Oral Oncology D6537 Oral Complications

Kathy Dockter, RDH, MSOncology Dental Support ClinicSpecial Patient Care ClinicUMKC-SOD

1989National Institutes of

Health Consensus Conference

“Oral Complications of Cancer Therapies”

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.

Oral Cancer 30,000 diagnosed each year 9,000 die each year Only 50% will survive 5 years Oral cancer 5th 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

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

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.

Tumor Catagories

Head and Neck origin Primary Tumors Metastatic tumors

Hematopoetic origin Non head and neck tumors

Common Surgical and Medical Management Modalities

Surgical resection Local excision Block resection with grafting Free flap grafting Radical/modified neck dissection

Radiation therapy Chemotherapy

Radical Neck Dissection: fast and simple operation

Modified Radical Neck Dissection

IJVSAN

IJV

SAN

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

Role of the Oral Health Team in the Care of the

Patient with Cancer

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

Objectives

Prevent/control salivary gland dysfunction

Assist nutritional goals

Reduce risk of bone necrosis

Chemotherapy

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

Chemotherapy-Eradicate rapidly growing cells of tumor

Administered by these methods:

Orally (pill form) Intramuscular Intravenous Intrathecal Reservoir

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

Central Venous Catheter Porta-Cath

Hickman

Broviac

Powerport – implantable port

Hickman Catheter

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

www.chemocare.com/whatis/what_is_nadir.asp

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

Tx During Chemotherapy

Seek consultation with oncologist

Blood counts ordered day before tx. Infections – culture lesions Prevent caries and demineralization Pain management

Complications

Direct CYTOTOXIC effects of chemotherapeutic agents on oral tissues

Indirect effect of MYELOSUPPRESSION

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

Oral Manifestations

Related to Drug protocol - 40-50% of patients develop oral side effects Drugs Dose Duration

Patient’s mucosal integrity Oral and systemic status

Cancer patients infections causing death, estimated that 56% of the time infection originates in the mouth

Radiotherapy

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

IMRT:IntensityModulatedRadiationTherapy

RADIOTHERAPY EARLY ORAL EFFECTS

Mucositis LATE ORAL EFFECTS

Xerostomia Trismus Progressive endarteritis Osteoradionecrosis

XRT Oral ManifestationsAcute

Change in taste Xerostomia/salivary gland

dysfunction Mucositis/ulceration/pain Infection Nutritional deficiency

Oral Manifestations XRT Chronic

Salivary gland dysfunction Increased periodontal

disease Trismus Soft tissue necrosis/

osteoradionecrosis (ORN) Caries from radiation

Mucositis and Ulceration

Mouth

Pharynx

Esophagus

Gastrointestinal (GI) mucosa

Patient may experience Pain Infection

May lead to sepsis/life-threatening in neutropenic patient

Need to culture

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

Patient may experience

Neurotoxicity Numbness/constant Deep pain

Often bilateral Mimics toothache – but cannot be found

Dental developmental abnormities in children

Head and Neck Cancer patientPre-radiation

Consult radiation oncologist for fields and dose

Oral/dental evaluation

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

Dental Treatment

Eliminate potential infection or irritation

Remove ortho bands

Stability of periodontal disease

Oral hygiene instructions

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

Dental plan

Eliminate oral/dental disease Remove hopeless teeth and

perform all necessary surgery to prevent osteoradionecrosis risk

Allow extraction sockets to heal 10-14 days prior to starting cancer therapy

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

Dietary recommendations

Limit highly cariogenic foods Increase water consumption Do not compromise adequate

calorie intake Suggest sugar-free gum/candy

Xylitol

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

Pain Control

Bacterial plaque control

Adequate moisture

Avoid irritation

Palliative strategies

Biotene mouth rinses-Alcohol free and antibacterialBiotene moisturizers for lips and cheeksBiotene gum is sugar free

Stomatitis Cocktail

Antibiotic

Antifungal

Steroid

Antihistamine

Topical anesthetic

Rx: 80 ml 2% viscous xylocaine 80 ml Maalox 100ml distilled waterDisp: 260 ml Sig: Swish for 1 minute and expectorate

Saliva stimulants: Sugarless gum and lozenges

Artificial saliva products

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 capsulesDisp: 14 capsulesSig: Take one capsule two times per day for seven days

Transplant

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

Bone Marrow Transplantation

Autologous (self) marrow peripheral stem cells

Allogeneic (related/unrelated donor)

Syngeneic (twin)

Transplant

BMT Leukemia Lymphoma Multiple Myeloma

Organ Kidney Transplant Heart Transplant

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

Graft-Versus Host Disease Allogeneic bone marrow transplant

Acute/Chronic – white lacey pattern Mucositis Mucosal atrophy Ulcerations Oral infections

(candidia) Lichenoid reaction Lupus-like changes Xerostomia/rampant decay Gingival overgrowth (Cyclosporin)

GVHD-Intra-oral chronic

Therapies include Topical steroids Aazathioprine Tacrolimus Psoralen with ultraviolet A light

therapy (PUVA).

Photo courtesy of Gerry Barker

Rejection Process

1st 120 days maybe fatal Dental treatment

100 days – emergency only 100-365 – emergency/OH/xerostomia After 365 routine dental treatment Chronic GVHD Drug induced gingival overgrowth

Following BMT

Invasive dental treatment only after consult with BMT coordinator or oncologist

All elective treatment - delay one year following transplant

Psychosocial Issues

Cancer Diagnosis

Loss of control

Loss of life style

Loss of self-esteem

“Cancer-patient” role

Psychological Response to Cancer

Anxiety Depression Hopelessness Denial Anger Bargaining Acceptance

Acceptance

Verbalize “Cancer”

Participates in treatment planning

Asks appropriate questions

Keeps appointments

Proceeds with planned treatment

Barriers to Appropriate Treatment

Financial

Lack of self-efficacy

Lack of support system

Empathy

Speak to and look at patient

Let patient lead you

Treat the patient as an individual with cancer, not as ‘a cancer’

Resources

Patients literacy level

Web sources

SOD website http//:www.umkc.edu/dentistry

Laryngectomy

Electrolarynx

Resources

www.nohic.nider.nih.gov www.doep.org www.spohnc.org www.oralcancerfoundation.org www.nci.cih.gov www.cancer.org www.surgeongeneral.gov

Resources

www.kccancer.infowww.cdc.gov/tobaccowww.nstep.orgwww.lungusa.org/tobaccowww.americanheart.orgwww.ada.orgwww.quitcommit.comwww.nicoderm.com