Dental Management Of The Cancer Patient€¦ · Factors Important in the Dental Management of...

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Dental Management Of The Cancer Patient

Dr. Rafik Al Kowafi BDS, MSc, German board of Oral and Maxillofacial Surgery ( Berlin Germany), Doctoral degree by

LBMS

Introduction

• The dentist is an important member of thecancer team.

• A variety of dysfunctions can result from oralcancer and its treatment.

• The dentist should be involved ininterventions designed to prevent and/ormanage oral complications PRIOR TO,DURING AND FOLLOWING cancer therapy.

5 May 2014 LIMU 2Dr. Rafik Al Kowafi

Pre-Treatment Evaluation

• Pre-treatment evaluation is importantbecause many of the complications of oralcancer therapy can be reduced or eliminatedby proper treatment and management of oraldisease prior to treatment.



• Relevant initial data that should be collectedincludes:

1. Information related to cancer diagnosis.

2. Medical history.

3. Dental history.

4. Dental and periodontal status.

5. Nutritional status.


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The pre-treatment evaluation and examination should include the following:

1. A thorough hard and soft tissue examination.

2. A complete periodontal examination.

3. Evaluation of the patient’s level of oral hygiene.

4. A complete radiographic examination.


Evaluation of the Oral Mucosa

All areas of the oral mucosa should be carefully examined.

Any lesions that are discovered should be eliminated and their causes removed where possible.


Evaluation of the Dentition and Periapical Region

Infections of the dental pulp and periapicalpathoses can be potential sources of systemiccomplications in cancer therapy.

Therefore, all caries and periapical diseaseshould be documented and eliminated priorto cancer treatment.


Oral Manifestations of Chemotherapy

About 40 % of the patients receiving chemotherapyhave oral complications.

These complications include the development of oneor more of the following:

1. Mucositis

2. Ulceration

3. Neurotoxicity

4. Xerostomia

5. The use of myelosuppressive drugs indirectly causebleeding, anemia and infection.


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Mucositis

Oral reactions to chemotherapy depend on drug protocol, dosage of the drug (s) used and the patient’s tolerance to the chemotherapeutic agents.


Oral Manifestations of Chemotherapy: Hemorrhage

Intraoral hemorrhage can occur secondary tothrombocytopenia, which develops from bonemarrow suppression.

Intestinal and/or hepatic damage may lowervitamin K-dependent clotting factors (II, VII,IX, X) contributing to the hemorrhage.



Additionally, tissue damage may release tissuethromboplastin, which may cause DIC. DIC can leadto a hemorrhagic diathesis resulting from theconsumption of platelets and clotting factors and theactivation of plasminogen.

Oral petechiae and ecchymosis secondary to evenminor trauma are the most common presentations.

The labial mucosa, tongue and gingiva are the sitesmost commonly involved with oral bleeding.




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Pre-Radiation Therapy Evaluation

If radiation therapy is to be utilized then thedentist should consider the following:

1. Are there any salivary glands within thefiled of radiation? Radiation of the threepairs of major salivary glands can reducesaliva by up to 90 %. The resultantxerostomia can lead to a variety of clinicalproblems.


Pre-Radiation Therapy Evaluation

2.Is either jaw within the field of radiation? If theanswer is yes, then the possibility of osteonecrosis(osteoradionecrosis) exists. This risk is greater inthe mandible.

3.What other tissues will be included within theradiation field? Trismus can develop if the TMJand/or the muscles of mastication are irradiated.One must also consider the effects of radiation onthe oral mucosa and on taste buds as well.


Factors Important in the Dental Management of Patients Receiving

Radiation Therapy1. The dose of radiation given to the bone.

