmentif RT is administered during growth

FIGURE 1 : Oral and dental complications of radiotherapy (adapted from MacGarthy et al., 2005)}

IntroductionEvery year in Ireland more than 400people arediagnosed with headand neck cancer.' The term 'intra-oral cancer' or 'oral cavity cancer'refers to particular forms of head and neck cancer, specifically thoseclassified by the Internat ional Classi f icat ion of Disease-O2

TABLE 1 : The Radiat ion Therapy Onc ology G roup a c u t e radiationmorbidity scoring criteria.^'Mucous membranes(mucositis)Grade 0 No change over

baselineGrade 1 Mild pain, may

require analgesia

Grade 2 Patchy mucositisthat mayproduceserosanguinousdischarge and/ormoderate painrequiring analgesics

Grade 3 : Confluen t fibrinous= J mucositis that may

include severe painrequiring narcotics

Grade 4 Ulcration,haemorrhage.

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Salivary gland(salivary hypofunction/xerostomia)No change over baseline

Mild mouth dryness, slightlythickened saliva, slightlyaltered taste, but changes arenot reflected by altered feedingbehaviour (e.g., increased useof liquids with meals)Moderate to complete dryness,thick, sticky saliva andmarkedly altered taste.

Acute salivary gland necrosis

classification C01-C06.^ Radiotherapy (RT) is used to treat intra-oralcancers as a primary treatment modality oras anadjuvant treatmentpre or post surgery.' ' ' It is the ultimate aimof theRT team to deliversufficient RT to control the tumour, while sparing as much normalhealthy tissue from irradiation as possible.' Irradiation of susceptibletissues, including the mucosal lining of the mouth, nose andaero-digestive tract, the salivary glands and pharyngeal co nstrictor m uscles,causes acute and late side effects (Figures 1 and 2 ). ' Acute side effects,occurring within 90 days of treatment, include mucositis, trismus,infection anddysphagia. Late side effects include osteoradionecrosis,radiation caries and periodontal disease.Dental management of the oral cancer patient is multidisciplinary andincludes oral-maxillofacial surgeons andspecialist/consultant dentistswho liaise with general dental practitioners (GDPs) and auxiliarydental team members (Figure 3). Dental management should beginpre treatment and continue during and after treatment.*"'* In recentyears, significant advancements have been made in thedelivery of RT,particularly in thearea ofsparing tissues surrounding the tumour fromradiation. Some of the more significant advances in RT and theireffects on thedental care of patients areoutlined in this paper.Oral and dental com plications of radiotherapyMucositisMucositis can range in severity from areas of erythema to ulcersexhibiting necrosis andb leed ing . ' ' " It Is a serious complication ofradiotherapy occurring in almost 100% of i rradiated pat ie nts. '" TheRadiation Therapy Oncology Group (RTOG) scale is often used tograde mucositis (Table 1). Mucositis causes pain, which affects and isaggravated by swa llowing. This leads to reduced food intake, weigh tloss and, in severe cases, can necessitate nasogastric or percutaneousendoscopie gastrostomy (PEG) feeding and interruptions to RTtreatment plans."''"* Areas that readily develop mucositis include thesoft palate, tonsillar pillars, buccal mucosa, lateral border of the


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Peer-reviewedJO!JRNAL OF THE !RiSH DENTAL ASSOC!AT!QN

FICURE 2: Side effects of radiotherapy, including muco sitis (a), dry mouth (b), osteoradionecrosis (c) and radiation caries (d).

Dental hygienists

Speech and langg^herapistsoiogistsMaxillofacial technicians

Community/cancer liaison officer

MD T co-ordina tor and database manager Ilinical specialist nurse:Smoking cessation adviserHead and neck cancer co-ordinator

FICURE 3: Care of the oral cancer patient is multidisciplinary.

