4 Consensus conference summary statement: All cancer patients should have an oral examination before initiation of cancer therapy.Treatment of pre-existing or concomitant oral disease is essential in minimizing oral complications in all cancer patients.
5 Oral Cancer 30,000 diagnosed each year 9,000 die each year Only 50% will survive 5 yearsOral cancer 5th lowest survival rate of 13 major cancers100% receiving radiation to head and neck have permanent serious oral sequela40% receiving chemotherapy experience disability and dose limiting oral sequela
6 Overview45% males and 38% females will experience an invasive tumor some time in their life (ACS 2008)All practicing dentists will manage cancer patients at some time in their careerThere are many opportunities as dentists to improve the quality of life for these individualsManaging cancer patients can put them at significant risk if appropriate precautions are not followed
7 Plan for Best OutcomeManagement of patients follows a continuum extending from diagnosis to long term post restorative car.The goal for each patient is to maintain as much masticatory and esthetic function as possible.Plan for each patient depends upon the proposed medical and surgical managementEach patient is unique and requires significant thought in treatment planning process.
8 Tumor Catagories Head and Neck origin Hematopoetic origin Primary TumorsMetastatic tumorsHematopoetic originNon head and neck tumors
9 Common Surgical and Medical Management Modalities Surgical resectionLocal excisionBlock resection with graftingFree flap graftingRadical/modified neck dissectionRadiation therapyChemotherapy
10 Radical Neck Dissection: fast and simple operation
11 Modified Radical Neck Dissection IJVSANSpinal accessory nerveInternal jugular veinDifficult surgery because lymph nodes around and under spinal accessory nerveSANIJV
12 Management Modalities Radiation therapyConventional linear accelerator, plane fieldInterstitialIMRT(Intensity modulated radiation therapyChemotherapyConcombitant therapy (prior to/in conjunction with radiation therapyConcombitant therapy after radiationPalliative chemotherapy
13 Role of the Oral Health Team in the Care of the Patient with Cancer
14 Cancer Therapy Oral Management Objectives Improve oral function and quality of lifeImprove and maintain oral hygiene – to reduce oral complicationsElimination oral infectionsPrevent potentially fatal systemic infections of dental originPrevent painReduce risk of destruction of dentition
15 Objectives Prevent/control salivary gland dysfunction Assist nutritional goalsReduce risk of bone necrosis
17 CHEMOTHERAPY NOT curative for oral and pharyngeal SCCA Platinum-based drug therapyCombined modality chemo-radiotherapyWeek 1, 3, 5 of XRTPalliative treatment used for otherwise untreatable advanced or recurrent cancer
18 Chemotherapy-Eradicate rapidly growing cells of tumor Administered by these methods:Orally (pill form)IntramuscularIntravenousIntrathecalReservoir
19 Chemotherapy Protocol Combination of several drugsDelivered in sequential rounds over several monthsTime allowed between rounds to allow body to recover from drug toxicity
31 ComplicationsDirect CYTOTOXIC effects of chemotherapeutic agents on oral tissuesIndirect effect of MYELOSUPPRESSION
32 Mucositis: Normal mucosal cells as well as cancer cells can be destroyed by chemotherapy, resulting in friable oral tissues and ulcerations.