2. Pre-treatment dental status, dental hygiene status and the desire to retain teeth in the field of radiation.

3. Are extractions necessary and if so the techniques employed.

4. The allowance for healing time following extractions.

5. The likely compliance of the patient to preventive dentistry.


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Radiation Therapy

The side effects of therapeutic radiation are:A. Temporary side effects:

1. Mucosal ulcers

2. Pain

3. Dysgeusia/hypogeusia

4. Candidiasis

5. Dermatitis

6. Erythema

7. Alopecia

B. Permanent side effects:1. Xerostomia

2. Cervical caries

3. Osteonecrosis

4. Telangiectasia

5. Epithelial atrophy

6. Alopecia


Osteonecrosis (Osteoradionecrosis)

Osteoradionecrosis is one of the more seriouscomplications of radiation to the head andneck.

It occurs less commonly today than in the pastbecause of better treatment modalities andthe focus on prevention.

Radiation damages the osteocytes and themicrovascular system of bone leaving ithypocellular, hypovascular and hypoxic.


Osteoradionecrosis

• One is left with non-healing, dead bone in thisprocess.

• On radiograph osteoradionecrosis appears asan ill-defined radiolucency that may developzones of relative radiopacity as dead boneseparates from vital areas.

• Pain, cortical perforation, fistula formation,surface ulceration and pathologic fracturemay occur.


Osteoradionecrosis


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Osteoradionecrosis


Osteoradionecrosis


Osteoradionecrosis


Osteoradionecrosis


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Risk of Bone Necrosis with Radiation Therapy

The risk of bone necrosis increases with:

1. Radiation does and to a lesser extent volume ofthe bone irradiated.

2. The presence of teeth.

3. The presence of bone trauma.

4. The presence of periodontal disease.

5. The presence of concurrent chemotherapy.


Osteoradionecrosis

Prevention of the bony necrosis is the bestcourse of action.

Since the vascularity of bone actuallydecreases with time following radiationtherapy, extractions should be carried outprior to therapy and post-radiationextractions (after the 4th month post-radiation)should be avoided.


Prevention of Osteoradionecrosis

Prior to therapy the following should occur:

1. All questionable teeth should be extracted if they can notbe restored.

2. All oral foci of infection should be eliminated.

3. Ideally a healing time of at least 3 weeks between dentalprocedures such as extractions and the initiation ofradiotherapy significantly decreases the chance of bonenecrosis.

3. A program for excellent oral hygiene should be initiatedand maintained.


Treatment of Osteoradionecrosis

• Conservative treatment consists of: gentiledebridement with the removal of sharp, bonyspicules and non-vital bone; use of antibioticpacks and frequent irrigation.

• General dentists may wish to call upon theoral surgeon for more aggressive surgicaltreatment and the use of hyperbaric oxygen.

• Unfortunately, healing is often prolonged.


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Xerostomia

• Dry mouth is a frequent complication ofradiation therapy as salivary glands are verysensitive to radiation.

• As previously noted up to a 90 % reduction insaliva may occur when all 3 pairs of majorsalivary glands are irradiated.

• The effect may begin within a week ofinitiation of the radiation therapy.


Xerostomia

• Dramatic decreases in saliva flow can benoted during the first 6 weeks and furtherdecreases may occur for up to 3 years.

• The return of salivary gland function tonormal after radiotherapy is quite variableand appears to be dose related.

• Dependent on dose (tolerance ~ 32 Gy)


Xerostomia


Sequelae of Radiation-Induced Xerostomia

These sequelae include:

1. A decrease in saliva with a concomitant increase in viscosity.

2. A decrease in the pH of the oral cavity.

3. Development of dysphagia.

4. Development of mucositis.


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Sequelae of Radiation-Induced Xerostomia

5. A decrease in retention of removable prosthesesand increase in “sore spots”.

6. Adherence of food and cellular debris to the oralstructures.

7. A shift in the diet to softer foods, which areusually carbohydrates.

8. A shift of the microflora to include a greaterabundance of Lactobacilli, cariogenic Streptococciand Candida.

9. Radiation caries.


Management of Radiation-Induced Xerostomia

The patient should be instructed to:

1. Rinse frequently with sterile water/saline.

2. Use commercially available artificial salivasubstitutes.

3. Use salivary stimulants such as sugarlessgum/candy or institute drug therapy.

4. Apply lubricating agents to the lips to preventcracking.

5. Pilocarpine post-radiation, amifostine concurrentwith radiation for prevention.


“Radiation Caries”

This rampant form of dental caries is, of course,xerostomia induced.