E x t e n d e d t e a m : surgeons (e.g. cardiothoracic); anaesthetists/ITU/HDU;'pain specialists; psychiatrists; psychologists/counsellors; general m edicaitmi,: practitioners; administration support; comm unity care J ^ H

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tongue, pharyngeal walls and portions of the larynx.'^ It is estimatedthat 9-19% of RT interruptions are due to severe muco sitis,'^ Mucositiscom mo nly remains at peak levels for tw o weeks after RT; however, insome patients severe mucositis may persist for five to seven weeks.""Xerostomia and xerostomia-related side effectsXerostomia is the mo st freque nt com plaint follo win g RT and itssequelae include: caries; infection; impaired masticatory function;nutrit ional deficiency; challenges with prosthetic rehabil itation;difficulty with speech; and, loss of taste.'*''*'^'"-^^ Xerostomia may beginafter the first week of RT."Persistent xerostomia can significantly impinge on the quality of lifeand psychological well-being of the RT patient.^' Serous acini of theparotid gland are particularly sensitive to radiation.^^ The usual dosefor oral cancer treatment is 60-70Gy delivered over six to sevenweeks.^' The mean dose of RT leading to permanent impairment ofthe parotid is 24Gy for unstimulated fiow and 26Gy for stimulatedsalivary flow." However, when parotid sparing techniques areemployed and the dose to the sub-mandibular gland is below 39Gyxerostomia rarely occurs,^''-^^ In some cases gland function can berecovered, particularly where only one parotid gland has been fullyirradiated,*'^' However, long-term retrospective analysis has shownthat 65% of patients experience moderate to severe xerostomia,which requires support, following RT,^'^ The RTOG scale is also used tograde xerostomia (Table 1),Other oral side effects of RTOther serious side effects of RT include osteoradionecrosis (ORN),*candidal infection,^*'^' periodontal disease^ and muscle fibrosis^"(Figures 1 and 2) , The pathogenesis of ORN is not fully understood,although it is thought to occur as a result of irreversible damage tobone vascularisation and impairment of bone remodelling,* ORNmore commonly affects mandibular bone^ and can range from smallasymptomatic bone exposures that remain stable or heal withconservative management, to severe necrosis requiring surgicalintervention and reconstruction,^^Advancements in the delivery of radiotherapyAdvancements in radiotherapy generationWhen Initial studies on the delivery of RT to treat head and neckcancers began in 1896, neither the quantity nor the quality ofradiation could be measured, and side effects included burning of theskin leading to necrosis and sloughing,^^ During the 1950s, cobalt-60became a widely used source of RT, However, com pared to mod ernRT techniques, cob alt-60 em its relatively low-energy photons soionising radiation is deposited superficially, causing increased mucosaland cutaneous toxicity. Its use is now limited to palliative care andtreatment of cancers in the developing world.^^ The development oflinear accelerators to generate RT has facilitated increased tissuepenetration and tissue sparing.^^ Using linear accelerator-derived RT,multi- leaf coll imators and data derived from computed tomography(CT) scans, the RT beam m ay be shaped to m atch that of the tumo urs;June/July 2013140 : VOLUME 59 (3)

