24 Mar Dental Implants After Head and Neck Cancer
Written by: Ryan S. Lee, DDS, MPH, MHA, FAGD, FICOI, DIDIA
Yes, You May Be a Candidate, with Caveats and Clinical Considerations! (Part 1 of 2)
Every cancer survivor I know is a hero in a unique way. The thousands of oral and head/ neck cancer survivors I have met and treated have one thing in common: all of them have firmly dealt with their cancer diagnosis, courageously battled weeks/months-long cancer treatment, and have made heroic efforts, even after cancer, to deal with the many lifelong side effects of cancer treatment.
But why must these cancer survivors live with missing teeth, painful teeth, ill-fitting dentures? Unfortunately, so many struggle with these issues, which affect chewing/ nutrition, confidence/self-esteem, speech/ function, and many other downstream health outcomes. Too many cancer
survivors are told that they are not candidates for dental implants because they had radiation or chemotherapy.
Well, let me tell you something. This is simply NOT true, and I would like to set the record straight. Cancer survivors, even those who received many weeks of radiation to the oral cavity and head/neck area, even those who received a combination of radiation, chemo, and/or surgical resection, OFTEN ARE candidates for dental implants and CAN receive safe, predictable implant therapy. Many dental practitioners have placed dental implants in many thousands of cancer survivors for over a decade. This has been one of the most satisfying aspects of my career and highlights my daily role as a dentist and dental oncologist.
Have you ever pondered any of the questions below?
1. Are cancer survivors candidates for dental implant treatment?
2. If so, what are some caveats and clinical considerations that are unique to cancer patients, which must be considered to ensure safe and predictable treatment outcomes?
3. How do I find the right dentist, one that is trained in performing dental implants for patients that had radiation, chemotherapy, and other cancer treatment modalities?
4. Are there any ways for dental implants to be more affordable for cancer patients and survivors?
These are some of the most common questions patients and their family members ask. Dental Oncology, as most readers are aware, is a specialized field of dentistry that is dedicated to the management of the unique needs of cancer patients and survivors. While cancer centers, hospitals, and even dental private practices do a credible job in providing dental care before patients receive radiation, chemo, or transplant, too many cancer survivors are left on their own after cancer therapy even when they experience on-going dental issues. This is where a dental oncologist can help. Please allow me to help a bit here by answering the first two of the aforementioned questions, in brief. The latter two questions, please allow me to answer in a follow-up article.
Are cancer survivors candidates for dental implant treatment? First and foremost, the prognosis or the likelihood of success behind any medical or dental procedure must consider the risks, benefits, and alternatives. This is what every doctor and healthcare professional does before suggesting options, performing surgical treatment, and managing the post- operative outcomes. So, what are the risks of dental implant therapy for cancer survivors? When it comes to dental implants, cancer survivors have the same risks that all other non-cancer survivors have, including infection, pain, swelling, etc., the great majority of which alleviate over a matter of days, if not a week or two. Dental implants, in today’s age of minimally-invasive surgery and digital dental technology, have a 92-95% success rate the first time around.
Beyond the usual risks, however, cancer survivors who received radiation are at a risk of a unique complication known as osteonecrosis (or osteoradionecrosis). In short, the effects of radiation to kill cancer cells, while incredibly important and necessary, also damages the fine blood vessels in the jaws. Because these blood vessels often do not regenerate in areas like the parotid gland or the mandible, the body’s ability to heal and integrate a dental implant (made of titanium or zirconia) can be compromised. With fewer blood vessels in the jaw, there are fewer cells within the site of the implant placement to enable proper and timely clotting, healing, and osseointegration, or bone ingrowth into the implant itself. When a non-cancer patient (who never had any radiation to their head/ neck or jaws) has a tooth extracted or an implant placed, the gum tissue closes naturally over a week or two, and everything heals uneventfully in a matter of days or weeks. When a cancer survivor (who often had as many as 6-7 weeks of daily radiation therapy) has a tooth extracted or an implant placed within the area previously radiated, the same gum tissue may take weeks, months or longer to close. Sometimes, the gum tissue stays open, exposing the jaw bone underneath, often creating an opportunity for infection and swelling, not to mention pain. This is, in essence, defines osteonecrosis.
Unfortunately, there is no surefire way to treat osteoradionecrosis without months/ years-long conservative management or surgical intervention that often involves removal of parts of the jaw. No concrete cure exists for osteoradionecrosis to date, so we must avoid it. And the risk of osteoradionecrosis actually gets worse the more years you live after radiation. This risk never goes away and is a lifelong concern (those blood vessels never regenerate in certain parts of the jaw).
