Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And we have a panel for you today with two UAB physicians to focus on radiation therapy for oral cancer. Joining me is Dr. Christopher Willey, he's the Hale-Stephens ROAR Endowed Professor for Distinctive Radiation Research; and Dr. Michael Kase, he's an Associate Professor and the Assistant Director of the Advanced Education and Maxillofacial Prosthodontics and Dental Oncology Fellowship.

Doctors, thank you so much for joining us today. And Dr. Willey, I'd like to start with you. People don't necessarily equate dentists and radiation oncologists and put those two together. Can you tell us how that comes about and how you collaborate to plan treatment for oral cancer patients?

Dr. Christopher Willey: So, many people consider Radiation-Oncology a smaller specialty in general. In fact, there are probably many doctors that don't know a whole lot about what we do because we are a relatively small specialty, whereas dentists are actually quite prevalent, as you might imagine.

So, because patients are often seen in a dentist office on a regular basis, sometimes these oral cancers or even pre-cancerous lesions are identified first by a dentist who may even perform a biopsy or refer to an Ear, Nose, Throat specialist for a biopsy. And so, many times, patients may get their original diagnosis from a dentist.

I would say in terms of our collaboration, it's actually quite thorough because the dental health is critical for how patients are going to respond long-term to radiation in terms of the oral health. So in other words, injury to the jawbone is really one of the most dreaded side effects from successful radiation treatments called osteoradionecrosis. It really depends on excellent dental care, particularly pre-treatment. And so, we have to work with dentists before we can even start treating a patient with radiation.

And so since radiation is commonly used following surgical resection of an oral cancer, we really critically depend on dentists for this. And so, we are blessed here at UAB because we have an actual dental oncologist, someone who specializes in it. So, although many people may first get into the system through their local dentist, really Michael Kase has been a key contributor to the head and neck cancer program here at UAB because of his specialized training. So, I'll probably let him tackle the second half of this question.

Dr. Mike Kase: Thanks, Dr. Willey. And thanks for having us on here, Melanie. But I echo his statements 100% in that we do work together so closely, and it's probably not often thought of that way, Radiation-Oncology and Dentistry. And Radiation-Oncology being a smaller specialty, well, the Dental Oncology world, which I live in, is probably much smaller than that even.

So, while we do work together very closely, there is also this very small facet of care in Dentistry that treats these patients. And it's important that we get to see them, like Dr. Willey said beforehand, so we can help manage their care throughout treatment and afterwards, especially because it's more the educational component that these patients benefit from. Ideally, they see a dentist, they see their general dentist, and they're usually doing an awesome job making sure that their oral health is up to par. But it's really, really important that they get educated on those side effects that happen as they go through the radiation, and therefore, how to take care of themselves in the future. Because like Dr. Willey said that  osteoradionecrosis is a big problem that we really want that patient to avoid, if at all possible.

So, that's a rough overview of how we work together. They'll see the patient initially, get them set up for the conceptual plan, and then they'll send them to me. And then, we'll do our preradiation evaluation where we kind of assess them beforehand and see if there are any teeth that need to come out and then educate them on what to expect and how to take care of themselves down the road. So, that's kind of the bird's eye view of it.

Melanie Cole, MS: Well, thank you both so much. And Dr. Kase, you got to my next question before I asked it, but I'd like you to expand a little on your evaluation and the intervention, specific dental extractions, restorations that you prioritize before radiation begins.

Dr. Mike Kase: Absolutely. So, that's the common misnomer I think that happens, is patients that might not have the same type of care that we offer here with our Radiation-Oncology Department, that fully understands all this is they'll go see their general dentist. And like I said, they do spectacular jobs with normal dentistry and oral care. But if that dentist isn't versed in treating these patients, they end up getting a normal type of dental treatment plan. And I'll be honest, I'm not really concerned about small little fillings or if there's a little bit of recession on a certain area, I'm more concerned about what teeth are going to be problematic a year or two from now. Because unfortunately after radiation, and this is kind of a blanket statement, but after radiation, we cannot extract teeth anymore for risk of that osteoradionecrosis. So, it's our job to determine, A, what teeth need to come out beforehand, so what teeth are essentially hopeless at this point? Or B, what teeth are going to be problematic in the future?

And that could be to the extent of, "Well, this tooth has a big crown and is already root canal-treated and is likely to be in that high dose region," or it could be a tooth that might be angled inward towards the tongue. And that tongue is where that tumor is, and there's going to be surgery and radiation scarring it down, and that tooth is just going to irritate that tissue over time. So, again, we cannot extract this tooth after radiation, so our job is to figure out which ones are going to benefit that patient to come out beforehand.

