Introduction The morbidity associated with non surgical treatment of cancer is significant It affects the quality of life of the patient Sometimes the complications are so severe that treatment needs to be interrupted that leads to compromised prognosis and increased health care cost ID: 1000622
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1. Oral complication of non surgical cancer therapies, diagnosis and treatment
2. Introduction The morbidity associated with non surgical treatment of cancer is significant.It affects the quality of life of the patient.Sometimes the complications are so severe that treatment needs to be interrupted that leads to compromised prognosis and increased health care cost.Wide range of oral complication often appear concurrently , complicating diagnosis and management.Oral complication induced by cancer therapies result from complex interplay of multiple factors
3. Complications associated with non surgical management of oral cancer Intense oral and pharyngeal pain Xerostomia Oral mucositisOropharyngeal candidiasis
4. Current approach to minimize the incidence and severity of oral complications of cancer therapies are Elimination of pre existing dental, periodontal and mucosal infections Implementation of basic oral care protocolPrompt diagnosis and management of oral complications during and after cancer therapy. An interdisciplinary approach , including dental professional , is required to work in close collaboration with the patient .
5. Type of cancer therapies Hematological malignancy patientHead and neck cancer patientPatient receiving targeted cancer therapiesHematological Malignancy PatientMay receive moderate to high does of chemotherapy with or without hematopoietic stem cell transplantation .Factors that determines the oral complication of the treatment depends upon Oral health prior to the treatment Intensity of cancer treatmentGenetic susceptibility of oral mucosal injuryHSCT related toxicities
6. Head and Neck Cancer Patient Treatment of oral cancer Surgical excisionHead and neck radiation Multi modality treatment Neo adjuvant chemotherapy Adjuvant chemotherapy Concurrent chemotherapy
7. Basic Oral Care Protocols for Chemotherapy and Head and Neck Radiation Patient Elimination /stabilization of selected oral disease prior to chemotherapy Oral care during and after treatment Oral DecontaminationTooth brushing 2-3 times with soft nylon bristled toothbrush.Should be supplemented with atraumatic dental flossing once dailyFluoridated tooth paste should be usedApplication of 1% neutral fluoride gel in dental tray for minimum of 5 minutes application in patient with high caries activity or patieOral Hydration
8. ORAL MUCOSITIS Oral Mucositis refers to injury to the oral mucosa that results in increased vascular permeability tissue edema, atrophy, and eventually ulcerations covered by a necrotic pseudomembrane in some instances. It is painful and debilitating condition that has a dose and rate limiting toxicity of cancer therapy. Seventy-five to 80% of bone marrow transplant patients who have undergone conditioning regimens with high-dose chemotherapy and radiation experience mucositisIt leads to sever pain, increased risk of local and systemic infection , compromised oral and pharyngeal function and oral bleeding .
9. Most common cause of pain during the treatment of cancer and most distressing side effect of head and neck radiation therapy .In neutropenic patient , the risk of systemic infection due to oral opportunistic is increased with mucosal ulceration . The ulcers of mucositis tend to be deeper and markedly more painful than those typically Unlike aphthous stomatitis, mucositis ulcers do not have a typical inflammatory component and so do not have a peripheral ring of erythema. Ulcer development is associated with increased pain and inability to tolerate normal foods.
10. Ulcers may be focal and localised or consolidated and diffuse. Their borders are generally poorly defined. There are no sentinel sites for lesions of mucositis. Any part of the movable mucosa can be involved, although the buccal mucosa, floor of the mouth, lateral and ventral borders of the tongue and soft palate are most frequently involved. The more heavily keratinised mucosa is usually not involved in mucositis. The course of mucositis is generally predictable and depends on the cancer treatment associated with its generation. The first sign of oral mucositis is white appearance of mucosa caused
11. Pathogenesis of Oral Mucositis Cytotoxic chemotherapy and radiotherapy agentDirect effect on connective tissue and vascular elements mucosal elementsThinning of epitheliumLoss of barrier Development of mucositis
12. World Health Organization (WHO) Oral Mucositis Scale(modified from)Grade 1 (mild) Oral soreness, erythemaGrade 2 (moderate) Erythema, ulcers, but oral intake not preventedGrade 3 (severe) Oral ulcers interfering with oral intake and requiring liquids onlyGrade 4 (life-threatening) Oral ulcers to the extent that oral alimentation is impossible
13. Phases of development of mucositis Phase I—Initiation Chemotherapy or radiation-induced reactive oxygen species (ROS) and lipid peroxidation results in DNA damage, release of pathogen-associated molecular pattern (PAMP) and damage-associated molecular pattern molecules (DAMPs) and cellular apoptosisPhase II—Signaling ROS stimulate the NF-kB pathway, which induces production of proinflammatory cytokines (TNF-α, IL-1β, IL-6)Phase III – Amplification Proinflammatory cytokines trigger tissue injury, apoptosis, vascular permeability, and activation of cyclooxygenase-2Phase IV—Ulceration occurs, which serves as a portal of entry for microorganisms. The presence of bacteria activate macrophages and neutrophils to further produce proinflammatory cytokinesPhase V—Healing Signaling from the submucosa promotes epithelial migration, proliferation and differentiation
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15. Management of Oral Mucositis Basic oral care Pain management – usually starts with NSAIDs as it is not associated with increased risk of hemorrhage. Later it can be combined with opioids as the intensity of pain increases 2% morphine mouthwash in or 0.5% doxepin mouthwash dependent on cancer treatment.If food/liquid intake is severely compromised than percutaneous endoscopic gastrostomy tube feeding may be indicatedDietary counselling
16. Salivary Gland Hypofunction and XerostomiaRadiation therapy may induce salivary gland hypofunction and xerostomia.Radiation therapy for head and neck cancer may leads to substantial decline in salivary secretion and xerostomiaRadiation therapy as total body radiation and irradiation for hematopoietic stem cell transplantation also leads to xerostomia.Salivary gland may have potential to gradually regain secretion within 1-2 years if gland sparing radiation therapy regimen has been applied eg intensity modulated radiation therapy.If the radiation dose to the parotid gland is below 26 Gy and below 39Gy for submandibular gland.
