proper management of cancer patients from dental view

cancer patients proper management from oral and dental point of view and medical point of view.

1. DENTAL MANAGEMENT OF CANCER PATIENTS

2. Learning objectives 1- Identifying oral complications of cancer treatment . 2- Describe the clinical features of oral mucositis , xerostomia and osteonecrosis. 3-Establish prevention strategies to avoid oral complication of cancer treatment. 4- Describe the dentist role in management of oral complication of cancer treatment . 2

3. Treatment of Cancer It may involve single , or multimodality therapy, consisting of: Surgery Radiation Chemotherapy Hematopoietic cell transplantation, Hormone therapy A combination of two or more of the above. 3

4. Oral Complications of Chemotherapy A-Direct toxicity: Oral mucositis . Xerostomia. Neurotoxicity: acute pulpitis-like pain in 6% of cases. B. Indirect toxicity :(bone marrow suppression) Infections :Bacterial, fungal & viral Oral bleeding 4

5. Oral Complications of Radiotherapy A. Acute reactions: (7-14 days) Oral mucositis – Partial xerostomia(50% ) B. Chronic or late complications:(months to years) Severe xerostomia Oral mucosal atrophy Post-radiation dental caries Osteoradionecrosis Loss of taste Muscle & joint fibrosis → limited function Nutritional impairment 5

6. 1-Oral Mucositis

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8. 1-Oral Mucositis It is the most common cause of pain during the treatment of cancer. Oral mucositis develops 7 -14 days after chemo- or radio- therapy. Healing of chemotherapy -related oral mucositis occurs in 2-3 weeks; whereas radiation-related oral mucositis requires 3-6 weeks to heal.

9. Pathogenesis of OM 9

10. Prevention & Management of Oral Mucositis According to the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) (2020) 1-Basic oral care (maintaining good oral hygiene oral hydration, avoiding irritation) is suggested during the course of cancer therapy 2- Benzydamine hydrochloride is effective as preventive agent in radiotherapy induced OM when radiation dose less than 50 GY 10

11. Prevention & Management of Oral Mucositis 3- Photo biomodulation using low level laser therapy is recommended in management of OM with special attention to patient with oral cancer. 11

12. 4-Systemic analgesics to control pain . 5- morphine rinse 2% is suggested in management of pain in OM. 6-cryotherapy is recommended in prevention of OM induced chemptherapy 12

13. 2.Hyposalivation and Xerostomia 13

14. Radiotherapy beside decreasing the amount of saliva also, results in a change of salivary composition : Reduced pH (pH<6.75) Increase in cariogenic micro-organisms , ( Streptococcus mutans, Lactobacillus species), and Candida species.

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16. Prevention of Hyposalivation and Xerostomia Prevention of radiation damage to salivary glands is done by beam arrangement . Shielding prostheses may be fabricated and used during radiotherapy. 16

17. STIMULATION OF SALIVARY FUNCTION For patients with residual gland function, high fluid intake and the sugarless gum or candies may be used. For patients with permanent gland damage use of salivary substitutes . 17

18. 3. Oral Infection 18

19. Bacterial, fungal and viral infections may occur as a result of cancer chemotherapy . In chemo- and radiotherapy, the most common clinical oral infection is candidiasis . Oral and perioral viral infections are most commonly associated with herpes viruses , particularly Herpes simplex virus (HSV).

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21. Prevention and Management of Infection Following Chemotherapy Dental treatment should be timed after WBCs counts return to an appropriate level with the use of appropriate antibiotics. 21

22. Topical or systemic antifungals are used according to severity. Both acyclovir and valacyclovir are recommended. 22

23. 4.Post-Radiation Caries

24. Caries resulting from cancer therapy may be due to : Hyposalivation Altered salivary composition. A shift in oral flora towards cariogenic bacteria. Dietary changes.

25. 4.Post-Radiation Caries Caries associated with hyposalivation typically: Affects the cervical third and the incisal edge and cusp tips of the teeth, Has a rapid onset and progression, May become evident as early as three months following the initiation of radiotherapy.

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28. Prevention and manegment Preventive measures for H & N cancer patients before, during, and after radiotherapy include: Strict oral hygiene Limitation of cariogenic foods Remineralizing mouthrinse solutions

29. Daily self-application of topical fluoride, (1% NaF gel in custom-made fluoride carriers) or toothpaste with a high fluoride content (3% NaF ) twice a day

30. The use of resin-modified glass ionomer, composite resin or amalgam restoration, and not a conventional glass ionomer restoration in patients who have been treated with radiotherapy

31. 5.Osteoradionecrosis (ORN)

32. It is the most severe complication of bone irradiation (5-15% of cases) . The incidence of ORN in mandible (90%) is much higher than maxilla . The risk of necrosis is lifelong and may occur many years after irradiation. 32

33. Risk Factors for ORN Dose of radiation (high risk when dose > 8000 Gy ). The presence of teeth in a high-dose radiation field . The presence of dental or periodontal disease or irritation.

34. Extraction in Irradiated Patient and Risk of ORN 35 Highest risk of ORN Extraction during radiotherapy High risk of ORN Extraction just before radiotherapy Lowest risk of ORN Extraction 12 months or more after radiotherapy

35. Prevention of ORN in patients receiving radiotherapy Prior to radiation therapy, teeth should be scaled and root planed, with OHI. Mechanical irritation should be eliminated. Extraction of non restorable teeth, 7 to 14 days and up to 21 days prior to radiotherapy. Postpone elective dental procedures. Stop smoking and maintain good nutrition

36. MANAGEMENT OF OSTEORADIONECROSIS Irrigate with saline. Antibiotics (topical and systemic). Sequestra may be managed with limited resection or may require mandibulectomy. Hyperbaric oxygen: HBO therapy is prescribed

37. 6.Trismus 

38. The prevalence of trismus in head and neck radiotherapy is 10- 40%. Limited mouth opening may cause reduced nutrition and compromised oral hygiene , that can result in dental caries. 39

39. Prevention of Trismus (inter-arch distance) should be measured before radiotherapy , and it should be measured frequently to ensure its maintenance. Patients at risk of trismus should be put on home exercises to maintain maximum opening, as soon as radiotherapy begins. 40

40. MANAGEMENT OF TRISMUS In patients with trismus, the exercise program should be combined with physiotherapy to regain the lost inter-arch distance . Prosthetic appliances (dynamic bite openers) containing springs and bands designed to re-stretch the muscles have been helpful in some patients. 41

41. Sum up Role of dentist 42

42. The pretreatment evaluation should include: An examination of the head and neck, oral soft tissue and oral cavity as a whole. A complete periodontal evaluation . A full series of dental radiographs 43

43. Patient education . Affected individuals must understand how to : - perform effective self-care to safeguard their oral health. - adopt healthy diets and avoiding tobacco and alcohol use. 44

44. Prior to the start of cancer treatment: Dental prophylaxis, to reduce the severity of oral complications (specifically oral mucositis). Small or incipient caries lesions may be treated with fluoride. Caries lesions involving the pulp require active intervention. Patients who need teeth extracted must undergo surgery before cancer treatment begins. Nonemergency dental treatment can be delayed.

45. Thank you