My team at the Victoria Cancer Clinic includes a dietitian. I’ve called her a couple of times now to inquire about “bulking up”. This is the process of putting on mass now that my body will later burn up later when I’m not able to eat as much as I need.
Everything I’ve read (thanks all you bloggers out there) indicates that I’ll lose 20-40 lbs. My dietitian thinks that I should put on 10-15 lbs, based on me being 6’1″ and 169 lbs. She also confirmed something that Dr. Pite (the clinic’s dentist) said: although our bodies normally go to our body fat to get needed energy when we start a diet, our bodies go first to muscle mass when we’re in radiation treatment. So, it’s good to put on weight in advance of treatment, but it’s best if that we put on muscle mass rather than fat.
My wife picked up a great big jar of 100% natural whey protein powder from Costco. It’s vanilla flavoured, and tastes just fine when blended (I use a Magic Bullet) with milk.
My dietitian had me check to confirm that the powder does not contain any antioxidants. It turns out that, although antioxidants are really good things to eat, and that although they do fight the growth of cancer, our consumption of them is counter-productive when undergoing cancer treatments. That’s because antioxidants fight the processes that result in cells being damaged (a good thing, normally), but when we’re undergoing treatment, our treatments are actively trying to damage cancer cells. By consuming significant amounts of antioxidants during treatment, we fight the treatments’ effects.
That being said, the amount of antioxidants that are normally found in the food we eat isn’t sufficient to significantly counteract radiation and chem therapies. So, eat well, eat antioxidants, but don’t take the large doses of antioxidants that are found in many protein powders.
My dietitian says that, under normal circumstances, a male my size should be eating around 77 gm of protein a day. But, in advance of treatment, I should be eating about 110-115 gm per day. According to what I remember her saying, the human body can absorb about 80% of whey-based proteins, but only 40-60% of plant-based proteins. So, for the money, whey-based proteins are a better source for those of us trying to bulk up.
But protein ingestion isn’t enough; one needs to exercise in order to have the body store protein as muscle mass rather than fat. The more protein we eat, the more exercise we need. For the past couple of months I’ve been riding my bike about 12.5 km each morning, and my legs are showing improvement for that. I’ve also, as of today (Thursday June 27), registered myself at the Oak Bay Recreation Centre to get three one-on-one sessions with a personal trainer. It appears from an email that I got that I’ll be assigned to a trainer who is a practising, and winning, body-builder herself. I’m hoping that she can help me add about 20 lbs of muscle over the next 6-8 weeks (i.e. before I can no longer eat and become too fatigued to work out anymore). I’m expecting that some of that 20 lbs will come from existing fat.
Unfortunately, I won’t be able to start training immediately. I’m going up to Kelowna to visit my aging parents this coming Canada Day weekend, and I’m having two molars removed on Wednesday July 3. After the extractions, I’ll have to keep my exertions low, so I don’t pop any clots. With luck, soon.
There are different types of radiation therapy, including, but not limited to, Stereotactic Body Radiation Therapy (SBRT), Intensity-modulated Radiation therapy (IMRT), Volumetric-modulated Arc Therapy (VMAT), and Proton Therapy. I need to talk to my radiation oncologist to learn which is planned for me, and why. As of June 26, 2019, I believe the Victoria Cancer Clinic will be recommending that I receive VMAT.
SBRT
Stereotactic body radiation therapy administers very high doses of radiation, using several beams of various intensities aimed at different angles to precisely target the tumor. The best candidates for this procedure are patients with small, well-defined tumors who cannot tolerate surgery.
IMRT
Intensity-modulated radiation therarpy is a type of three-dimensional conformal radiation therapy (3D-CRT) routinely used in the treatment of cancers. Unlike “standard” 3D-CRT, IMRT is capable of producing dose distributions that conform to the planning treatment volume and deliver a reduced dose to surrounding tissues and vital organs. This has come with the cost of increased treatment time and a larger volume of normal tissue receiving low radiation doses.
VMAT
Volumetric-modulated arc therapy is a type of IMRT where the linear accelerator rotates 360 degrees around the patient while simultaneously delivering the radiation, increasing the number of angles and decreasing the high dose radiation to normal tissues.