this technique is know n as three-dimensiona l con formai RT (CRT).Intensity-modulated RT (IMRT), a further technological advancement,allows the creation of dose gradients across the beam and the d eliveryof different doses to different targets simultaneously, further tailoringthe delivery of RT to the specific tumour size and sparing surroundingtissues," IMRT may allow further tissue sparing, leading to a reductionin RT-induced side effects.However, studies comparing IMRT and CRT have shown mixedresults. Chen et al. (2009)^'' studied 49 patients with oral cancer andfound no significant difference in acute toxicity (mucositis) betweenpatients treated with CRT and IMRT. Late toxicity could only bemeasured in 30 of the patients, and while it was shown that patientstreated with IMRT had significantly less moderate to severexerostomia and dysphagia, 100% of patients experienced somedegree of both xerostomia and dysphagia. Patients in both groupsexperienced fibrosis and trismus, but the sample size was too small toderive statistical significance. In a similar study. Chao et al . (2001)showed that patients treated with IMRT had higher rates of stimulatedsalivary flow than those treated with CRT.^^ However, follow-up times(six mo nths) were sh ort; recovery of the glands can continue for up to12 months post RT.^Brachytherapy, a method of RT delivery whe reby the radioactivesource is placed inside or in close proximity to the area being treated,has been investigated for treatment of oral cancers; however, its use islimited to patients presenting with early T l and T2 cancers.^^^Advancements in radiotherapy treatment protocolsand imag ing techniquesMean dose to the parotid gland is the best predictor of functionfollow ing RT ^'''' and RT techniques aimed at sparing the parotidglands include inverse planning RT,^* intra-operative RT,'' RT boosttec hn iqu es " and ipsilateral RT.^*'"'''^ Ipsilateral delivery of RT haspreviously shown some success in the treatment of tonsilar andoropharyngeal cancers.''^''^ Vergeer et al . (2010) investigatedipsilateral RT in the treatment of well lateralised oral cancers.'"Promisingly, only 5% of patients had grade 2 or greater xerostomia(RTOG scale) at two to three years post treatme nt. However, ipsilateraldelivery is only suitable for well lateralised early stage cases where therisk of contralateral node metastasis is low,''" In Vergeer's study 50%of the oral cancer patients in the study had cancer of the gingivae,which is not representative of the usual distribution of oral cancers.Inverse planning and RT boost techniques are alternative RT deliverytechniques, which aim to spare radiosensitive tissues by deliveringhigher doses of radiation to the tum our site and conven tional fractionsto secondary sites." Neither technique has been successful ateliminating RT-associated toxicities. Butler et al . (1999) investigatedsimultaneous modulated accelerated RT boost: 80% of patientsreported grade 3 mucositis (RTOG scale) and 45 % had grade 2 orhigher xerostom ia." P arliament et al. (2004) showed more promisingresults using inverse planning; however, 80% of patients in the studywere suitable for bilateral parotid sparing.'" Intra-operative RTfacilitates treatment of the margins of tumours at the time of excision;


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FICURE 4: Pre radiation therapy radiation, a stent may be made.

however, a high-dose single fraction delivered to normal tissuescreates a high risk of late complications and surgery must take placein a dedicated RT suite. "As techniques for the generation and delivery of RT have advanced, sotoo have the techniques available for imag ing the tu mo ur tissues priorto and during RT.'''' Sharp dose gradients used with IMRT requireaccurate tumour imaging.'''' CT is the standard imaging modality usedin RT treatment planning. However, when used in conjunction w ithmagnetic resonance imaging (MRI), detailed definition of soft tissues,representing microscopic tumour extension, can be generated, andartefacts (e.g., am algam ) cause less interference.^^ Recently, the use ofpositron emission tomography (PET) has made staging andsubsequent follow-up more accurate and facil i tates improveddetection of occult contra-lateral lymph node mtastases.''" In thefuture more radio-resistant hypoxic areas of tumours could beidentified by PET imaging and targeted with higher doses of radiation;however, investigations regarding acute toxicity would also berequired.^Deriving meaningful results from the many RT delivery studies isdifficult due to insufficient follow-up times,''^ lack of placebo orb l in ded assessment , ' ' ' ' ' fa i lu r e / i na b i l i t y to take base l inemeasurements'""'"' and small study populations."-''^ Few studies arelimited to oral cancers and therefore results presented are not specificto oral cancer.'" In addition to the adjunctive treatment underinvestigation, subjects are often given concomitant chemotherapy;however, effects of how this additional variable may influence studyoutcomes are rarely considered.^^'*-^A wide range of grad ing schemes is used, in particular to grade qua lityof life (QoL) and xerostomia.^^-^**-"^-^' Craff et al . (2007) reportedhigher OoL scores for patients treated with IMRT; however, astatistically significant number of patients treated with CRT wereunemployed and a higher number of CRT patients had co-morbiditiesand lymphatic involvement.^' Henson et al.^^ (2001) and Parliamentet al.^^ (2004) used different questionnaire instruments to assesspatient-reported xerostomia. In contrast to the results of Parliament et