Radiation caries is predominantly cervical in location.

The patient must be educated as to the role ofdental plaque in the etiology of dental caries andperiodontal disease.

Brushing and flossing techniques must be taught andreinforced.




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Prevention of “Radiation Caries”

• A fluoride program should be instituted andmaintained.

• Neutral fluoride is best tolerated by patientswith an oral mucositis.

• Fluoride gel delivery is best accomplishedthough the use of custom trays.

• Daily five-minute application is recommendedduring therapy with weekly office visits.


Prevention of “Radiation Caries”

Following completion of radiation therapy, dentalappointments should be scheduled at 1 to 3 monthintervals depending upon the patient’s needs.

Excellent oral hygiene is of paramount importance inthe prevention of radiation caries yet brushing,flossing, commercial toothpastes and mouthwashesmay become a source of irritation in the irradiatedpatient.


Trismus

Fibrosis of the normal soft tissues that fall within theradiation field is often an insidious complication ofradiation therapy.

Trismus typically occurs progressively from 3 to 6months after the conclusion of radiation therapy.

As the result, jaw opening can be severely limited.

Once it occurs, physiotherapy consisting ofstretching exercises and special appliance cansometimes be useful.


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Mucositis

• Most patients receiving radiation orchemotherapy develop mucositis to somedegree and both modalities of treatment haveclinical presentations.

• Mucositis related to chemotherapy developswithin a few days of treatment while radiationmucositis begins during the second week oftherapy.


Mucositis

• The earliest manifestation is the developmentof a whitish discoloration from a lack ofsufficient desquamation of keratin.

• This layer is soon lost to be replaced by anatrophic mucosa, which is edematous,erythematous and friable.

• Ulcers soon develop and are covered by aremovable yellowish pseudomembrane.


Mucositis


Mucositis


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Mucositis


Mucositis

Pain, burning and discomfort are severe andmay be worsened by eating and by oralhygiene procedures.

With the change in the oral microflora due toxerostomia, the patient may developinfections such as the candidal infection.


Candidal infection


Candidal infection


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Treatment of Oral Mucositis

Mild to moderate mucositis can be palliatedby the following:

1. BMX ((Benadryl-Maalox- Xylocaine) mouth rinse.

2. Warm saline rinses used as needed.

3. One part hydrogen peroxide to 4 parts saline inan atomizer sprayed into the mouth andexpectorated.



Severe mucositis can be palliated by the following:

1.Topical anesthetic spray e.g. Cetacaine spray used5 to 10 minutes before meals to allow the patientto eat.

2.Dyclonine hydrochloride (Dyclone) 0.5 %, swish 5to 10 mls in the mouth. This has longer durationand decreased cardiac toxicity when compared tomany topical anesthetics.

3.Oral viscous lidocaine has caused seizures inchildren so use accordingly.



4. Acetaminophen with codeine elixir, can beswished and swallowed to give both local andsystemic effects. This should be used 15 to 30minutes before meals.

5. Chlorhexidine decreases the mucositis andulcerations in chemotherapy but is noteffective in radiation mucositis.


Conclusions

1. Many complications of cancer therapy can beprevented or controlled by treating diseasedoral sites prior to cancer therapy.

2. Cancer treatment often causes changes thatrequire long-term management.

3. The dentist can play an important role in thecare and management of the cancer patient.

FOR MORE INFORMATION AND UPDATE PLEASE VISIT.http://www.cancer.gov/cancertopics/pdq/supportivecare/oralc

omplications/HealthProfessional


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