193 Tooth extractions and weight loss in OPSCC 6 Introduction The incidence of oropharyngeal cancer, predominantly squamous cell carcinoma, has increased over the past 30 years from less than 300 new diagnoses in the early 1990s to nearly 700 in 2018 in the Netherlands alone [1]. This is consistent with global figures, in which the increased incidence of Human Papilloma Virus (HPV) related oropharyngeal squamous cell carcinoma (OPSCC) has the largest share in this growth, especially among men in developed countries [2]. A better prognosis for HPV-positive OPSCC, combined with young age at diagnosis and thus a longer life expectancy, has increased awareness of late treatment-related toxicity [3]. Radiotherapy (RT) alone or in combination with chemotherapy (cisplatin) (CRT) or biotherapy (cetuximab) (BRT) is the main therapy for OPSCC with osteoradionecrosis (ORN) as one of the most feared toxicities. Although the risk of ORN has decreased with current advancements in radiotherapy techniques and better oral health regimens, cancer located in the oropharynx remains a risk factor for ORN due to its location proximate to the mandible [4-7]. Comprehensive dental assessment of potential oral sources of infection (poor prognosis teeth) prior to RT is an example of improved oral health regimes. In the Netherlands, oral health recommendations prior to RT are based on a protocol that dates from 1992, which has been revisited in 2018 [8-10]. Removal of poor prognosis teeth that are identified as potential oral source of infection is a common recommendation in the prevention of ORN. This is however complex and controversial. Tooth extractions result in a reduced number of functional units (Table 1) and impair the ability to masticate and swallow, contributing to decreased health-related quality of life (QoL) [6, 11-13]. Indeed, this deterioration in mastication has been associated with oropharyngeal dysphagia [14, 15]. Furthermore, it has been demonstrated that oropharyngeal dysphagia is significantly related to involuntary weight loss [16, 17]. Cachexia, clinically characterized by unintended weight loss and low muscle mass [18], has a negative effect on treatment-related toxicity and oncological outcome. Head and neck cancer patients with weight loss and/or low muscle mass experienced higher levels of toxicity, more unplanned hospital admissions, and poorer overall survival [19-21]. Therefore, it is of utmost importance to prevent weight loss during oncological treatment and to elucidate contributing risk factors [21]. Nutritional management targeting malnutrition to prevent or limit weight loss is an essential part of head and neck oncological treatment. Regularly, tube feeding (TF) may be necessary to achieve these goals [22].
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