key: cord-289445-t9qnsddo
authors: Rocha, Breno Amaral; Mendes, Polianne Alves; Lima, Lucianne Maia Costa; Lima, Mateus Costa; Souza, Paulo Eduardo Alencar de; Grossmann, Soraya de Mattos Camargo; Souto, Giovanna Ribeiro; Horta, Martinho Campolina Rebello
title: Why it is crucial to maintain oral care for patients undergoing head and neck radiotherapy during the COVID-19 pandemic
date: 2020-08-07
journal: J Stomatol Oral Maxillofac Surg
DOI: 10.1016/j.jormas.2020.07.009
sha: 
doc_id: 289445
cord_uid: t9qnsddo

nan

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. (Table 1 ) [2] . Such effects can cause oral complications during RT itself (i.e., acute complications) or a few months, even years, after RT (i.e., chronic complications) [1] . In prevent those complications, the prophylaxis and management of RT's potentially toxic effects require dental teams specialized in caring for patients with cancer, which can, in turn, help to improve the quality of cancer care.

Such pre-emptive action needs to begin in the pre-RT period. At that stage, consultation with the patient should be performed with the aim of diagnosing and treating existing oral diseases, as well as planning preventative measures for possible complications (e.g., mucositis) [1] , [3] . Indeed, patients who have not received such consultation have demonstrated a higher risk of complications [1] . Therefore, in the pre-RT period, two particular procedures should be performed. First, the adequacy of the oral environment (e.g., restorations and extractions of teeth with questionable prognosis) should be examined, and infectious foci as well as traumatic and retentive factors should be eliminated. Second, guidance on the importance of strict oral hygiene and oral care to be followed during RT should be provided.

During RT itself, the patient needs to be routinely examined by the dental team. In response to the appearance of any toxic oral effects, specific therapeutic measures have to be taken to relieve pain, maintain oral food intake, and prevent the temporary or even permanent interruption of RT. In the post-RT period, preventative and curative care for later effects needs to be provided, along with rehabilitative care. Thereafter, because the risk of Radiotherapy and Oncology (ESTRO) [5] , the performance of dental oncologists has been affected [6] , [7] . In particular, the high risk of viral infection faced by dental teams and patients, chiefly via fluids and aerosols for the oral cavity used in certain dental treatments [6] , [8] , has prompted dental services to postpone or discontinue appointments [9] . Nevertheless, the adequacy of oral care that accommodates infection control measures currently recommended by competent [10] entities can allow dental care for patients with cancer to be maintained. For such care to continue, however, dental teams need be vigilant and provide safe environments for themselves and their patients [8] , [10] .

To that purpose, personalized treatment plans for patients and partnerships with radiation oncologists are essential [9] . Prescreening over the phone can reveal symptoms possibly associated with COVID-19 and may justify postponing in-person consultation. If such consultation is deemed safe, then general safety measures need to include assessing the patient's body temperature, practicing frequent hand hygiene, disinfecting equipment and clinical surfaces, and using personal protective equipment consisting of masks (i.e., N95 or FFP2), disposable medical aprons, gloves, glasses, and face shields [8] , [10] . Prior to procedures, chlorhexidine mouthwashes can help to J o u r n a l P r e -p r o o f reduce the viral load of the SARS-CoV-2 [4] . In oral care before, during, and after RT, droplet-and aerosol-generating procedures should be avoided, and extraoral imaging exams (e.g., panoramic radiography and cone beam computed tomography) should be used instead of intraoral radiographs [8] . In the pre-RT period, tooth extractions should be performed atraumatically and using resorbable sutures [9] . Last, the use of handpieces, rotating instruments, and triple syringes should be reduced; atraumatic restorative procedures or the chemical-mechanical removal of carious lesions are promising alternatives [8] , [9] .

During RT, in response to the appearance of unwanted effects, antibiotic, anti-inflammatory, analgesic, and topical medications (e.g., artificial saliva, mouthwash with saline, and bicarbonated water) should be prescribed [3] , [9] .

At the same time, mucositis may appear in association with oral pain and odynophagia. Due to the intensity of symptoms, some cases may require RT to be suspended and/or the use of enteral and parenteral nutrition. Among possible therapeutic measures for mucositis, photobiomodulation therapy (i.e., laser therapy) stands out, given its antalgic, reparative, and anti-inflammatory effects [3] , with no production of aerosols. Considering the need to reduce patients' visits to clinics [6] , the use of remote patient support via virtual visits can facilitate continued contact with and immediate clinical attention when needed [7] . In view of the need to continually update guidelines for the prevention of COVID-19, updated information can be obtained from national and international bodies and organizations [10] , including the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC).

Altogether, we believe that maintaining oral care for patients with HNC in RT is possible, as long as biosafety guidelines for preventing COVID-19 are followed and respected [10] . The role of the dental oncologist aims, above all, to contribute to the quality of life of cancer patients. As in our service at the Radialis Santa Casa Radiotherapy Clinic (Montes Claros, Brazil), those measures can positively impact the quality of patient care in RT centers around the world.

Declarations of interest: none. Note. RT = radiotherapy; IMRT = intensity-modulated radiotherapy.

PDQ ® Supportive and Palliative Care Editorial Board. PDQ Oral Complications of Chemotherapy and Head/Neck Radiation. Bethesda, MD: National Cancer Institute

Evidence-based management strategies for oral complication from cancer treatment. MASCC/ISOO; 2011

Management of chemo/radiation-induced oral mucositis in patients with head and neck cancer: A review of the current literature

Clinical Significance of a High SARS-CoV-2 Viral Load in the Saliva

Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: an ASTRO-ESTRO consensus statement

Head and Neck Cancer Care in the COVID-19 Pandemic: A Brief Update

Implication of COVID-19 in oral oncology practices in Brazil, Canada, and the United States

What dentists need to know about COVID-19

Provision of Continuous Dental Care for Oral Oncology Patients during & after COVID-19 Pandemic

The French Society of Stomatology, Maxillo-Facial Surgery and Oral Surgery (SFSCMFCO). Practitioners specialized in oral health and coronavirus disease 2019: Professional guidelines from the French society of stomatology, maxillofacial surgery and oral surgery, to form a common front against the infectious risk

This study was financed in part by the Coordenação de Aperfeiçoamento de