Head & Neck Oncology, May 2024 - DENT4060 PDF

Head & Neck Oncology Dr Janice Chuang Specialist in Special Needs Dentistry BDS (Singapore), DClinDent (SND) (Queensland), MRACDS (SND) Acknowledgements to Dr Lydia See, Dr Claudia Lopez Si...

Head & Neck Oncology Dr Janice Chuang Specialist in Special Needs Dentistry BDS (Singapore), DClinDent (SND) (Queensland), MRACDS (SND) Acknowledgements to Dr Lydia See, Dr Claudia Lopez Silva and E/Prof Laurence J Walsh DENT4060 May 2024 Learning objectives 1. Understand the oral complications in head and neck cancer 2. Understand the role the general dentist plays in multidisciplinary care of persons with head and neck cancer Dental pre-assessment Support through treatment Post-treatment maintenance Epidemiology 7th most common cancer in Australia Source: Cancer Australia Squamous cell carcinoma >90% of H&N malignancies Most commonly involve mucosa of the oral cavity oropharynx larynx Smoking and alcohol consumption Chief risk factors Higher risk of 2nd primary oral cancer (field cancerization) Cancer type and extent Site Anatomical location of cancer – E.g. NPC, laryngeal SCC, tongue SCC Extent Cancer staging (TNM) T: Tumour extent N: Extent of nodal involvement M: Presence of distant metastases (Chow, 2020) Treatment modalities Resection Surgery Neck dissection Reconstruction Definitive Radiation therapy Adjuvant Palliative Concurrent chemoradiation Chemotherapy Palliative Immunotherapy Pembrolizumab, nivolumab Treatment modalities Resection Surgery Neck dissection Reconstruction 3D simulation for surgical Source: Royal College planning (Alfouzan, 2018) Pathologists of Australasia (Hernandez-Villa, 2016) Treatment modalities Optic chiasm Pituitary gland Inner ear Parotid gland Teeth, jaw bones Skin, mucosa  The dentist’s role Dental pre- Support through Post-treatment Early detection assessment treatment maintenance Survivorship MDT Cancer treatment Diagnosis & Surgery Rehabilitation and Treatment Chemotherapy restoration planning Radiotherapy Patient’s journey  The role of the dentist 1. Prevention and early detection  Oral cancer screening 1. Visual examination of oral tissues 2. Palpate the neck (Beacher & Sweeney, 2018) Risk factors 1. Lifestyle risk factors Smoking, alcohol Tobacco and alcohol account for 75% of oral SCC 2. Immunosuppression Immunosuppressant use in – autoimmune disease – HSCT / organ transplant  The dentist’s role Dental pre- Support through Post-treatment Early detection assessment treatment maintenance Survivorship MDT Cancer treatment Diagnosis & Surgery Rehabilitation and Treatment Chemotherapy restoration planning Radiotherapy Patient’s journey Dental pre-assessment goals 1. Prepare patient for ST & LT side effects of cancer therapy 2. Minimise interruption of cancer treatment from acute dental concerns 3. Prevent future complications, e.g. osteoradionecrosis 4. Develop an appropriate preventive regime to counter increased challenge to oral structures from oncology treatment Let’s talk about side effects Short Long term term Chemotherapy – side effects Bone marrow suppression Mucositis Neutropenia Dry mouth Thrombocytopenia Loss of taste Acute dental infections > pain, sepsis (dysgeusia) Opportunistic infections (e.g. candidiasis) (Walsh, 2010) Oral side effects of RT SHORT-TERM Mouth ulcers (mucositis) Hyposalivation / xerostomia Loss of taste (dysgeusia) Source: https://www.aaom.com/assets/condition-information/mucositis2.jpg Oral side effects of RT LONG-TERM Hyposalivation / xerostomia Parotid dose > 30Gy Radiation caries Osteoradionecrosis Periodontitis Trismus (Beacher & Sweeney, 2018) Oral side effects of RT LONG-TERM Hyposalivation / xerostomia Radiation caries Osteoradionecrosis Periodontitis Trismus Source: Google images Oral side effects of RT LONG-TERM Hyposalivation / xerostomia Radiation caries Osteoradionecrosis Periodontitis Trismus Source: https://pubs.rsna.org/doi/10.1148/rg.297095050 Oral side effects of RT LONG-TERM Hyposalivation / xerostomia Radiation caries Osteoradionecrosis Periodontitis Trismus Oral side effects of RT LONG-TERM Hyposalivation / xerostomia Radiation caries Osteoradionecrosis Periodontitis Trismus Source: Google images Dental pre-assessment goals 1. Prepare patient for ST & LT side effects of cancer therapy 2. Minimise interruption of cancer treatment from acute dental concerns 3. Prevent future complications, e.g. Dental osteoradionecrosis treatment plan 4. Develop an appropriate preventive regime to counter increased challenge to oral structures from oncology treatment Read the referral  Dental treatment plan 2. Minimise interruption of 1. Remove existing foci of infection cancer treatment Remove teeth with poor 3. Prevent future prognosis* complications Stabilise periodontal disease 4. Develop an appropriate 2. Stabilise large carious lesions preventive regime 3. Reduce mucositis Improve perio health Smoothen sharp edges of teeth Advice on denture use  Dental treatment plan Consider need for prophylactic extractions to prevent ORN 2. Minimise interruption of A. Patient's prognosis cancer treatment 3. Prevent future complications B. Risk of ORN with future extractions 4. Develop an appropriate preventive regime C. Other modifying factors which increase ORN risk D. Tooth prognosis E. Perceived benefits of retaining teeth Develop a preventive regime 1. Twice daily toothbrushing, high fluoride toothpaste Mucositis: detergent free toothpaste, baking soda mouthrinse 2. Baking soda mouthrinse Baking soda mouthrinse Dissolve 1 teaspoon 3. Remineralising agents baking soda in 1 glass of 4. Low sugar diet water Rinse after eating, before brushing To relieve dry mouth 1. Frequent sips of water 2. Drink enough water each day For most people, this is 1.5 – 2 liters per day 3. Bicarbonate mouthwash 4. Olive or coconut oil/ full fat milk PRN 5. Saliva stimulants 6. Saliva replacements  The dentist’s role Dental pre- Support through Post-treatment Early detection assessment treatment maintenance Survivorship MDT Cancer treatment Diagnosis & Surgery Rehabilitation and Treatment Chemotherapy restoration planning Radiotherapy Patient’s journey Support during treatment Oral mucositis – pain management Pain relief mouthrinse or Difflam mouthrinse Oral hygiene advice Dry mouth advice Assess for any oral viral, bacterial, fungal infection – communicate with medical team Avoid elective dental treatment  The dentist’s role Dental pre- Support through Post-treatment Early detection assessment treatment maintenance Survivorship MDT Cancer treatment Diagnosis & Surgery Rehabilitation and Treatment Chemotherapy restoration planning Radiotherapy Patient’s journey Regular dental reviews Consider the permanent aftermath of radiation therapy Regular reviews every 3-6 months, depending on caries risk Monitoring of cancer recurrence Continue mx of caries and dry mouth Preventive oral care regime Dry mouth advice Nip dental disease in the bud Appropriate choice of restorative material in high caries risk patients Extractions post-H&N RT: assess risk Request radiation field map Only irradiated sites can develop ORN Occurs more commonly where dose > 60 Gy Other risk factors that impair healing Poor oral hygiene, smoking, alcohol, immunocompromise, poor nutrition If in doubt, refer to oral surgeon or specialist in SND Acknowledgements: Dr Lydia See If you suspect ORN Always review extraction sockets Refer if suspect ORN Notani’s classification of mandibular ORN Grade Description I ORN confined to alveolar bone II ORN limited to the alveolar bone and/or mandible above the level of the inferior dental canal III ORN involving the mandible below the level of the inferior alveolar canal and/or skin fistula and/or pathological fracture Acknowledgements: Dr Lydia See Thank you