Melanie Cole, MS: This is such an interesting topic. And as we said, people don't realize how well you two work together and how special this program is at UAB Medicine. And, Dr. Willey, as we think about these oral side effects of radiation, how do different radiation modalities impact oral health differently, and how does that affect your planning for the patient?

Dr. Christopher Willey: I would say in terms of types of treatment plan that we would utilize includes typically x-rays would be the most commonly used. Proton therapy is another modality. Electrons are occasionally used for cancers in the head and neck region, perhaps like a lip cancer or something like that that's very close to the oral cavity may utilize those.

And then, rarely, at least at UAB, rarely, we will sometimes use implantable radiation. Temporary brachytherapy it's called, which is essentially short therapy using radioactive isotope in a catheter. The mainstay, however, is the x-ray treatment or photons. And the issue for photons is that they enter the body, they're focused at the targets, but they also have what's called exit dose, they pass through the body. And so, the cumulative dosimetry from the various beams that come in to treat the patient's cancer are inevitably going to hit some of the jaw bone and teeth. And so, the impact on that is really based on the dose and volume that each of those structures have received during the treatment course.

On top of that, one of the major contributors to this is what we do to the saliva glands. So, the submandibular glands are close to the high risk areas typically for oral cancer with what are level I and level II lymph nodes. The floor of mouth and tongue are very close. And so, a lot of times there's going to be injury to those which can dry the mouth out. And as we know, the saliva is really our first barrier of defense against injury for the oral cavity. And so, that can be impacted. The parotid glands, the large parotid glands can be hit. They can be somewhat spared often with oral cancer cases, less so probably for oropharynx. But bottom line is all these things can be impacted.

The advantage of something like proton therapy, which uses a heavy particle instead of the massless x-ray treatment, is that a proton enters with a certain amount of dose, but then stops very abruptly. And so, in some cases, proton therapy can spare the oral cavity. Some, I would say, it probably does a better job for tumors a little farther back, let's say oropharynx like tonsillar or soft palate type targets, proton therapy can very well spare the oral cavity.

The problem for protons is that different metal material can affect how the protons enter. And so, sometimes, depending on, let's say a dental amalgam, or some type of clip from surgery that might be in close proximity to what we need to treat, it can create kind of a shadow where the protons can't effectively treat the area. So, sometimes you have to send it from other angles and things like that.

Bottom line is that when the target is really in the front of the mouth for oral cavity cancers, there's really not a ton that can be done to spare the target if really the target's there. So, while we can do some things and everything's customized for our patients, there's really always risk. And that's why the preventive therapy that Dr. Kase provides is absolutely critical.

Melanie Cole, MS: Well, Dr. Kase, why don't you expand on that based on what Dr. Willey was just saying? Speak about the oral hygiene protocols that patients follow before, during, and after radiation therapy, some of the innovative strategies that you've come up with to enhance patient adherence to these guidelines during treatment. Speak about what you do and why it's so important.

Dr. Mike Kase: Sure. So, Dr. Willey really hit the nail on the head there talking about the dry mouth, that xerostomia that's secondary to the osteoradionecrosis, and very related to it is that xerostomia, that dry mouth, that's probably the biggest problem we have to deal with. So, as we evaluate these patients and we see that if they come in and it's obvious they haven't seen a dentist in a long time, it's pretty easy to tell, you have to convince them that after radiation, well, now they need to see that dentist that they haven't been seeing every six months, every three or four months. They have to increase the frequency to make sure that we have this professional help because that dry mouth, that xerostomia, allows the protective elements of the saliva to be depleted. So, the mechanical ability to clean teeth by washing, you know, debris and food stuff away, as well as the chemical component, the enzymes and the minerals in our saliva, which is depleted as well.

So, seeing a dentist every six months or so, which you normally recommend, usually isn't enough. So, they really have to up the frequency. And that can be very challenging for a patient that hasn't seen a dentist in 20 years. Habits are the hardest thing to break. So, that's the type of patient you have to be extra aggressive at if you see teeth that aren't in great shape, because you can't really expect them to go from never seeing a dentist to seeing them every four months or every three months.