al., Henson et al . found that patients did not re-establish pre-treatment saliva levels, raising the question of whether Henson'squestionnaire showed greater responsiveness or whether subjects inParliament's study had, on average, better salivary functionpreservation.Correlations between salivary flow measurements and patient-reported xerostomia are often weak. Cerezo et al. (2009) using theCTCAE (Common Terminology Criteria for Adverse Events) tool formeasuring xerostomia, found that subjective measurements tend tounderestimate salivary flow.''" Jensen et al." (2007) also found littlecorrelation between patient-assessed symptoms according to theEORTC (European Organisation for Research and Treatment ofCancer) questionnaires (C30 and HS[N35) and objective salivary flowmeasurements. Eisbruch et al.^'' (2001) described a low correlationbetween symptoms and salivary measurements, and concluded thatboth subjective questionnaires and measurement of the saliva shouldbe included in xerostomia evaluation. The main objective ofminim ising side effects is to improv e Q oL; therefore, in clinical practicesubjective symptoms may be more relevant.""New m ethods of RT delivery, volum etric intensity m odulate d arctherapy^"'^^ and particle therapy,^^'^^ aim to further minimise sideeffects; however, it is anticipated that the dentist's role will remaincritical and that the field of dental oncology will continue to gainmore recognition.Adjunctive treatments used in the delivery of radiotherapyTo minimise side effects, many research groups have investigated theadministration of adjunctive therapies concomitantly with RT. Suchtherapies include laser therapy," anti-fungals,-^*'"" pilocarpine,^^ zincsupplementation,^^ amifostine"'" ' and chemotherapeutic agents."' '" 'Surgical repositioning of the sub-mandibular gland has also beeninvestigated, although not in the treatment of oral cancer patients."'^' Some success has been shown by the use of adjunctive therapies.Patients on amifostine showed significantly less grade 2 or higherxerostomia and higher unstimulated salivary flow rates.""^ The

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administration of antifungals has been shown to significantly reducethe severity of mucositis and the number of interruptions to thedelivery of RT.^* However, to date, no adjunctive treatment hassuccessfully managed to eliminate the side effects of xerostomia,mucositis and ORN.Dental managem ent of patients receiving radiotherapyDespite the many advances in the delivery of RT, side effects remainunavoidable, particularly in patients who continue to smoke and/orconsume alcohol , and in pat ients who require concomitantchem otherapy and RT delivery to nodal sites ." Fundamental dentalcare of oral cancer patients has not changed significantly."Thoroughoral hygiene (OH) practice, regular fluoride use, conservativetreatment p lans and management of xerostomia remain thecornerstones of treatment. A flow chart outl ining ideal managementof the dental patient is shown in Figure 5. Reports published by theNational Institute for Clinical Excellence (NICE) (2004) and theScottish Intercollegiate Guidelines Network (SIGN) (2006) haveemphasised the importance of the dentist within the multidisciplinaryteam (MDT) and have recommended roles for specific members of thedental team.'^''" For example, the NICE report suggests that althoughspecialist dentists may form part of the MDT, long-term dental careshould be provided by the primary care dental team." Recentchanges in dental manage ment are mainly focused on standardisationof dental care, and defining roles and responsibilities wi thin the de ntalteam.Dental management pre RTThe most important risk factors for complications following RT for oralcancer are pre-existing oral and dental disease, and poor oral careduring and after cancer therapy.' The pre-RT dental visit thereforeremains critical; patients are more likely to have their teeth now thanin the past"^*^ and studies have shown that between 58% and 97% ofpatients examined prior to RT needed imm ediate d ental care.'"'"'''Treatment must be carried out promptly to maximise healing timeand 'ideal' treatment plans often need to be adapted.' Pre-RT patientsmust be educated regarding the side effects of RT; trays are made fordelivery of fluoride and/or chlorhexidine, and the importance ofmeticulous OH and long-term regular dental visits is emphasised(Figures 4 and 5).Patient assessment requires decision making and clinical skills, and isbest carried out by experienced dentists who can design treatmentplans using information provided by other members of the MDT, e.g.,tumour size and location, radiation dose and field of therapy.' Suchinform ation may influence the decision to extract teeth and the designof radiation stents.Radiation stents are custom-made devices that displace or shieldtissues, and which are used to position patients in repeatablepositions, increasing the consistency of RT delivery to th e tu mo ur site(Figure 4).^'"' The stents are usually fabricated by th e den tal team , andwhile they do not prevent R T-related side effects, they can reduce theincidence and severity of mucositis and xerostomia.^''^ Intra-oral leadJune/July 2013142 : VOLUME 59 (3)

