ut bai 5 (english)2009

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Page 1: Ut bai 5 (english)2009

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Page 2: Ut bai 5 (english)2009

DENTAL COMPLICATIONS OF HEAD & NECK RADIOTHERAPY

Multidisciplinary approach in cancer treatment

Dental care: early in the patient’s treatment

Aims of dental care:

- To prevent

- To reduce side effects of radiotherapy

- To promote good oral health post-radiation

Page 3: Ut bai 5 (english)2009

Dental complications of head & neck radiotherapy

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��������������������All 4 taste are affected:

- Salty sensation : all over the tongue

- Sweet sensation : anterior surface & tip of the tongue.

- Sour sensation : lateral surfaces.

- Bitter sensation : circumvallate papillae

Xerostomia & Radiation-induced damage to taste buds -> Hypogeusia (2 wks after the start of radiotherapy) -> Ageusia

-> partially restored 20-60days & fully restored 2-4 months post-radiation.

> 60 Gy: permanent loss of taste.

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�Radiation-induced salivary gland acinar cell

inflammation, fibrosis & degeneration

�6 - 10 Gy: Hyposaliva

�Restored 6-12 months post-radiation.

But not restored if > 50 Gy, no saliva if >70 Gy.

�Alteration of oral environment (candidiasis,

dental caries, dysphonia, dysphagia) -> potentially

serious systemic consequences (malnutrition).

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1. Candidiasis� Most common infection during radiotherapy,

post-radiation, esp. With persistent xerostomia.

�Acute: erythema, burning sensation,

mistaken for radiation mucositis.

�Chronic: most common in corners of mouth.

2. Cariogenic microorganism (S. mutans,

Lactobacillus, Actinomyces,…) predominate

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Clinically distinctive pattern:1.Smooth surfaces are the 1st affected:

Circumferential caries at the ementoenamel junbction.

2.Caries in many sufaces of a tooth, in many teeth3.Caries progression are fast.

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TeethTeeth� Xerostomia -> polycaries.

� Decalcification ???

� Dental pulp: decrease in vascularity with fibrosis & atrophy -> decrease in response to infection, trauma, yet pulpal pain is less severe.

� Tooth development:

Prior to calcification: destroy tooth bud.

Late stage of dev.: arrest growth, enamel & dentine irregularities.

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Circumferential caries at the cementoenamel junction -> crown amputation

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OsteoradionecrosisOsteoradionecrosis (ORN)(ORN)

An irreversible, progressive devitalisation of irradiated bone.

A bone ischemic necrosis caused by radiation.One of the most serious sequences of radiotherapy.

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� 1922 Regaud� 1926 Ewing: Osteomyelitis in irradiated bone� 1971 Titterington: Osteomyelitis secondary to

irradiation� 1970 Meyer: Radiation+Trauma (initiator)+Infection� 1983 Marx: Microorganism may not play a pivotal role.ORN is not a primary infection of irradiated boneSpontaneous ORN may be related to higher radiation

dose.However, where trauma is associated with ORN, it is

caused by tooth removal (88%).

Pathophysiology of ORN

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““3H3H”” TissueTissue

HypovascularHypovascular

HypocellularHypocellular

HypoxicHypoxic

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Team work: Radiation Therapy (RT)

1. Determination of radiation:

- Fields

- Dose, how much to the jaw bones,

- Salivary glands included in the RT field

2. Dental therapy based on RT plan

3. Patient education about oral complications

4. Discussion of the importance of oral hygiene.

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ORAL MANAGEMENT OF THE CANCER PATIENTS

Prior to head and neck radiation therapy

1. Extraoral examination: face, neck

Intraoral exam: lip, buccal mucosa, gingiva, tongue, floor, palate

2. Diagnosis of dental treatment: Panorex diagnosis, evaluation of dental caries, calculus & periodontal disease, endodontic & mucosa lesions.

3. Dental treatment: Extraction - Prosthetic surgery – Caries removal,

Smoothing of any rough or sharp surfaces - Calculus removal

4. Prevent tooth demineralization and radiation caries: daily fluoride

5. Oral hygiene instruction

6. Tobacco & alcohol cessation, dietary counseling

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Indications:1. Root fragment or advanced caries2. Bone pathology: periapical infection 3. Advanced periodontitis

4. Furcation involvement 5. Erupting or unrupted teeth causing complication

At least 14 days for tissue healing prior to radiotherapy

(usually 14-21 days).

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ORAL MANAGEMENT OF THE CANCER PATIENTS

During radiation therapy

1. Monitor patient’s oral hygiene -Keep mouth moist & clean. Treat infections

2. Dietary counseling

3. Monitor patient for Trismus: - Check for pain or weakness in masticating muscles.

- Exercise 3 times/day X 20 times, opening as far as possible.

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After radiotherapyFrequent Dental follow-up to reinforce palliative &

preventive measures: Recall for the first 1-2 or 3 months, 6 months & 1 year.

At each visit:

- Check for mucositis (only 2-3 wks), xerostomia, demineralization & caries, signs of infection, trismus, recurrent tumor.

- Emphasize oral hygiene

Daily fluoride treatment:

1.1 % neutral sodium fluoride gel for 5 minutes/day.

0.4 % stannous fluoride gel

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How to Use Custom Fluoride Carriers (Trays)At bedtime, Place a thin ribbon of the fluoride gel into each

tray so that each tooth space has some fluoride. The fluoride can be spread into a thin film that coats the inside of the trays, by using a cotton-tipped applicator, finger or toothbrush.

Seat the trays on the upper and lower teeth and let them remain in place for 5 minutes.

