I M P R O V I N G
O R A L
H E A LT H
D U R I N G
C A N C E R
C A R E
SUMMER 2021
ARMORNEWSLETTER ARMOR TRIAL UPDATES After a year like 2020, everyone was collectively ready for some new hope. The ARMOR team follows all University of Pennsylvania and CDC recommended infection control procedures to help keep everyone healthy. Our team is fortunate to have received the Covid-19 vaccine earlier this year, ensuring we can care for our study participants and our families safely. The trial continues to recruit new study participants and to provide our subjects with oral care during their treatment for head and neck cancer. With summer in full swing, our team at the Center for Clinical and Translational Research is taking a collective sigh of relief. We can’t help but feel grateful for all that our research team, our study participants, the friends and family that serve as their support systems, and the dedicated team of physicians, nurses, and other staff who have contributed to the ARMOR Trial over the past year, have accomplished!
Thank you for your continued support!
HEALTHY SMILE, HEALTHY YOU! Even if you aren’t receiving radiation any longer or getting daily Twilio texts asking about your home care, practicing good oral care should continue for the rest of your life. You worked hard during your treatment to maintain good oral health: keep it up! Jana sends her best to all of you, and would like to remind you to:
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Brush your teeth for two minutes, twice a day. Make sure to use a high fluoride prescription toothpaste, such as Prevident, once a day to help prevent tooth decay post radiation therapy.
Floss or use an interdental cleaner (like floss picks or soft picks) regularly; the length of floss you use should extend from roughly the tips of your fingers to your inner elbow (see photo above).
3 If you are suffering from symptoms of dry mouth, ask your dentist if a moisturizing mouth rinse is recommended for usage, with no alcohol content.
ARMORNEWSLETTER
DR. CHANG CHIMES IN Oral Care After Cancer Care We teamed up with Dr. Brian (Myung) Chang, Director of Maxillofacial Prosthodontics at the Oral & Maxillofacial Surgery Department at Perelman Center for Advanced Medicine (PCAM). Dr. Chang is part of an interdisciplinary team of dentists and radiation oncologists at PCAM. He has dedicated over 25 years of research and clinical care to patients undergoing cancer therapy. He delivers highly integrated and personalized oral rehabilitation care for head and neck cancer patients, from when they first undergo surgery, through the rest of their lives. Dr. Chang provided some answers to frequently asked questions patients have about osteoradionecrosis, a potential complication of radiation therapy. 1 I ’ve heard osteoradionecrosis is a potential side effect of radiation/chemoradiation. Can I do anything to prevent this from happening? Radiation therapy is used to kill cancer cells, but the treatment also harms healthy cells at the same time. One complication of this therapy is a condition called osteoradionecrosis. Osteoradionecrosis is non-healing, exposed bone in a previously radiated area of the body, usually the lower jaw in head and neck cancer patients, that has been treated with radiation. Starting cancer treatment in good oral health is key to preventing and minimizing oral toxicities associated with radiation and/or chemotherapy. If you have any pre-existing oral issues such as a dental infection or abscess, cavities, or gum (periodontal) disease, you will need to make sure the issue can be resolved as much as possible before starting treatment. Maintaining good oral health during and after cancer care is also extremely important to prevent complications such as osteoradionecrosis. This may include simple, yet effective habits such as routinely brushing and flossing your teeth, increased exposure to a prescription-strength fluoridated product, and more frequent follow-ups and hygiene visits with your dental professionals.