shields, used in the treatment of lip cancers, and positioning masks,for patient imm obilisation during RT delivery, are also used as aids forthe protection of healthy tissues.^'^'''A current lack of evidence-based clinical guidelines means thatdecision making regarding extractions relies heavily on the clinician'sexperience." Bruins et al. (1999) surveyed hospital-based dentists andoral-maxillofacial surgeons and found a high level of similarity in theirdecisions on which teeth to extract, despite the lack of guidelines,'^contrary to the findings of Hong et al.^^ (2010). However, there is noevidence for prophylactic dental clearance before RT.''^'''' In additionto design and fabrication of radiation stents, consultant/specialistmaxillofacial prosthodontists are often requ ired to liaise with surgeonsin planning dento-facial prosthesis.*Dental management during RTTreatments available for the management of mucositis are limited.Current management of mucositis Is mainly palliative; however,research and development of targeted therapeutic interventions isongoing." In mild cases some relief is provided by mucosal coatingsolutions and anaesthetic agents such as lidocalne lollipops andbenzydiamine hydrochloride rinses. More severe cases can bemanaged with analgesics and systemic antifungals if there is a risk ofcandidiasis.* Patients should be advised to use a soft toothbrush,gauze or mouth sponges, and chlorhexidine mouth rinses, and toleave dentures out. Jaw stretching exercises should also beencouraged during RT to m aintain m aximal mou th opening andprevent muscle fibrosis." Routine dental treatment should bepostponed until after RT, and patients requiring emergency dentaltreatm ent during RT should be m anaged in specialist centres.Dental management post RTFollowing RT oral cancer patients remain at high risk of carles, oralinfection and oral functional impairment, which can seriouslycompromise OoL and necessitate life-long regular prophylaxis.'^ Ifcomplex restorative work, including Intermediate and definitiveprosthesis, are required after surgery, care should continue with aconsultant/specialist maxillofacial prosthodontist.^ Dental Implantscan be considered; however, implants placed in irradiated bone havean increased risk of failure com pared to those placed in non-irradiatedbone."*Existing treatments for xerostomia offer some relief from thesymptoms of dry mouth, but fail to restore gland function."Management of xerostomia may include saliva substitutes, andfrequent intake of fluids, and systemic cholinergics (e.g., pilocarpine)can also be prescribed where residual gland fun ction remains.ORN is a late com plication of RT and the risk of developing it increasesover time.** Advances in RT have decreased incidence rates from11.8% pre 1968 to approximately 3% currently."**' '* Risk of ORNneeds to be evaluated by the clinician, but it is now recommendedthat patients requiring extraction should be managed in a specialistcentre.**""*^ Endodont ic t reatment should be favoured overextraction and, when necessary, extractions should be as atraumatic


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Peer-reviewedJOURNAL OF THE !R!SH DENTAL ASSOCIATION

EDUCATIONImportance of good OHSide effects of RTJaw exercisesImportance of regular dental care

Stents fabricationPre-prosthetic surgery(alveoloplasty and torus removal)

Management of mucositis

Complete assessment Treatment of pre-existing problems, e.g.,caries, defective restorations, ill-fittingdentures, periodontitis, candida