Proton Therapy
Proton therapy allows for the effective treatment of complicated head and neck tumors, while minimizing the radiation dose to vital structures such as the eyes, mouth and brain. Vital physical functions such as vision, smell, taste and swallowing remain virtually untouched when a patient is treated with proton therapy.
Proton therapy, unfortunately, is not available at this time anywhere in Canada.
I went in today (June 25) to have my teeth cleaned. Because I’m not on a dental plan, I’ve been going for a cleaning just every 9 months. I do a really good job with dental floss and an electric toothbrush (Philips Sonicare), but it’s time to increase the frequency now that my salivary glands are not going to be protecting my teeth the way they have in the past.
My hygienist recommended a super-soft manual toothbrush for when my I develop mucositis. She also said that Colgate Prevident 5000 would probably be just as good as Clinpro 5000 at providing the fluoride required to fight cavities in the future.
My hygienist and regular dentist conferred with each other, and agreed with the cancer clinic’s dentist that, if I’m going to have the top tooth removed, the bottom might as well come out. It won’t have any function (because it won’t have anything to grind against), and will become a potential source of problems.
On leaving, I scheduled another cleaning for late October (4 months from now) when (I hope) my mouth will be OK to be cleaned; I might be a little overly optimistic on that.
Well, I think I’ll go ahead with having the teeth extracted. While I think it’s unlikely that I’ll have develop problems related to osteoradionecrosis (ORN), the problems are not ones that I ever want to deal with. The decision, really, comes down to the concerns that, as I age, it’s possible that I won’t be able to care for my teeth as well as I currently do, that I’ve had a root canal done on the root-exposed tooth (making it more susceptible to cracking and decay), and that my cancer agency dentist, my personal dentist, and my radiation oncologist each asked exactly the same question, “Why wouldn’t you have them removed?” They all believe that the cost of losing a couple of molars pales in comparison to the cost of having ORN, even though the likelihood of actually developing ORN might be low.
The following is for those of you who want to see what questions I asked, and what information I considered in making my decision. I haven’t spent a lot of time trying to make this pretty.
One thing that I also asked was, “If I have those two teeth removed, is it likely that, over the next 20-30 years, the remaining teeth on my left side will migrate to the back of my jaws, increasing the spaces between them and making them more prone to cavities and infection, and increasing the chance that I’ll need to have one of them removed?”
The answer from both Dr. Pite and my regular dentist was, “Yes, they could migrate. Typically, the teeth tend to tip mesially/anteriorally (i.e. toward the front). It is believed to be a function of nature to close spaces as the teeth are worn. Some people do have teeth tip backwards, but that’s very unusual.”
So, again, I’ll go ahead with the extractions. If my teeth happen to tilt backwards to fill in some jaw space, then hopefully that’ll just make it easier to floss and brush them.
Background: Factor Probabilities
I tried to determine the probability that I will develop ORN as a result of having my exposed-root tooth extracted post-RT. By my thinking, that probability is the product of the following probabilities. Making some assumptions/guesses about those probabilities leads me to think that the probability that I will develop ORN resulting from the removal of the root-exposed tooth in my maxilla that is at the edge of the area that will be irradiated by a dosage that significantly increases my chances of getting ORN is just 1.875%. That, to me, is not cause for alarm. But I recognized that it’s based on guesses. And if I round that up to 2%, it means that of 50 people, I might be the one to develop ORN complications. I don’t want to be that person.
Probability that the tooth will require removal post RT. I had a meeting with my regular dentist on June 18, and she couldn’t get me a percentage probability for whether I’ll need to have that tooth removed, but she did point out factors that I had forgotten or wasn’t familiar with. The exposed-root tooth has had a root canal, meaning it’s more susceptible to future problems, and as we age, all of our teeth become more likely to develop problems that might result in the need for extraction. So, my guess is probability that the tooth will have to be extracted as some point in the future is around 50%.
The root canal/endodontic treatment was probably the most significant item that made me bring up the possibility to extract. If you developed a cavity on the exposed root due to 1) difficulty cleaning given the angulation 2) dry mouth/xerostomia, this is a difficult area to deal with. Saying that, we do have the option to utilize a newer material called SILVER DIAMINE FLUORIDE which could help intervene if a cavity is discovered there early enough.