Before starting radiation/ chemoradiation therapy, your oncologist should recommend a dental clearance in which the dentist performs an oral examination and predetermined prevention of osteoradionecrosis. This prevention includes the extraction of teeth with questionable or poor prognosis before the start of radiation/ chemoradiation. Your providing dentist should be in constant communication with your multidisciplinary cancer care team to make informed treatment decisions. There are specific criteria the dentist performing the dental clearance will follow when determining if a questionable tooth is restorable, or if it must be extracted. Teeth with poor prognosis are extracted if they are in parts of the jaws expected to receive a high dose of radiation. Any extraction that is performed should be allowed to heal for 10 days to three weeks before the start of radiation/ chemoradiation therapy. Decayed teeth must be restored by the dentist prior to chemoradiation therapy. If you wear dentures, these should also be evaluated to ensure they fit properly and will not cause tissue irritation after chemoradiation therapy. These measures of treating dental cavities, ensuring the proper fit of dentures, and extracting teeth with a poor prognosis prior to radiation/chemoradiation can prevent osteoradionecrosis in most cases.
2 What are the recommendations for dental implants after radiation/chemoradiation? Oral rehabilitation to replace missing teeth with dental implants is one viable option for improving the quality of life for head and neck cancer patients. However, dental implants have a greater risk of failing due to the effects of radiation/chemoradiation therapy. Causes of failure can be due to osteoradionecrosis and/or changes to the tissue remodeling system in the oral cavity. There is no scientific consensus about the threshold dose of radiation affecting dental implant survival. The risk of osteoradionecrosis is related to radiation dose, volume of irradiated tissue and the timing of implant placement. Typically, dental implants are placed 6 months after radiation/ chemoradiation therapy. There is currently no evidence from clinical trials to verify the “best” timing for dental implant placement. If you are considering dental implants as a replacement option for your teeth, be sure to alert your dentist of your cancer radiation/chemoradiation history so they can consider your health status when making treatment decisions.
3 What are the recommendations for dental extractions after radiation/ chemoradiation? A conservative approach is recommended regarding the extraction of teeth after radiation/chemoradiation therapy. Extremely mobile periodontally compromised teeth can be safely extracted with minimal risk of osteoradionecrosis. Current research states that the development of osteoradionecrosis is highest when extractions were conducted within 2-5 years post-radiotherapy at an incidence of 22.64% If an extraction is indicated, a minimally traumatic extraction technique, prophylactic antibiotics, platelet-rich plasma (PRP) and steroids in order to reduce osteoradionecrosis are indicated. Another prevention modality surrounding osteoradionecrosis is the use of hyperbaric oxygen (HBO) therapy. Common protocol for this therapy is 20-30 dives (HBO sessions) before extraction of a tooth, and 10 dives beginning immediately after the extraction. Research recommends root canal therapy as an atraumatic treatment alternative to tooth extraction when indicated.
4 I had some teeth removed prior to my radiation/chemoradiation. When can I start the process to get a removable prosthesis fabricated? Removable dental prostheses should be avoided in patients with radiation/ chemoradiation therapy unless they are essential for esthetics or function. The soft tissue must be adequately healed before the fabrication of removable prosthesis can be initiated. It is suggested that dentures can be inserted at least six months or delayed by up to a year after radiation/chemoradiation therapy. Removable dental prostheses should be routinely evaluated and adjusted in areas of pressure in the mouth, which could result in the increased risk for ulcerations and osteoradionecrosis. CONTACT DR. CHANG pcamomfs@pennmedicine.upenn.edu 215-662-3580
CENTER FOR CLINICAL AND TRANSLATIONAL RESEARCH UPDATES The Clinical and Translational Research (CCTR) team has been growing! We are happy to introduce Cheryl O’Donnell Flynn (Research Dental Hygienist), Renee Tangi (Research Dental Assistant), and Collin Kather (Lead Clinical Research Coordinator) as new members of our team. A number of ongoing and upcoming research projects are also in the works. You may recognize the names of the ARMOR trial’s OM evaluators as Principal Investigators in current studies, including: |T he FIRE Trial: a collaboration between the School of Dental Medicine and Wharton School of Business which aims to track pain symptoms of burning mouth syndrome in real-time with a smartphone app. By tracking in real-time, pain symptoms are recorded closer to occurrence, which reduces reliance on patient memory, and may help to better characterize pain symptoms. The FIRE trial is led by PI Dr. Eugene Ko of Oral Medicine. |A Study on the Role of the Dentist in Vaccination for COVID-19 and Human Papillomavirus (HPV): Led by PI Dr. Katherine France of Oral Medicine, this study aims to determine patient attitudes around the role of the dentist in vaccinations for both COVID-19 and human papilloma virus (HPV). HPV is the leading cause of oropharyngeal cancers, primarily of the tonsils, tonsillar crypt, the base of the tongue, and a very small number of front-of-the-mouth, oral cavity cancers. Due to the relationship between HPV and the oral cavity, it is essential to explore the ways that dentists can play an important role in public health measures, like administering vaccinations against the two widespread conditions of HPV and Covid-19.
