Goals of management Management of Oral Cancer

Transkript

1 Goals of management Management of Oral Cancer รศ.ทพญ.ดร. พรพรรณ พ บ ลย ร ตนก จ ผศ.ทพ.ดร. ชาญว ทย ประพ ณจ าร ญ ภาคว ชาเวชศาสตร ช องปาก คณะท นตแพทยศาสตร จ ฬาลงกรณ มหาว ทยาล ย Prevention recurrence other complications/diseases Minimal patient morbidity 1 2 Management Prior to cancer therapy During cancer therapy After cancer therapy PRIOR TO CANCER THERAPY 3 4

2 Prior to cancer therapy Objectives Prior to cancer therapy Risk factors assessment eliminate potential sources of infection provide preventive care Maintaining oral hygiene Taking an impression for study cast obturator preparation fluoride tray preparation 5 6 Risk factors assessment Risk behaviors tobacco alcohol consumption lack of dietary intake of fresh fruit and vegetables oral sex behavior (HPV risk ) immunocompromised patient 7 Comprehensive oral assessment to identify existing oral disease, potential risk of oral disease planning the treatment to reduce oral symptoms and sequelae before during and after cancer therapy 8

3 All should be treated before the start of cancer treatment The comprehensive evaluation should be Examination Treatment performed at least 1 month before cancer treatment starts to permit adequate healing from any required invasive oral procedures dental caries pulpal / periapical tissue infection periodontal tissue status defective restoration other urgent abnormality filling Endo Tx scaling/ Perio tx extraction all indicated teeth grinding sharp edge tooth/ restoration ill-fitting denture discontinued Ortho.Tx until 1 year after completion Ca Tx 9 others 10 Extracting teeth Grinding sharp edge teeth/ restoration Teeth indirect association with tumor Teeth in the direction of radiation beam that may be a problem in the future To reduce the risk of trauma to mucosa To reduce the severity of mucositis & discomfortable Teeth with doubtful prognosis e.g. deep caries, deep periodontal pocket, non-vital tooth Loose primary teeth/ tooth expected to exfoliate during cancer treatment 11 12

4 Establish a schedule of oral surgery/complete invasive procedures at least At least 3 weeks before head&neck radiotherapy starts At least 10 days before myelosuppressive chemotherapy begins Clayman,L. Clinical controversies in oral and Maxillofacial surgery: Part two. Management of dental extractions in irradiated jaws: a protocol without hyperbaric oxygen. Makkonen T.A. Dental extractions in relation to radiation therapy of 224 patients. 13 Maintaining Oral hygiene Oral hygiene instruction Poor oral health Increased incidence and severity of oral / systemic complications Oral disease stabilization before chemo/radiation therapy 14 Fluoride tray preparation DURING CANCER THERAPY 15 16

5 During cancer therapy During cancer therapy Objectives Monitoring patient s oral hygiene Supportive care Preventive care Dental treatment is avoided Advised against wearing removable appliances during treatment Supportive Tx Fluoride supplement During cancer therapy Complications Infection Bleeding Mucositis Xerostomia Precaution Dental Tx in patient during chemotherapy Bleeding/ bacteraemia Performed CBC within prior to any dental Tx Postpone the treatment platelet count <75,000 platelets/mm 3 present of abnormal clotting factors absolute neutrophil count <1,000 cells/mm

6 Mucositis Acute inflammation of the oral mucosa White/yellow slough, erythema, usually with ulceration Painful to speak, eat and swallow Healing complete in 2-3 weeks after completion cancer therapy Grade Clinical presentation 0 Normal 1 Soreness with/without erythema 2 Ulceration and erythema 3 Ulceration and extensive erythema, patient cannot swallow solid food 4 Mucositis of such severity that feeding is not possible WHO oral mucositis scale 21 Supportive Tx Mucositis to reduce frequency and severity OHI Use of mild flavored toothpaste Mouthwash: 0.9% NaCl, sodiumbicarbonate MW Avoiding of spicy, acidic, hard, hot food/drinking Water-soluble lubricants Oral cooling for 30 mins prior to chemotherapy 22 Xerostomia Saliva becomes thick, viscous, acidic Onset within 14 hours of cancer therapy Radiotherapy Xerostomia can be prolonged Can last up to 2 years post therapy Often permanent Chemotherapy Salivary flow usually returns to normal within 2 months Supportive Tx Hydroxypropyl cellulose for covering ulceration Medications Difflam MW (15% benzydamine hydrochloride MW) Sig. 15 ml. 4-8 times staring before radiotherapy continuing during Tx and for 2-3 weeks after Tx 2% lidocaine MW used prior to eating 23 24

7 Supportive Tx Xerostomia for saliva stimulation Chewing gum (sugar free) Massage Medications Pilocarpine HCl 5-10 mg 3-4 times/day Cevimeline HCl 30 mg 3 times/day Medications (FDA approving) ยา ขนาดยา ระยะเวลาออกฤทธ ข อห ามใช และข อควรระว ง Pilocarpine HCl 5-10 mg 3-4 times/day 2-3 hours Pulmonary disease, Asthma, Cardiovascular disease, Narrow angle glaucoma Cevimeline HCl 30 mg 3 times/day 3-4 hours Narrow angle glaucoma Pulmonary disease, Cardiovascular disease, Gallbladder disease Supportive Tx Xerostomia Saliva substitution 27 Prevention of xerostomia Medication Amifostine (organic thiophosphate cytoprotective agent) Reports have been shown to protect salivary gland and reduce mucositis. lack of long term data??? Method 3D radiation: adjustable radiation intensity IMRT (intensity modulated radiation therapy) VMAT (volumetric modulated arc therapy) 28