It is not just the exposed root that concerns me. If the root canal gets reinfected (happens in 7-17% of cases), you can have it retreated with another root canal. If this is unsuccessful (25-35% of the time it is unsuccessful), the options are 1) extraction 2) surgically remove the root tips… both surgeries are ill-advised post-radiation)
Dr Adam Pite, June 2019
Probability that the irradiated area will include the root-exposed tooth? High.
Probability that the dosage in that region will exceed a value that is more likely to lead to ORN? High
There exist differing opinions on the size of dosage required to induce ORN. The Canadian Cancer Society says, “The risk of developing osteoradionecrosis increases when the dose of radiation received is greater than 60 grays”. (https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/osteoradionecrosis/?region=bc). This threshold dosage of 60 Gy is also reported in other studies referenced below. 60 Gy is greater than the 56 proposed by my radiation oncologist, and greater than the 50 Gy that Dr. Pite referenced. Dr. Pite says, “We review this often in my implant surgical groups. The debate there is about “is it 55 or is it 50″. 60 is presumed to be absolute.”
Probability that ORN will develop after an extraction of the problematic tooth in the maxilla? Very low
It appears from my reading that the risk of developing ORN is actually very low, especially in the maxilla where my problematic tooth is. Dr. Pite concurs with my understanding.
The Canadian Cancer Society says, “Osteoradionecrosis is a rare side effect that develops some time after radiation therapy has ended.” (same page as above).
It also says “Very rarely, osteoradionecrosis can start in the upper jaw, or maxilla.” Dr. Pite says, “Higher vascularity, it is presumed, likely leads to lower risk. The bone in the maxillary posterior is much less dense and more vascular. Agreed, I have seen ORN mostly on the mandible, but it is certainly there.”
An abstract in The Laryngoscope indicates that ORN results in just 2.6% of IMRT-with-chemotherapy cases. I note that the abstract does not indicate which stage patients were at. (https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.24712)
A study reported at https://www.sciencedirect.com/science/article/pii/S1368837516302238?via%3Dihub reported that ORN happened in 4.3% of oral cancer cases, and that of those cases only one was in the maxilla. I infer from this report, however, that the low probabilities are for ORN from RT only, and don’t reflect the effect of post-RT extractions.
The following articles report on post-RT extractions, but do not provide probabilities.
the irradiated area will include the root-exposed tooth
0
100
75
the dosage in that region will exceed the threshold
0
100
50
ORN will develop after an extraction of the problematic tooth in the maxilla
2.5
25
10
Product (%)
0
25
1.875
Additional comments from Dr. Pite
I’m not sure where the numbers come from exactly, but here’s what I’d say:
RISK OF DENTAL CARIES
1) difficult area to clean (back outside of root, tough to access with cleaning aids, toothbrush etc)
2) dry mouth post-radiation
3) root surface is 13X softer than enamel
ACCUMULATED RISK OF SIGNIFICANT DENTAL CARIES: difficult to determine, but certainly we see lots of these situations in non-radiated senior patients that result in tooth loss
RISK OF ROOT CANAL REINFECTION
1) 7-17% depending on the study
2) if re-treated with another root canal, 25-35% unsuccessful
ACCUMULATED ROOT CANAL REINFECTION RISK= 1.75% to 5.95%
I met with my ENT for the final time June 17. I asked him to clarify again why I was not a candidate for surgery, notably TORS. He said, as he’d said in an earlier meeting, that after having surgery I would still need to have radiation. What he didn’t say, but what I now understand, is that my radiation therapy will hit not just the primary site at the base of my tongue, but also the lymph nodes on the right side of my neck that have swollen dramatically, and likely the lymph nodes on the left side of my neck as well. So, there’s no way of getting away from having radiation. His take on this is that it is standard practice in Canada to not do surgery on squamous cell cancers that have advanced beyond the primary site at the base of the tongue, because there’s very little likelihood that all the cancer will be caught. The standard procedure, where radiation, not surgery, is the primary treatment, consistently results in good long-term survival rates, and that’s what Canadian doctors are focused on.
So, yes, I could go to the USA to have TORS done, and possibly take advantage of reduced radiation dosages that would result in reduced side effects, but BC doctors do not currently support those treatments, and the BC Cancer Agency would not fund those treatments.
I accept this doctor’s arguments. I’ll skip surgery.