We hope you’ll keep in touch and share your happy news as well, whether it’s big or small! Please feel free to send us an email at PDM-ARMORTrial@dental.upenn.edu with any news you’d like to share with our team. From the CCTR family to yours, we hope you have a relaxing, happy, and healthy summer!
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TEAM UPDATES We’ve all been busy making up for lost time and are looking forward to some more healthy normalcy in the coming months. Here is what we’ve been up to in the last few months: |D r. Corby is hoping to finally be able to spend some time with her family in Brazil later this year, after almost two years. She has started new studies to improve nutrition during cancer care, which she is very excited about! |M arta is hoping to go see her parents in September; otherwise she is just enjoying the summer: her favorite season! |M ichelle is looking forward to spending time at the beach with her family this summer. |M att will complete his MSEd in Statistics, Measurement, Assessment, and Research Technology (SMART) in August of 2021. | J ana moved into a new house with even MORE room for her plant collection! She’s been busy with taking online classes but is using her summer break from school to take a trip this August to tour Yellowstone, Glacier, and Grand Teton National Parks. |D r. Dennis Sourvanos is actively working toward his DScD research projects and recently enrolled in a Regulatory Sciences Certificate Program with the Perelman School of Medicine Institute for Translational Medicine Applied Therapeutics (ITMAT). |C heryl’s year has been exciting for a few reasons; her middle son has graduated from college with his degree in biology (hopefully landing a job soon!) and she is celebrating her 25th wedding anniversary in September by going to Charleston, SC with her husband. |R osa has been busy kickboxing and adventuring around new neighborhoods in the city on her bike. |R enee is happy her life has returned to some “normalcy” after the winter. She’s had some home renovations completed, which was fun since she loves to shop! With the summer officially here, Renee has attended a few parties and enjoys spending some good quality time at the beach/pool with her family. |Y uan enjoyed making dumplings and playing video games with her daughter. She was also selected as a recipient of two awards for her research, the Colgate Award for Excellence in Research (CARE) and the IADR Joseph Lister Award for New Investigators.
Pineapple Whip with Almond or Coconut Milk
Makes 4-6 servings
WHAT’S GOOD ABOUT THIS RECIPE? Honey helps the body’s infection-fighting system (immune system). It can also help symptoms of oral mucositis (mouth sores). Using full fat almo nd or coconut milk provides some healthy fat, which can help stop weight loss. The cold temperatu re can feel good on mouth sores. Adding protein powd er is a good way to increase protein in a form you can drink. INGREDIENTS 6 to 7 cups frozen pineapple 1 cup pasteurized almond milk or full-fat, pasteurized coconut milk 2 scoops protein powder (optional) 1 tablespoon honey DIRECTIONS 1. Put all ingredients in a blender or food processor. 2. B lend until combined, smooth, and slush y, like soft ice cream or sorbet. 3. P our into dishes or glasses and serve. If you have extra, it can be frozen and served later. Source: St. Jude’s Research Hospital has ident ified this recipe as being helpful for people suffe ring from symptoms of oral mucositis.
CONTACT THE ARMOR TRIAL STUDY TEAM AT: PDM-ARMORTrial@dental.upenn.edu 917-586-9089