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Oral Oncology D6537 Oral Complications Kathy Dockter, RDH, MS Oncology Dental Support Clinic Special Patient Care Clinic UMKC-SOD.

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Presentation on theme: "Oral Oncology D6537 Oral Complications Kathy Dockter, RDH, MS Oncology Dental Support Clinic Special Patient Care Clinic UMKC-SOD."— Presentation transcript:

1 Oral Oncology D6537 Oral Complications Kathy Dockter, RDH, MS Oncology Dental Support Clinic Special Patient Care Clinic UMKC-SOD

2 1989 National Institutes of Health Consensus Conference Oral Complications of Cancer Therapies

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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 years Oral cancer 5 th lowest survival rate of 13 major cancers 100% receiving radiation to head and neck have permanent serious oral sequela 40% receiving chemotherapy experience disability and dose limiting oral sequela

6 Overview 45% 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 career There are many opportunities as dentists to improve the quality of life for these individuals Managing cancer patients can put them at significant risk if appropriate precautions are not followed

7 Plan for Best Outcome Management 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 management Each patient is unique and requires significant thought in treatment planning process.

8 Tumor Catagories Head and Neck origin Primary Tumors Metastatic tumors Hematopoetic origin Non head and neck tumors

9 Common Surgical and Medical Management Modalities Surgical resection Local excision Block resection with grafting Free flap grafting Radical/modified neck dissection Radiation therapy Chemotherapy

10 Radical Neck Dissection: fast and simple operation

11 Modified Radical Neck Dissection IJVSAN IJV SAN

12 Management Modalities Radiation therapy Conventional linear accelerator, plane field Interstitial IMRT(Intensity modulated radiation therapy Chemotherapy Concombitant therapy (prior to/in conjunction with radiation therapy Concombitant therapy after radiation Palliative 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 life Improve and maintain oral hygiene – to reduce oral complications Elimination oral infections Prevent potentially fatal systemic infections of dental origin Prevent pain Reduce risk of destruction of dentition

15 Objectives Prevent/control salivary gland dysfunction Assist nutritional goals Reduce risk of bone necrosis

16 Chemotherapy

17 CHEMOTHERAPY NOT curative for oral and pharyngeal SCCA Platinum-based drug therapy Combined modality chemo-radiotherapy Week 1, 3, 5 of XRT Palliative treatment used for otherwise untreatable advanced or recurrent cancer

18 Chemotherapy-Eradicate rapidly growing cells of tumor Administered by these methods: Orally (pill form) Intramuscular Intravenous Intrathecal Reservoir

19 Chemotherapy Protocol Combination of several drugs Delivered in sequential rounds over several months Time allowed between rounds to allow body to recover from drug toxicity

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21 Central Venous Catheter Porta-Cath Hickman Broviac

22 Powerport – implantable port

23 Hickman Catheter

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25 Absolute Neutrophil Count ANC = total WBC X (%Segs + Bands Risk high if count < 1,000/mm3 Nadir (lowest blood counts) 7-14 days after a round or course of therapy adir.asp adir.asp

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28 Oral/Dental Evaluation Prior to or During Chemotherapy Indwelling central venous catheter American Heart Assoc. prophylactic antibiotic regimen prior to invasive tx. Clotting factors Platelet count (<50,000/mm3) abnormal clotting factors (PT, PTT, fibrinogen) Absolute neutrophil count

29 Tx During Chemotherapy Seek consultation with oncologist Blood counts ordered day before tx. Infections – culture lesions Prevent caries and demineralization Pain management

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31 Complications Direct CYTOTOXIC effects of chemotherapeutic agents on oral tissues Indirect effect of MYELOSUPPRESSION

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33 Post chemotherapy Monitor patient till all side effects resolved, including immunosuppression Place patient on normal dental schedule Remind patient to maintain optimal oral health Month following chemotherapy treatment, blood values should return to normal

34 Oral Manifestations Related to Drug protocol % of patients develop oral side effects Drugs Dose Duration Patients mucosal integrity Oral and systemic status Cancer patients infections causing death, estimated that 56% of the time infection originates in the mouth

35 Radiotherapy

36 RADIOTHERAPY Primary method of treatment for Stage I-II Radiation alone 70+cGy Adjuvant Stage III-IV Approx. 60cGy/ Chemo added Positive or close margins Thickness > 7mm Multiple positive nodes Extracapsular spread Perivascular or Perineural invasion

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38 IMRT: Intensity Modulated Radiation Therapy

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40 RADIOTHERAPY EARLY ORAL EFFECTS Mucositis LATE ORAL EFFECTS Xerostomia Trismus Progressive endarteritis Osteoradionecrosis

41 XRT Oral Manifestations Acute Change in taste Xerostomia/salivary gland dysfunction Mucositis/ulceration/pain Infection Nutritional deficiency

42 Oral Manifestations XRT Chronic Salivary gland dysfunction Increased periodontal disease Trismus Soft tissue necrosis/ osteoradionecrosis (ORN) Caries from radiation