My radiation oncologist (RO) phoned me yesterday to say, “What would you like to know?” I think he called because I’d been calling the radiation clinic at the Cancer Clinic, asking a variety of questions about my upcoming overall treatment, and the clerk who was very patient with me thought maybe it was time for the oncologist to just clear up my concerns as best as possible.
One of my questions was about who I should be talking to. The BC Cancer Agency states that their patients will be assigned to a team of people who work together and with the patient to develop a treatment plan and then execute that plan. Although I knew a team had been put together, I had not received any notifications from anyone on that team letting me know what the next steps were, other than from clerks saying, “your appointment with X is on this date.”
Prior to retirement, I’d been an IT consultant for most of my working life, and all projects that I worked on always had project managers whose job was to ensure that all project participants understood what was going to happen when, and who was responsible for what. So I was expecting that my cancer team would include a single individual who would be my primary contact for all questions relating to who would do what, and when.
My radiation oncologist told me that, under normal circumstances, he would be the person who initially would bring me up to speed on what was planned and how treatment would progress, and that it would be the clerks who would make arrangements to ensure all was done in an orderly fashion. My guess is that most new patients simply wait for that first meeting, do most of their learning about the disease at that first meeting, and that they accept treatment recommendations without first doing as much investigation as I do.
But I’ve always been a person who tries to really understand the ramifications of a decision before proceeding with a plan. Not knowing all the ramifications of developing osteoradionecrosis (ORN), and the likelihood of doing so, makes me leery of simply accepting the “you should have two of your teeth removed” recommendation. And taking the time to understand the reasons and ramifications kind of throws a monkey wrench in the scheduling of appointments that the clerks try to do.
So, the radiation oncologist called to see how he could help me.
I asked him how staging my cancer is done, and he explained that the Victoria clinic uses the AJCC edition 8 guidelines to provide prognostics, but uses edition 7 guidelines for treatments. Edition 8 identifies the likely progression of the disease, but doesn’t prescribe treatments. Many BC oncologists don’t believe that there is enough solid evidence that de-escalating treatments for HPV+ oropharyngeal cancer will result in the same high survival rates that current treatments have.
I asked him about radiation dosage de-escalation options, and he noted that, even if de-escalation of radiation doses was a thing that they did, reductions would apply only to the primary cancer site. In my case, at best they would decrease my 70 Gy on the primary site to about 66 Gy. On the elective sites (the right and left sides of my neck), they would continue the proposed 56 Gy. The elective radiation is targeted on the cancer cells that might have spread but that they can’t see on CT scans, and 56 Gy is what’s felt to be required to deal adequately with those.
I told my RO that my current biggest issue was that the cancer clinic’s dentist was recommending that I have two teeth removed, because the elective dosage would probably hit the jaw where there was an exposed-root tooth on which I’d had a root canal. My RO said, essentially, “Why wouldn’t you have the teeth removed?” He’s another person who, while deferring to my dentist’s recommendation, feels that the cost of losing two teeth pales to the cost of developing ORN complications.
We left the phone call on good terms. I think he was impressed with the amount of digging into the source materials I’d read on line, and I was familiar with what was likely to happen to me, and that I was very well aware of all the potential downsides so that I could make an informed decision about whether to have the teeth removed.
As noted in the previous post, the Victoria Cancer Clinic’s consulting dentist (Dr. Adam Pite) has recommended that I have two teeth removed to reduce the likelihood that I will have major problems in the future resulting from osteoradionecrosis (ORN). For the next couple of days, I’m going to be looking into whether or not that’s something I really want to go ahead with.
My primary concern is the possibility that I’ll have healthy, useful teeth removed unnecessarily. Dr. Pite is basing his recommendation on the following.
The likelihood of developing ORN as a result of having post-RT extractions is fairly high.
I want to discover what the percentage likelihood really is.
The following abstract indicates that ORN results in just 2.6% of IMRT-with-chemotherapy cases. The abstract does not indicate which stage patients were at.
The following article indicates that ORN resulted in just 2.5% of stage I/II OPSCC cases treated with IMRT. I note, however, that although the article was published in 2016, the relevant studies that it refers to were published in 2013 and 2014
The likelihood of ORN increases significantly over 50 Gy.
Some studies indicate the figure could be 60 Gy. If that’s the case, then the 56 Gy that might hit the bone around the problematic tooth is below the threshold, so maybe I don’t need to have the teeth pulled.
