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MANAGEMENT%20OF%20HEAD%20

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Dental Assistant. Reception Staff. Dental Management. And may involve: Radiation Therapy ... Medical/dental management of these patients is complicated and ... – PowerPoint PPT presentation

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Title: MANAGEMENT%20OF%20HEAD%20


1
MANAGEMENTOF HEAD NECK RADIOTHERAPY PATIENTS
  • Dr. Gillian Soskin
  • General Medicine D344/QP344
  • March 11, 2005

2
Head Neck Cancer Diagnosis
3
Squamous Cell Carcinoma
  • 90 of all oral cancers
  • 50 5-year survival
  • can occur in
  • tongue
  • skin
  • throat
  • soft palate

4
Radiation Treatment Centres In Ontario
Sudbury
Ottawa
Kingston
London
Toronto
Windsor
5
Treatment plan is based on
  • anatomical considerations

6
Treatment plan is based on
  • Staging of disease using TNM classification
  • Eg. T3N2M0 laryngeal carcinoma

7
Treatment plan is based on
  • age of patient

8
Treatment plan is based on
  • co-morbid conditions

9
Treatment Options
OR
/-
/-
/-
/-
10
Treatment Options
  • no treatment
  • palliation

11
Dental Management
  • Will involve

General Dentist Hygienist Dental
Assistant Reception Staff
12
Dental Management
  • And may involve

13
Radiation Therapy
  • External beam
  • most common
  • largest fields

14
Radiation Therapy
  • Brachytherapy
  • interstitial implantation of radioisotope-filled
    needles

15
Radiation Therapy
  • Brachytherapy
  • interstitial implantation of
  • radioisotope-filled needles

16
Radiation Therapy
Au grain or Iridium Implants
17
Radiation Dosimetry
  • How much?
  • Where?

18
How much radiation?
1 rad 1 centiGray (cGy) 200 cGy per
day 5 days per week 1000 cGy
per week
19
How much radiation?
Total dose ranges from 6000 cGy 7000
cGy 6 7 WEEKS of treatment
20
Where are the radiation fields?
  • unilateral or bilateral?
  • neck only?
  • posterior mandible and neck?
  • oral cavity and neck?
  • base of skull to clavicles?

Impact on oral health!!!
21
Dental Consultation
  • Clinical examination
  • charting (odontogram)
  • visual (other lesions?)
  • palpation

22
Dental Consultation
  • Radiographic examination
  • Panorex
  • intra-oral films as required

23
Dental Consultation
  • Diagnoses
  • Dental
  • Caries
  • Periodontal disease
  • Other Pathology
  • Medical
  • co-morbidities

24
Dental Consultation (cont.)
  • Treatment Plan based on
  • prognosis of individual teeth
  • past dental history (compliance)
  • sequelae and potential complications from
    radiotherapy
  • LONG TERM RISKS!

25
Dental Treatment
  • Must be done immediately
  • no delay in radiotherapy
  • cancer is progressing!!

26
Dental Treatment
  • Extractions
  • abscesses, gross caries
  • advanced periodontal disease
  • heavily restored teeth w/ poor OH
  • Must have 2 weeks healing prior to start of
    radiotherapy!!!

27
Dental Treatment
  • Cleaning
  • Restorations
  • Complete these during healing phase
    post-extraction

28
Dental Treatment
  • Dentate?
  • fabricate custom fluoride trays

29
Dental Treatment
  • Dentate?
  • daily topical application
  • 1.23 APF gel
  • 2 Neutral NaF gel

30
4 minutes once a day EVERY DAY for the rest of
your life!!
31
Dental Treatment
  • Edentulous?
  • Poorly-fitting dentures?
  • Candida?
  • Rx Nystatin before radiotherapy starts

32
Acute Sequelae
  • General
  • Weight loss (variable)
  • Nausea /- vomiting
  • Fatigue
  • Depression

33
Acute Sequelae
  • Extra-Oral
  • Cutaneous burns
  • Alopecia
  • Xeroderma

34
Acute Sequelae
  • Intra-Oral
  • Mucositis
  • erythema
  • ulceration

35
CANDIDIASIS
TREATMENT 1. Nystatin 100,000 u/ml oral
suspension 5 mL (1 tsp.) P.O. qid
Swish for 1 min. and swallow If another
organism or systemic infection is suspected,
alert the medical oncologist immediately
36
ORAL MUCOSITIS
TREATMENT 2. Diphenhydramine (Benadryl) elixir
Mixed with Kaopectate or Maalox 11 by
pharmacist 15 mL (1 Tbsp.) P.O. prn pain
Swish for 30 sec. then spit out
37
ORAL MUCOSITIS
  • TREATMENT
  • 0.1 Hydrocortisone rinse
  • 15 mL P.O. tid
  • Swish for 30 sec. then spit out
  • contra-indicated if active viral lesions
  • are present intra-orally