Deliver intermediateand definitive prosthesisManagement of radiation caries

Monitor for local recurrence of cancerRegular professional cleaning

Post RT

Monitor prosthesis hygiene

Baseline salivary flow measurementsTrays for prophylaxis delivery

Design of dento-facial prosthesis

Reinforce importance of OHand jaw exercises

Management of dry mouthReinforce importance of OHand frequent dental visits

Maintain healthy dentit ion, avoidingextractions whe re possible

Atraumatic extractionsFICURE 5: Dental managem ent o f the oral cancer patient before during an d after radiotherapy.as possible. Chlorhexidine mouthwash and antibiotic cover should beadministered prior to extraction, and placement of a splint to preventtrauma during healing should also be considered. There is currentlyno evidence that hyperbaric oxygen therapy reduces the incidence of

The roie of the GDPCompliance with OH routines is often difficult for oral cancerpatients.*' However, the importance of basic dental care, includinggood OH and regular dental assessment, should be emphasised. TheGDP is of ten best p laced to provide regular care to thepatient.^'^Aspects of oral care that can be carried out by the GDP, inconjunction with the dental hygienist where appropriate, include:^*" evaluation and reinforcemen t comp liance wit h OH measures and

fluoride use; diet analysis and advice; advice on prosthesis maintenance ; reinforcemen t of advice on lifestyle changes; regular professional cleaning; Mo nitorin g for signs of second primaries; reassurance for patients fearful of recurren ce; simple /routine restorative procedures; and , referral of patients to specialised centres for extractions and

complex restorative procedures.Monitoring for second primaries is particularly important; the

recurrence rate for oral cavity squamous cell carcinoma isapproximately 30%.'*''Discussion and conclusionsNew methods of RT delivery have reduced the side effects of RT fororal cancers; however, long-term irreversible damage to the salivaryglands, connective tissues, vasculature and bone is still induced,leading to unavoidable side effects. Recent publications haveattempted to define roles within the dental team and standardise careof the oral cancer patient, in particular the importance of long-termregular support within the community and specialised care wherenecessary. However, current recommendations for the dentalmanagement of the oral cancer patient tend to be based on expertopinion rather than evidence-based studies.Many challenges still face the dental team, including the lack of aneffective treatment to relieve the symptoms and sequelae ofxerostomia," the high number of patients lost to follow-up,*^ poorpatient compliance*' and the prevention of ORN.''^ In addition, manyoral cancer patients are not provided wit h specialist dental care; someare referred to their GDPs prior to RT, while others receive no dentalcare prior to RT.*"^"'' Scientific evidence has shown that good oralhealth is directly related to a patient's quality of life and therefore therole of the dental team in the management of the oral cancer patientbefore, during and after RT remains critical.It is hoped that in the future these challenges will be addressed by

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increased communication between all members of the cancer team,including dentists, and with the formulation of evidence-basedguidelines, in particular focusing on highlighting the role of the GDP,It is also hoped that dental care will continue to evolve concurrentlywi th new methods of RT delivery, thereby m aximising the inevitablyreduced QoL of the oral cancer patient.

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15. Parsons, |.T. The effect of radiation on normal tissues of the head and neck.In: Milion, R.R., Cassisi, N,),, (eds,). Management of Head and Neck Cancer:A Multidisciplinary Approach (2nd ed.). Philadelphia: j.B. LippincottCompany; 1994: 245-289.

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volume, and function relationships in parotid salivary glands followingconformai and intensity-modulated irradiation of head and neck cancer. Intj Radit Oncol Biol Ph/s 1999; 45 (3): 577-587.

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20 . Anand, AK., Jain, |., Negi, P.S., et al . Can dose reduction to one parotidgland prevent xerostomia? A feasibility study for locally advanced head andneck cancer patients treated with intensity-modulated radiotherapy. ClinOncol (R Coll Radiol) 2006; 18 (6): 497-504.

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C o p y r i g h t o f J o u r n a l o f t h e I r i s h D e n t a l A s s o c i a t i o n i s t h e p r o p e r t y o f I r i s h D e n t a l

A s s o c i a t i o n L i m i t e d a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d

t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y

p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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