The radiation oncologist’s preliminary plan is to irradiate the area around one tooth with 56 Gy over 35 doses, i.e. greater than Dr. Pite’s 50 Gy threshold.
I have not yet met with the radiation oncologist to discuss my treatment, and his plan currently is only preliminary. What if he decides after he receives more information, that something less than 50 Gy is appropriate? I’ve found pages that indicate radiation exposure could be much less than 56 Gy.
One cause of ORN complications is trauma to the jaw after radiation therapy (RT), and “trauma” includes tooth extraction. The reason that I might need to have one tooth extracted in the future, and post RT, is that it has an exposed root, which makes it susceptible to cavities and infection.
The only reason that I might have to extract the problematic tooth is that a cavity forms on it and it becomes infected. However, given that I’ve been keeping that tooth cavity free for over 20 years, and given that I’ll be seeing my hygienist more frequently in the future, is it likely that I won’t ever have to remove that tooth?
Are there prophylactic treatments that could be applied to the exposed root to make it virtually cavity proof?
The reason for extracting the other tooth is that it is opposite the first, might start to erupt further from the jaw when that eruption is no longer opposed by the other tooth, and then becomes more susceptible to cavities and infection.
What is the likelihood of significant future eruption, and could my dentist and I not manage that tooth to make it unlikely that it would get cavities?
I spoke to one of the clerks at the Victoria Cancer Clinic’s Radiation Therapy center. She told me that my radiation oncologist (RO) is doing a CT scan at the clinic, rather than using the results of the CT scan that I had done a couple of months ago, because 1) this scan will be connected to the clinic’s radiation equipment so that my RO can plan more accurately where to target the radiation, and 2) this new scan must be done after I’ve had teeth removed, after any swelling from the extraction disappeared, and after my jaw has obtained a new bite. The scan will be used to help build the mask that I’ll have to hold my head in position during radiation treatments.
The clerk also said that it would be perfectly OK for me to postpone the tooth extractions until after I’ve met with my RO on June 28. Postponing the extractions would mean that the CT scan would have to be postponed, so I need to let her know if I plan to postpone the extractions. She also said that if the extractions happened shortly after my meeting with my RO, then the start date for radiation therapy would be pushed out only about a week.
I left a voice mail with Dr. Pite’s office, requesting that they postpone my extractions until after June 28, and that they call me with the new time.
I left a voice mail with my regular dentist’s office, requesting that she call me so that we could chat about the extractions, because I’d simply like another dentist’s opinion.
I have an appointment with my ENT/surgical oncologist on Monday June 17. What I want to find out is:
if I’m a candidate for TORS
if I am a candidate for TORS, would the number of Grays hitting the area where my bare-root tooth is be lowered, reducing the likelihood that I’d eventually have osteoradionecrosis (ORN) complications
I learned today from a friend that Xylotol, the active ingredient in Xylimelts, is extremely toxic to dogs. Good to know; we sure don’t want Archer (our really wonderful Golden Retriever) to get hurt by this.
On another note regarding staging treatment strategies “Considerations in surgical versus non-surgical management of HPV positive oropharyngeal cancer” indicates “hypothyroidism is noted in 28–38 % of patients at three years, though may be as high as 55 % depending on the gland volume and amount of gland receiving over 45 Gy”. I hadn’t considered problems with the thyroid gland yet. When I look at the radiation plan diagram, though, it appears that my thyroid will not be irradiated, so I’m probably OK. But I should check with my RO when I talk to him.
The above page also includes the following.
Regarding toxicity, … osteoradionecrosis of the mandible – approximately 2.5 %
It’s important to note that the mandible is more likely than the maxilla to suffer ORN as a result of radiation. Therefore, maybe it’s possible that the likelihood of developing ORN where my root-exposed tooth is, indeed, very small. This is something I need to discuss with my RO.
Nuts. It looks like I should have a couple of teeth removed.
As I noted earlier, the BC Cancer Agency has two dentists in Victoria who provide dental consultation services to cancer patients who might have radiation or chemo treatments that will affect their oral health. One of those doctors is Adam Pite, and this morning I met with him so that he could check me out and make recommendations.