There's some other strategies we use like upping the fluoride dose in their toothpaste via prescription level toothpaste. They can use that every night before they go to bed. We usually have them brush for a couple minutes and then spit, but don't rinse. They want that extra protection as they're sleeping, because our salivary glands are least functional in the nighttime to begin with. And then, you couple that with that xerostomia and it causes some very bad conditions for the oral cavity, let alone being just very uncomfortable for the patient. And they only need to use that toothpaste once a day at nighttime. The rest of the day their regular toothpaste is fine.

We talk about things like drinking lots of water. There's not a whole lot of medications out there that help with the xerostomia, so instead you got to give the body what it needs to make saliva. So, drinking lots of water and then, you know, simple over-the-counter type medications like Biotene, which is a salivary substitute, non-prescription. So, patients can use that to give their mouth some relief. It makes them feel like they have the saliva but doesn't make them produce more so they end up having to reapply it throughout the day.

Some other ways we can help the patient, and Dr. Willey may have some insight into this as well, is if Dr. Willey is asking me to help them pinpoint the beam a little bit better, we can make a prosthesis or an appliance called the tongue positioner, which kind of opens the bite and pushes the tongue a certain direction and that allows that beam to avoid these structures that we do not want it to hit, to try and avoid things like contralateral salivary glands or the palate or whatnot. But that's just a rough list of the ways and things we talk about with the patient to help kind of reduce their side effects if possible.

Melanie Cole, MS: Thank you both so much for joining us. And before we wrap up, Dr. Willey, speak about any emerging technologies, protocols that improve the integration of dental and Radiation-Oncology care, and why this multidisciplinary collaboration at UAB Medicine is so important for patients with oral cancer.

Dr. Christopher Willey: If you look at even how the surgeons, surgical oncologists, from the ENT specialty, one of the major metrics that's utilized for quality of care is time from surgery to initiating radiation. The goal is to start therapy within six weeks. So if all these things require pre-treatment evaluation, extraction, then the radiation-oncology treatment planning process can take time because we have to make devices for positioning of the patient. We design the treatment in a computer world based on CT and other types of imaging modality. And then, there's quality control where we have to basically perform physics-based, measurements, from treatments on essentially phantoms, which are basically like mannequins of the head and neck area. All that has to be accomplished prior to giving the first fraction of radiation.

So, one of the key things that our head and neck cancer management team really has been trying to do is figure out how we can eliminate some of the roadblocks to achieving that six-week mark, because it actually is quite challenging. Some of them are social factors regarding maybe a patient comes from a rural area. They haven't seen the dentist in a long time trying to establish that care.

But I would tell you, we as well as many other practitioners around the country, have been dealing with the same challenge. And I would say for us the big inflection point for improvement in our numbers came from the recruitment of Dr. Kase. The ability to have evaluation sometimes before the patient even has their surgery, particularly when a patient comes through the OMFS team and also through ENT. We actually get a lot of these things done in such a timely fashion much better than could really happen I think in a community practice or even many academic institutions. And so, I would say really the focus of this, regarding our patient navigation I think is a critical element.

Other things that people are trying to do is come up with therapies that can reduce the side effects of radiation, preserve salivary gland function, things like that, all experimental. And we do often have clinical trials that are used to try to minimize these things. But I would say in terms of really practical and realistic focus for our patients is really trying to handle the patient navigation, because it's really critical that they get in to see Dr. Kase. And I know it keeps him extremely busy, but he's so responsive to everything we ask him to do.

Melanie Cole, MS: Dr. Kase, Dr. Willey has just given you a glowing recommendation here. Why don't you have the last word and tell us what you would like other providers to take away from this collaboration between dental care and Radiation-Oncology at UAB Medicine?

Dr. Mike Kase: I appreciate all those kind words, but it takes the team. Without him, without the rest of the Radiation-Oncology team cooperating and giving credence to what I do, I wouldn't be nearly as successful. So, it really is this wonderful institution here at UAB where we all get along so well and work together so well. And it's a constant work of progress too, like Dr. Willey was alluding to with the timing factor. You know, we've been working on it in our Oral Oncology Department in Oral Surgery since I've gotten here and we've gotten it pared down so well where I usually see the patients the same day the surgeons are seeing them for their surgical plan. So, implementing this as fast as we can, because we know how important that is. But again, without everybody's cooperation, without these head and neck working group committees that we're all part of, we wouldn't be nearly as successful. So, my hat's off to everybody here and understanding how important it is to work together. Because that's really what it's about, is working together to help the patient.

Melanie Cole, MS: Perfectly said. Dr. Willey and Dr. Kase, thank you so much for joining us today. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.