Of course, if the radiation was received to an area below the neck, say the GI system, then of course this has no relevance in the risk of a cancer survivor experiencing osteoradionecrosis of the jaw with dental implants. But, if a head/neck or oral cancer survivor did receive radiation
to the jaws and teeth, then of course he or she is at risk of osteoradionecrosis with any dental extraction, surgical gum / periodontal procedure, and dental implant treatment.
Then, how does the dental provider know who are candidates and who are not? What are some caveats and clinical considerations that are unique to cancer patients? Do you know how everyone in real estate says that it comes down to location, location, location? Well, in the world of dental oncology and oral implantology, it always come down to blood supply, blood supply, blood supply.
Let’s consider a cancer survivor with a base-of-tongue squamous cell cancer who finished chemotherapy and 6.5-weeks of radiation therapy in 2015. She is a healthy 57-year-old, has been cancer-free for 7 years, and now presents for management of missing lower left molars makes it difficult for her to chew properly. She has also noticed that her gums and facial structure is beginning to shrink on the lower left jaw area. She does not find her existing partial denture comfortable, which irritates her gums. It is also difficult to use because of her mild-to-moderate dry mouth, putting her at risk of cavities and periodontal disease.
The dental care provider, must determine how much blood supply is available in the posterior left mandible that will receive dental implants via several clinical considerations. First, the dose of radiotherapy received by the patient must be obtained from the radiation oncologist and/or radiation physicist at the cancer center. Second, the dose of radiation specific to the posterior left mandible must be assessed vis-à- vis maximum dose information, the specific location of the primary tumor, and the modality of radiation therapy (IMRT vs. 2D-RT). This information must be combined with clinical findings, such as bone density in the jaw, proximity of the nerves/sinus/ critical structures, periodontal health, cavity risk, dry mouth status, etc. Sometimes, even the presence (or the absence) of facial hair (e.g., peach fuzz in females and beards/moustaches in males, for instance) are markers that allow us to make a holistic or general decision in concert with the factors above on the safety and predictability of dental implants in cancer survivors with radiation history, as well as the ability to minimize the risk of osteoradionecrosis.
Understanding such risks and achieving optimal outcomes in cancer survivors needing dental implants means dental consultations with such patients often take an hour or two, which is different than the five minutes a dentist may spend doing a comprehensive dental evaluation after a hygienist’s cleaning procedure. Hence, it is recommended that cancer survivors, especially those who had radiation therapy, consult their dentist, dental specialist, or dental oncologist (or a dentist who has had training in cancer hospitals) for proper care.
If (and only if) the abovementioned factors are considered, cancer patients and survivors can successfully receive dental implants. I have had the blessing of placing many hundreds, perhaps a few thousand, dental implants in cancer survivors who had chemotherapy, radiation, surgery, transplants, etc. Often, these survivors can eat better, chew better, smile better, and prevent shrinking gums, jaw bone, and even facial deformities. We can help.
A follow-up article will answer the latter two aforementioned questions regarding finding the right dentist or dental oncologist, as well as ways to make dental implants more affordable. As a teaser, it can be stated that every cancer survivor and direct family member may qualify for a 40% discount on any dental care not covered by dental insurance. In our practice we call it our Survivor Smiles program, with industry support from large dental implant companies as well as us having some success with billing medical (not dental) insurance have enabled us to provide affordable fees for state-of-the-art minimally-invasive dental implant surgery and oral rehabilitation. Editor’s Note: Dr. Ryan S. Lee, DDS, MPH, MHA, FICOI, FAGD is a dual-fellowship trained dental oncologist in the fields of oral implantology and general dentistry. He is Founder and CEO of Morning Calm Dental Management, a group of 4 practices in NY, MA, RI, and CT that is dedicated to the dental care of cancer patients, survivors, and their family members. Dr. Lee graduated with honors from NYU College of Dentistry, followed by a general practice residency at Jersey City Medical Center and a 2-year surgical fellowship in Dental Oncology at Memorial Sloan Kettering Cancer Center. He has taught as a faculty member at NYU and also served as Department Chair of Dental Medicine in hospital/ academic settings in Cambridge, MA and Providence, RI. Dr. Lee’s private practice in midtown Manhattan, New York Center for Dental Oncology, was the first-ever private dental practice dedicated to dental oncology in the Northeast and still accepts new patients.