17. Xerostomia is the most common late adverse effect of radiation therapy in head and neck cancer patient with immense negative impact on the quality of life .It affects the general comfort and oral functions of speech, taste and chewing/swallowingIt results in inadequate food intake and difficulty in interactionManagement Symptomatic by stimulation of residual salivary gland secretory capacityUse of water, bland rinses and salivary substitutes
18. candidiasisCommon in head and neck radiation patient.In 37% cases during the treatment patient develops oro pharyngeal candidiasis.Most common cause is candida albicans.The clinical presentation could be Erythematous candidiasisPseudomembranous candidiasisChronic hyperplastic candidiasisAngular chelitis
19. More often oral candidiasis is associated with burning sensation in the oral cavity and altered taste .During the radiation therapy erythematous candidiasis is common ManagementTopical agent is preferred over systemic agent due to less side effects
20. Oral Bacterial Infection Patients receiving head and neck radiation are prone to develop oral mucosal infection/gingivitis due to Salivary gland hypofunction, Trismus, Oral mucositis/chronic mucosal radiation Compromised oral hygiene Periodontal infection and periapical infection, increases the risk of ORNChance to develop rampant caries
21. Prevention Efforts must be made to reduce the microfloraDental caries must be managed by supplemental administration of high dose of fluoride.Manage the salivary gland hypofunction with the help of artificial saliva or sipping of water frequently.Viral Infection Low risk of oral and perioral reactivation of latent virus/de novo viral infection.Most common virus is Herpes Simplex followed by HZV,EBV and cytomegalovirusPrevalence increases incase of combined chemo and radiation therapy
22. Dysgeusia (taste alteration Taste alteration is a common side effect of head and neck chemo and radiation therapy.There could be Hypogeusia –Decreased Taste sensation Dysgeusia – Distorted taste sensation Hypergeusia- Increased taste sensation Onset is usually within the first week of treatment due to the direct toxic effect on taste cells that further aggravates due to decreased salivary function , compromised oral hygiene , drug intake etc
23. halitosisDue to compromised oral hygiene during cancer treatment .Further aggravating factors can be Accumulation of food debrisOral mucositisOral candidiasisPeriodontal infectionSalivary gland hypofunction tumor or growth necrosis
24. Halitosis can be reduced by basic oral hygiene careLike emphasis on maintenance of tongue hygiene Use of antiseptic mouthwash may be usefulTrismus Common in patient undergoing head and neck radiation treatment Badly affects the food intake , speech and compromised oral hygiene .Radiation therapy can induce fibrosis of TMJ and oral soft tissue depending upon the area of radiation Radiation induced trismus can onset from the end of radiation therapy Severity unpredictable
25. Management Basic oral careExercise therapy involving vertical and horizontal motion by pushing the jaw in the opposite direction with the thumb and index finger, Placing a conical rubber plug or a stack of wooden tongue blades between the upper and lower front teeth (Increasing the number as needed)
26. osteoradionecrosisDefined as necrosis of bone due to obstruction in its blood supply Radiotherapy is largely used for treatment of head and neck cancer, as primary therapy, adjuvant to surgery, in conjunction with concurrent chemotherapy or as palliative treatment for late stage and unresectable head and neck malignancies.Patient receiving high dose of radiation has life long risk of development of ORN. It most frequently involves the mandible than maxilla
27. Marx staging of ORNStage IExposed alveolar bone without pathologic fracture, which responds to HBO therapyResponse to HBO therapyStage IIDisease does not respond to HBO therapy, and requires sequestrectomy and saucerisationStage IIIFull‐thickness bone damage or pathological fracture, usually requires complete resection and reconstruction with free tissue
28. Clinical signs and symptoms of ORNulceration or necrosis of the mucosa with exposure of necrotic bone for longer than 3 months, pain, trismus and suppuration in the area Neurological symptoms, such as pain, dysaesthesia or anaesthesia, as well as fetor oris, dysgeusia and food impaction in the area, are also usually present. Exposure of rough and irregular bone can result in physical irritation of adjacent tissues. Progression of ORN may lead to pathological fractures, intra‐oral or extra‐oral fistulae and local or systemic infection. Difficulties in mouth opening, mastication and speech frequently arise.
29. In patients treated with external beam radiation therapy (EBRT), osseous alterations usually appear in the body of the mandible (premolar and molar regions), whereas in those managed with brachytherapy, the lingual or buccal surfaces are affected. Management Based on prevention that begins with a comprehensive oral and dental care prior to radiation therapy and a close follow up after the radiation treatment .
30. If the lesion is small , management is conservative with limited surgical intervention and antibiotic therapy.But in case of large lesion removal of necrotic bone is must.Hyperbaric oxygen treatment is recommended to prevent ORN. But its clinical efficacy is inconclusive