8 Fluoride supplements 0.05% NaF mouth rinse at least once a day Fluoride tooth paste brushing At least 1000 ppm for children < 3 years ppm for children 3 years Up to 5000 ppm for adult AFTER CANCER THERAPY 2.2% fluoride vanish twice a year 1% NaF gel / 0.4% stannous fluoride gel application in custom made tray for 10 mins daily After cancer therapy After cancer therapy Objectives Supportive care Prevention Monitoring Sequelae risk is depend on Treatment received Age of patient at diagnosis Time since completion of treatment 31 32

9 After cancer therapy Maintaining oral hygiene Fluoride supplement Supportive Tx Filling Periodontal Tx Avoid crown restoration Avoid dental extraction in radiated Pt. Denture??? After cancer therapy Taste loss and taste alteration Complications Mucositis Xerostomia Taste alteration Rampant caries Jaw stiffness and limitation of mouth opening Bleeding/ bacteraemia (ORN) 35 36

10 Taste loss and taste alteration Direct damage to taste buds Related to xerostomia Onset on the start of treatment Sense of taste often returns after completion of radiation Partially restored in days Almost restored completely within 4 months Jaw stiffness and limitation of mouth opening Side effect of radiation Surgical intervention induce scar tissue mouth exercise by opening and closing the mouth as far as possible without pain then repeat 20 times; 3 times a day Dental recall Precaution after chemotherapy Bleeding/ bacteraemia confirm normal hematologic status prior to any dental Tx postpone the treatment Platelet count <75,000 platelets/mm 3 Present of abnormal clotting factors Absolute neutrophil count <1,000 cells/mm 3 Dental recall schedule after complete chemotherapy and all side effects, immunosuppression have resolved 39 40

11 (ORN) An area of exposed radiated bone necrosis that fails to heal over a period of 3-6 months in absence of local neoplastic disease. commonly in mandible 7% after tooth extraction in radiated Pt. 6% after tooth Ext. with antibiotic prophylaxis 4% after tooth Ext. with hyperbaric oxygen therapy (HBOT) Increasing risk in bisphosphanate received Pt. 41 Stage 0 Stage I Stage II Stage III Staging for ORN Mucosal defects only Radiological evidence of necrotic bone with intact mucosa Positive radiographic findings with denuded bone intraorally Clinical exposed radionecrotic bone, verified by imaging techniques, along with skin fistula and infection. Radiological evidence of bone necrosis within the radiation field, where tumor recurrence has been excluded 42 Precaution Avoiding tooth extraction, consideration to RCT Careful oral health monitoring Maintaining oral care + preventive supplements Abnormal tooth/ oral trauma should be Risk of ORN development Total radiation dose exceeded 60 Gy Large dose fraction with high No. of fractions Extraction causes local trauma uncontrolled periodontal disease Poor oral hygiene Timing of tooth extraction Ext. within 1-6 months after complete radiation reduces risk of ORN Continued use of tobacco and alcohol suddenly treated Ill-fitting prosthesis Immunodeficiency Pt. 43 Malnutritional Pt. 44

12 Prevention of ORN before extraction Antibiotic prophylaxis Prior to Ext. and continued until completion of healing Co-amoxiclav, amoxycillin, methonidazole Minimal trauma procedure and primary closure wound HBOT before and after tooth removal 0.2% chlorhexidine gluconate MW prior to Ext. Use of low /adrenaline free anesthesia 45 Hyperbaric oxygen therapy (HBOT) increase blood-tissue oxygen gradient fibroblast proliferation angiogenesis collagen formation 46 Treatment of ORN Exposed bone that is asymptomatic with no evidence of significant of soft tissue infection Antimicrobial rinse No surgical intervention Treatment of ORN Exposed bone associated with pain, soft tissue/bone infection Antimicrobial rinse Systemic antibiotic/antifungal Analgesic drug 47 48

13 Treatment of ORN Pathological fracture Exposed bone associated with soft tissue/bone infection that is not manageable with antibiotic due to the large volume of necrotic bone Antimicrobial rinse Systemic antibiotic/antifungal Analgesic drug Surgical debridement or resection 49 Alterative treatment of ORN Hyperbaric oxygen therapy Improve oxygen supply to damaged tissue and stimulate healing Improved outcome in treatment of ORN in late radiation tissue injury (LRTI) Ultrasound (more studies are required) Frequencies of 3mHz with ¼ intensity of 1W/cm 2 50 Alterative treatment of ORN Antioxidant agent (more clinical trials are required) Pentoxifylline (PTX) 800 mg/day (5days/week) facilitates microcirculation inhibits the inflammatory mechanism promotes fibroblast proliferation and formation of extracellular matrix Tocopherol (vitamin E) 1000 IU/day (5days/week) protects cell membrane against peroxidation 51