38
Acute Sequelae
  • Intra-Oral
  • Xerostomia

39
Acute Sequelae
  • Intra-Oral
  • Hypogeusia (diminished taste)
  • Odynophagia (painful swallowing)
  • 2o to mucositis/ulceration

40
Acute Sequelae
  • Intra-Oral
  • Dysphagia (difficulty swallowing)
  • may necessitate J-tube
  • may persist 2o to esophageal scarring

41
Chronic Sequelae
  • Xerostomia
  • begins 1 week into treatment
  • permanent!

42
Chronic Sequelae
  • Problems with xerostomia
  • increased caries risk
  • daily topical fluoride application
  • frequent recalls - every 3 months
  • increased cost to patient

43
Chronic Sequelae
  • Problems with xerostomia
  • increased trauma risk
  • soft tissues very dry
  • easily injured

44
Chronic Sequelae
  • Problems with xerostomia
  • thick secretions
  • change in mucousserous ratio
  • increased gag
  • difficulty wearing dentures

45
Chronic Sequelae
  • Problems with xerostomia
  • difficulty swallowing
  • H2O with/between meals
  • chronic Candidiasis

46
Chronic Sequelae
  • Trismus
  • 2o to fibrosis of muscles
  • exacerbated by pre-XRT trauma (ie. Surgery)

47
Chronic Sequelae
  • Problems with trismus
  • impaired nutrition if severe
  • very limited access for dental treatment
  • restorations
  • cleaning
  • inability to make/wear dentures

48
Chronic Sequelae
  • Physiotherapy for trismus

49
Chronic Sequelae
  • Edema
  • 2o to decreased lymphatic drainage from fibrosis
  • not usually a functional problem but cosmetic

50
Chronic Sequelae
  • Impaired wound healing
  • increased fibrosis
  • decreased circulation

51
Chronic Sequelae
  • Impaired wound healing
  • NO extractions without consultation
  • wait 6-9 months before dentures

52
Complications
  • Post- radiotherapy
  • potential for healing worse
  • length of time is NOT self-limiting

53
Complications
  • Soft tissue necrosis
  • 2o to trauma 2o to ischemia

54
Complications
  • Areas most susceptible
  • hard/soft palate
  • FOM, ventral surface of tongue
  • mucosa overlying internal oblique ridge
  • Treatment REFER

55
Complications
  • Definition Osteoradionecrosis
  • death of bone
  • following radiation

56
Complications
  • Osteoradionecrosis
  • hypoxic injury
  • devitalized bone will often not be painful!
  • patient may not be aware of it - LOOK!
  • radiographic changes may/may not be present
  • CLD often a problem, source of trauma

57
Complications
  • Problems with Osteoradionecrosis
  • superinfection with bacteria/fungus
  • sharp spicules will traumatize other soft tissues
    - more problems
  • can be progressive, potential en bloc resection
  • Treatment REFER

58
Hyperbaric Oxygen Therapy
  • helps to promote vascularity
  • growth of new blood vessels
  • increased oxygen tension
  • within tissues
  • Therefore helps healing process

59
Hyperbaric Oxygen Therapy
Prior to HBO
60
Hyperbaric Oxygen Therapy
During HBO
61
Hyperbaric Oxygen Therapy
Following HBO
62
Hyperbaric Oxygen Therapy
  • Only 2 facilities in Ontario
  • Hamilton
  • Toronto

63
Hyperbaric Oxygen Therapy
  • Marx Protocol (Prophylaxis)
  • 20 treatments
  • Extractions
  • 10 treatments

64
Hyperbaric Oxygen Therapy
  • Marx Protocol (Osteoradionecrosis)
  • 30 treatments
  • Resection
  • 10 treatments

65
Summary
  • Squamous cell carcinoma (head neck) represents
    4 of new cases
  • Average age of population increasing
  • Average practice will see these patients
  • Long-term follow-up necessary
  • Medical/dental management of these patients is
    complicated and requires a team approach

66
References
  • The Head Neck Radiotherapy Patient
  • Part I Oral Manifestations of Radiation
    Therapy
  • Part II Management of Oral Complications
  • Compendium (1994), vol. 15(2), pp.250-260

  • 15(4), pp.442-454
  • Head Neck Cancer Patients Receiving Radiation
    Therapy
  • ADA Oral Health Care Series

67
References
  • National Institute of Dental Craniofacial
    Research (www.nohic.nidcr.nih.gov)
  • Canadian Cancer Society (www.cancer.ca)
  • Oral Cancer Foundation
  • (www.oralcancerfoundation.org)
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