Before I go further, I’d like to thank Dr. Pite for reviewing the contents of this post to ensure that I haven’t misstated or misrepresented statements that he or his staff made. I want this blog to present, as much as possible, accurate information, not my recollections of what I thought I heard.
I first met with one of his assistants who walked me through the background on the effects of radiation on teeth, jaws, and salivary glands. She also talked about dental care during and after treatment. She provided me with three guides.
As you probably already know, radiation of the salivary glands may reduce their ability to deliver to the teeth the chemicals/minerals required to keep the enamel healthy. When the enamel deteriorates, and it does so quickly, your teeth become susceptible to cavities, resulting in the need for dental treatment. But, when you’re in the middle of radiation treatment, it’s not a good idea to go to a dentist to have your cavities fixed. So, you need to keep your mouth really clean, and you need to encourage saliva production. Dr. Pite’s office recommends that, to keep the mouth moist, patients drink plenty of water, chew gum, use Xylimelts, and use Biotene products.
I expected the water recommendation. I’ll probably start carrying a water bottle around with me all the time. The dental assistant also suggested that I have a second water bottle containing a salt-and-baking-soda-in-water solution as a mouth rinse, made from scratch each day and to be used every 2 hours during the day.
I can chew gum; just got to find a sugar free one. Hopefully, I won’t get oral ulcers that will make it uncomfortable to chew.
Xylimelts look interesting. You stick them to the inside of your mouth where the slowly melt and trigger siliva production.
Of the four Biotene products currently available to help with dry-mouth problems, the “oralbalance Moisturizing Gel” and “Moisturizing Mouthwash” appear to be the most appropriate for my situation. The manufacturers of Biotene indicate that the gel provides long-lasting relief from the feeling of dryness while one sleeps, soothes and protects oral tissues, and lubricates ones mouth to aid in swallowing food.
I need to get back to the dental assistant to see if, on top of the salt-water rinse every 2 hours, I should be using both the Xylimelts and the Biotene mouthwash (up to 5 times daily) during the day and the gel at night.
To counteract the loss of enamel, dentists in BC used to provide patients with fluoride gel and custom-formed tooth trays. Patients were supposed to use these gel trays for 30 minutes daily. That treatment regimen has been supplanted by the use of Clinpro 5000 toothpaste. Apparently, many people weren’t willing to do the 30 minutes per day, and the toothpaste is more effective at building up the enamel than the fluoride was.
I’ve been using toothpastes like Sensodyne for years to combat tooth sensitivity. I hope that Clinpro 5000 will counter act that sensitivity also.
OK, back to tooth removal.
The BC Cancer Agency has prepared a tentative plan for me that includes radiation therapy. That plan indicates that the lymph nodes on the right side of my neck and the base of my tongue will be hit with 35 doses of 75 Gy of radiation (definition of Gray). Other areas, like my upper and lower right jaw, and the rest of my neck, might be hit with 56 Gy 35#.
BC Cancer Agency’s preliminary idea of where radiation will be, and approximate dosages. The Upper and Lower teeth are those discussed in this post.
Dr. Pite explained that doses greater than 50 Gy are likely to result in osteoradionecrosis(ORN) of the jaw, which is death of the bone as a result of radiation, and that having ORN would mean I could not have teeth extracted in the future, because the extraction would result in infection of the bone, and that’s a tough infection to fight, sometimes resulting in disfigurement.
I’m only 63, and my teeth have not been and are not perfect, so it’s possible that I might need an extraction within the next 30 years or so, even though I’ve been pretty good about taking care of my teeth. Plaque builds up on my teeth faster than on many other people’s, so I try to floss and electric brush after each meal. Nevertheless, I still have a little gum recession. More importantly though, I have a number of fillings from childhood cavities, caps over some teeth that old fillings couldn’t hold together well, an implant where one cap on a tooth wasn’t capable of stopping the tooth from splitting, and one old root canal. I also had my top wisdom teeth removed about 30 years ago, and that’s where I’ve got a problem.
When one of the wisdom teeth was removed (the left, top, back molar that’s on the edge of the currently-proposed 56 Gy radiation region) a small chunk of bone or tooth root was left behind, and that eventually led to infection and surgery to clean up the smelly socket. That resulted in the root of the adjacent tooth to be exposed. Tooth roots are softer than the chewing surfaces of teeth, because they aren’t coated with the same layer of enamel. Therefore, tooth roots are more susceptible to cavities, but there’s no way to repair a cavity way at the back of that tooth. If the tooth starts to go bad, then it should be extracted, but you don’t want to do that when you have osteoradionecrosis, because that can lead to real problems.