33 Post chemotherapyMonitor patient till all side effects resolved, including immunosuppressionPlace patient on normal dental scheduleRemind patient to maintain optimal oral healthMonth following chemotherapy treatment, blood values should return to normal
34 Oral ManifestationsRelated to Drug protocol % of patients develop oral side effectsDrugsDoseDurationPatient’s mucosal integrityOral and systemic statusCancer patients infections causing death, estimated that 56% of the time infection originates in the mouth
36 RADIOTHERAPY Primary method of treatment for Stage I-II Radiation alone 70+cGyAdjuvant Stage III-IV Approx. 60cGy/ Chemo addedPositive or close marginsThickness > 7mmMultiple positive nodesExtracapsular spreadPerivascular or Perineural invasion
40 RADIOTHERAPY EARLY ORAL EFFECTS LATE ORAL EFFECTS Mucositis Xerostomia TrismusProgressive endarteritisOsteoradionecrosisRadiation is designed to kill the cancer cells by producing cellular damageUlceration and associated inflammation are called mucositisFirst and most common side effect of treatment.Hot and spicy foods should be avoided as well as those foods which may scrape the inside of the mouth.Alcohol and carbonated beverages may also irritate the mouthOral infections are very common, with chemotherapy it happens when the ability to fight infection is lost as the white blood cell count drops
47 Patient may experience PainInfectionMay lead to sepsis/life-threatening in neutropenic patientNeed to culture
48 Patient may experience BleedingReduction of platelets (transfusion)Taste alterationXerostomia/salivary gland dysfunctionRelated to length of txLower pH may lead to rampant cariesDry mucosa susceptible to pain, infection and irritation
49 Patient may experience NeurotoxicityNumbness/constantDeep painOften bilateralMimics toothache – but cannot be foundDental developmental abnormities in children
51 Head and Neck Cancer patient Pre-radiation Consult radiation oncologist for fields and dose
52 Oral/dental evaluation Medical status/medication analysisHard and soft tissueRadiographic pathologyPeriodontal diseaseOral hygiene practicesTobacco and alcohol habits
53 Dental Treatment Eliminate potential infection or irritation Remove ortho bandsStability of periodontal diseaseOral hygiene instructions
54 Considerations for dental treatment plan Patient age, previous dental history and experience also home carePrognosis and motivation of patientRT will cause dramatic decrease in salivary gland functionCaries incidence will increase as a function of reduction in salivaPeriodontal loss will be greater in area of radiation than in non treated areas
55 Dental plan Eliminate oral/dental disease Remove hopeless teeth and perform all necessary surgery to prevent osteoradionecrosis riskAllow extraction sockets to heal days prior to starting cancer therapy
56 Guidelines for areas to receive Radiation Therapy Teeth within fields anticipated dose 50G must be retained lifelong or should be removed prior to treatmentTeeth retained within fields receiving doses of 50G that need TE later usually require HBO prior to extractionTeeth that are retained within field of RT are highly susceptible to aggressive dental caries
57 Dietary recommendations Limit highly cariogenic foodsIncrease water consumptionDo not compromise adequate calorie intakeSuggest sugar-free gum/candyXylitol
68 Rx: 80 ml 2% viscous xylocaine 80 ml Maalox100ml distilled waterDisp: 260 ml Sig: Swish for 1 minute and expectorate
69 Saliva stimulants: Sugarless gum and lozenges Artificial saliva products
70 Medications for HSV Infection Associated with Chemotherapy Mucositis Acyclovir (Zovirax®) 400 mg capsulesDisp: 21 capsulesSig: Take one tablet three times per day for seven daysAcyclovir (Zovirax®) IVSig: 5mg/kg every eight hours for seven daysFamcyclovir (Famvir®) 500 mg capsulesDisp: 14 capsulesSig: Take one capsule two times per day for seven daysValacyclovir (Valtrex®) 500 mg capsules
71 Herpes Simplex Virus Infection: Extra-oral and intra-oral herpetic infections are common during immunosuppressions.
73 Bone Marrow – Stem Cell Transplant Preparative Regimens Goal: Eliminate disease by replacing defective cellsBone marrow destroyed by high dose chemotherapyWith or without TBI (total body irradiation)1500 – 2000 cGy to entire body
75 Transplant BMT Organ Leukemia Lymphoma Multiple Myeloma Kidney TransplantHeart Transplant
76 Pre-Bone Marrow Transplant Consult with oncologist (blood counts, catheter)Pre-med if necessaryEliminate infection/irritationDental treatment necessary up to 1 yearOral surgery with at least 7-10 days healing before date of bone marrow suppression
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