43 Mucositis and Ulceration Mouth Pharynx Esophagus Gastrointestinal (GI) mucosa

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47 Patient may experience Pain Infection May lead to sepsis/life-threatening in neutropenic patient Need to culture

48 Patient may experience Bleeding Reduction of platelets (transfusion) Taste alteration Xerostomia/salivary gland dysfunction Related to length of tx Lower pH may lead to rampant caries Dry mucosa susceptible to pain, infection and irritation

49 Patient may experience Neurotoxicity Numbness/constant Deep pain Often bilateral Mimics toothache – but cannot be found Dental developmental abnormities in children

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51 Head and Neck Cancer patient Pre-radiation Consult radiation oncologist for fields and dose

52 Oral/dental evaluation Medical status/medication analysis Hard and soft tissue Radiographic pathology Periodontal disease Oral hygiene practices Tobacco and alcohol habits

53 Dental Treatment Eliminate potential infection or irritation Remove ortho bands Stability of periodontal disease Oral hygiene instructions

54 Considerations for dental treatment plan Patient age, previous dental history and experience also home care Prognosis and motivation of patient RT will cause dramatic decrease in salivary gland function Caries incidence will increase as a function of reduction in saliva Periodontal 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 risk Allow 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 treatment Teeth retained within fields receiving doses of 50G that need TE later usually require HBO prior to extraction Teeth that are retained within field of RT are highly susceptible to aggressive dental caries

57 Dietary recommendations Limit highly cariogenic foods Increase water consumption Do not compromise adequate calorie intake Suggest sugar-free gum/candy Xylitol

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59 Custom Fluoride Carriers Daily fluoride gel – 1.1% NaF Absolutely needed for head and neck XRT patients Maybe needed for caries control in chemo patients

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64 Pain Control Bacterial plaque control Adequate moisture Avoid irritation Palliative strategies

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66 Biotene mouth rinses-Alcohol free and antibacterial Biotene moisturizers for lips and cheeks Biotene gum is sugar free

67 Stomatitis Cocktail Antibiotic Antifungal Steroid Antihistamine Topical anesthetic

68 Rx: 80 ml 2% viscous xylocaine 80 ml Maalox 100ml distilled water Disp: 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 capsules Disp: 21 capsules Sig: Take one tablet three times per day for seven days Acyclovir (Zovirax®) IV Sig: 5mg/kg every eight hours for seven days Famcyclovir (Famvir®) 500 mg capsules Disp: 14 capsules Sig: Take one capsule two times per day for seven days Valacyclovir (Valtrex®) 500 mg capsules Disp: 14 capsules Sig: Take one capsule two times per day for seven days

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72 Transplant

73 Bone Marrow – Stem Cell Transplant Preparative Regimens Goal: Eliminate disease by replacing defective cells Bone marrow destroyed by high dose chemotherapy With or without TBI (total body irradiation) 1500 – 2000 cGy to entire body

74 Bone Marrow Transplantation Autologous (self) marrow peripheral stem cells Allogeneic (related/unrelated donor) Syngeneic (twin)

75 Transplant BMT Leukemia Lymphoma Multiple Myeloma Organ Kidney Transplant Heart Transplant

76 Pre-Bone Marrow Transplant Consult with oncologist (blood counts, catheter) Pre-med if necessary Eliminate infection/irritation Dental treatment necessary up to 1 year Oral surgery with at least 7-10 days healing before date of bone marrow suppression

77 Graft-Versus Host Disease Allogeneic bone marrow transplant Acute/Chronic – white lacey pattern MucositisMucosal atrophy UlcerationsOral infections (candidia) Lichenoid reaction Lupus-like changes Xerostomia/rampant decay Gingival overgrowth (Cyclosporin)

78 GVHD-Intra-oral chronic Therapies include Topical steroids Aazathioprine Tacrolimus Psoralen with ultraviolet A light therapy (PUVA).

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80 Photo courtesy of Gerry Barker

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83 Rejection Process 1 st 120 days maybe fatal Dental treatment 100 days – emergency only – emergency/OH/xerostomia After 365 routine dental treatment Chronic GVHD Drug induced gingival overgrowth

84 Following BMT Invasive dental treatment only after consult with BMT coordinator or oncologist All elective treatment - delay one year following transplant

85 Psychosocial Issues

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87 Cancer Diagnosis Loss of control Loss of life style Loss of self-esteem Cancer-patient role

88 Psychological Response to Cancer Anxiety Depression Hopelessness Denial Anger Bargaining Acceptance

89 Verbalize Cancer Participates in treatment planning Asks appropriate questions Keeps appointments Proceeds with planned treatment

90 Barriers to Appropriate Treatment Financial Lack of self-efficacy Lack of support system

91 Empathy Speak to and look at patient Let patient lead you Treat the patient as an individual with cancer, not as a cancer

92 Resources Patients literacy level Web sources SOD website http//:www.umkc.edu/dentistry

93 Laryngectomy

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97 Electrolarynx

98 Resources

99 Resources


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