On top of that problem, if the back top tooth is extracted, then the bottom tooth across from it may start to create problems. Apparently, teeth naturally want to grow out of your jaw. Without a tooth to work against, the bottom one will move upwards, exposing more of its root surface, resulting in greater chance of cavities, and we know what that means.
So, net result, Dr. Pite recommends that I have both teeth removed, especially the top one with the already-exposed root that is difficult to clean.
One piece of good news associated with this is that BC’s Medical Services Plan will cover the cost of tooth extractions if they are done in the context of cancer treatment.
Because the extractions are free to me, because I’m not “scared” of extractions (or anything related to dental work), and because the guy with more knowledge and experience than I have has recommended that I do this, I’ve booked both extractions for next Wednesday June 19. That should give me time to do some research.
ORN , and it’s effects, are described well at the following pages.
Here are a few things I’ve learned about osteoradionecrosis.
It is more common in the mandible (i.e. lower jaw) than the maxilla.
ORN develops after radiation which exceeds 60 Gy (per Canadian Cancer Society), 50 Gy (per Wikipedia)
The risk of developing it increases in people for any of the following reasons.
person does not practise good dental oral hygiene
person develops dry mouth after radiation therapy
person suffers trauma to the bone following radiation, sometimes many years later (tooth extractions qualify as trauma, as do emergency surgeries following accidents, further cancer surgeries/biopsies, denture irritations)
In rare cases, ORN develops without any of the above causes having occurred
The likelihood of developing ORN is not absolute. It is not a necessary result of radiation therapy; it’s relatively rare. In fact, it appears that some studies indicate that it’s unlikely that ORN would develop in my kind of situation.
However, I also note that those studies appear from around 2007-2010, i.e. are 9-12 years old; maybe new studies have been done that contradict those findings?
As long as we’re talking about radiation, here’s a page from the Oral Cancer Foundation that outlines some of the side effects of oral cancer radiation treatment.
Next Activities
Wednesday June 19 – Tooth extractions (just 1 hour to extract 2 teeth under local anesthetic)
Thursday June 27 – Tooth cleaning with one of my regular dentist’s hygienists
Friday June 28 – Meet with my radiation oncologist to discuss my radiation therapy plan
Tuesday July 2 – The BC Cancer Agency has booked me another CT scan, this time at the Victoria Cancer Clinic. This is to provide the radiation oncologist with more info in preparation for improving his plan.
Thursday July 4 – Meet with medical oncologist to discuss chemotherapy plans
Change the frequency of my regular teeth cleanings from every 9 months to every 3 – 4 1/2 months
I received a phone call from the BC Cancer Agency today. Its purpose was to advise me of what’s happening with my file.
I was advised that the agency had booked me an appointment with a radiation oncologist for June 28, 2019.
I was also told that the agency needed more information before my medical team could make treatment recommendations. Therefore:
The agency would be booking a PET scan in Vancouver for me, and I should expect a phone call advising when that would occur.
I should expect to receive a phone call to set up an appointment with one of the two dentists in Victoria that the agency uses. The radiation will damage my salivary glands which in turn provide the minerals that keep the enamel of my teeth healthy, and might damage the bones and gum that hold my teeth. The dentist will determine if I should have work done on my teeth prior to having radiation treatments, because my teeth, gums, and jaw bones might be too compromised for me to have work done during or after the radiation.
Travel to Vancouver for the PET scan results in travel expenses. Thankfully, the BC Cancer Agency, through the Travel Assistance Program (TAP) covers travel costs for the patient. It will also cover travel costs for a caregiver if the patient is less than 18 years of age, or if the patient is incapable of travelling independently due to medical reasons. I called my ENT’s medical office assistant who said she would complete the Request For Travel Assistance form for me. I picked it up later that day. After the cancer agency has advised me of the date of my PET scan, I will call the “automated TAP line” which will issue me a confirmation number that I record on the TAP form. Then, when I travel by ferry to Vancouver, I will have to provide the TAP form to BC Ferries staff instead of paying for the fare out of my pocket.
Dealing with Base of Tongue Cancer 