After 5 minutes, remove the trays and thoroughly expectorate (spit out) the residual fluoride. Very Important - do not rinse mouth, drink or eat for at least 30 minutes (1 hour if possible) after fluoride use.

For head and neck radiation patients, begin using fluoride in the custom trays no longer than one week after radiotherapy is completed. Repeat daily for the rest of your life!!

Remember that tooth decay can occur in a matter of weeks if the fluoride is not used properly.

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Care for Fluoride Carriers (Trays)Rinse and dry the trays thoroughly after each use.

Clean them by brushing them with a toothbrush and toothpaste.

Occasionally, the trays can be disinfected in a solution of sodium hypochlorite (Clorox) and water. Use one tablespoon of Clorox in about one-half cup of water. Soak them for about 15 minutes.

If the trays become covered with hard water deposits, soak them in white vinegar overnight and brush them the next morning.

Do not boil the trays or leave them in a hot car as they may warp or melt.

Pamela Sandow, University of Florida College of Dentistry

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After radiation therapy

Mucositis- Rinse mouth with salt/bicarbonate

¼ tsp baking soda & 1/8 tsp salt in 1 cup of warm water, several times a day.

- 2% viscous lidocaine, analgesics

- Sip water

- Avoid highly seasoned and coarse foods.

- Avoid trauma (use soft-bristle toothbrush)

- Maintain good oral hygiene

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Oropharyngeal CandidiasisRisk: myelosuppresion, mucosal injury, salivary compromise, steroids

Diagnosis: history, risk factors, examination, culture as needed.

Treatment:

1. Topical antifungal agents (systemic if indicated)

. Clotrimazole troche (10 mg) 4-5 times/day

. Nystatin oral suspension (100,000 U/ml): 5 ml, 4 times/d

. Nystatin pastilles (200,000 U) 4-5 times/d

. Fluconazole solution (e.g. 10 mg) swish 3 times/d

. Amphotericin B oral suspension (100 mg/ml) 1 ml, 4 times/d

2. Nonmedicated oral rinse

3. Remove dentures, Nystatin ointment for denture wearers

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After radiation therapy

Management of the Xerostomic Cancer Patients- Sialogogues: pilocarpine HCl, sulfarlem S25

- Saliva substitutes (spray or gel)

- Sip water or sugar-free liquid, use sugar-free candy

- Lifelong, daily applications of topical high concentration fluoride gel.

- Avoid mouth rinse with alcohol

- Antimicrobials

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Dental filling

Use topical Fluoride daily (15 min X 3 times/day)

Antimicrobials: eg. Chlorexidine

Treatment of xerostomia

Frequent recall visits

Refrain from taking sugar containing food & drink.

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Radiation & postradiation physical therapy

inlcuding range-of-motion exercises.

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HBO Appointment ProtocolHBO Appointment Protocol22--2.5 atmospheres pressure for 90 minutes per day2.5 atmospheres pressure for 90 minutes per day

Each treatment takes ~ 130 minutes

• 10 minutes - pressurization• 30 minutes - 100% oxygen• 5 minutes - air break• 30 minutes - 100 % oxygen• 5 minutes - air break• 30 minutes - 100% oxygen• 20 minutes - depressurization 1.3 ATA

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New Technology:

Intensity Modulation Radiotherapy

IMRT

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Higher total dose (65 Gy) & dose per fraction (2.17 Gy) to the primary tumor and involved nodes (red in 3D reconstruction and green color wash) Lower total (54 Gy) dose and dose per fraction (1.8 Gy) to the

elective nodes (purple in 3D reconstruction & orange color wash).

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Parotid gland sparing intensityParotid gland sparing intensity--modulated radiotherapy (IMRT): modulated radiotherapy (IMRT):

A dose distribution to deliver a high dose to the target volA dose distribution to deliver a high dose to the target volume (blue ume (blue contour and red contour and red colourcolour wash) whilst sparing the parotid gland (pink wash) whilst sparing the parotid gland (pink contours) can be achieved with IMRT. contours) can be achieved with IMRT.

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Comparison between conventional and intensityComparison between conventional and intensity--modulated postmodulated post--operative radiotherapy for stage III and IV oral cavity cancer ioperative radiotherapy for stage III and IV oral cavity cancer in terms of n terms of

treatment results and toxicity treatment results and toxicity WenWen--Cheng Chen, Cheng Chen, Oral Oncology 2008Oral Oncology 2008

The aim of this study was to assess the treatment results and toxicity profiles of post-operative conventional radiotherapy (Conv-RT) and IMRT for stage III and IV oral cancer. During the period from 4/2002 to 12/2005, a total of 49 patients with stage III and IV OSCC were treated with radical surgery followed by post-operative RT. 27 patients received Conv-RT while 22 received IMRT. Only 3 patients received adjuvant chemotherapy. With a median follow-up time of 3.3 years, the 3-year overall survival and disease-free survival rates for patients who received Conv-RT vs IMRT were comparable.

There was no significant difference in acute toxicity between the two different RT techniques. However, in terms of late toxicity, patients receiving IMRT had significantly less moderate to severe xerostomia and dysphagia than those receiving Conv-RT (36% vs 82%, p = 0.01 for xerostomia and 21% vs 59%, p = 0.02 for dysphagia). Post-operative Conv-RT and IMRT are equally effective in terms of tumor control for locally advanced oral cavity cancer. Patients receiving IMRT had comparable acute and significant less late toxicity than those receiving Conv-RT.

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32 yearld old, female2000: Tonsil cancer -> Radiotherapy 70 Gy2004: ORN -> hemimandibulectomy (left)

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2004: Dental caries -> HBO 20 times + extraction upper teeth and root canal treatment lower teeth 2008: ORN stage 2 (right)-> treatment??????

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