Dental Management of Cancer Patients PDF

Lecture VIII Dental management of cancer patients A patient having cancer is treated by one or more of the following modalities: 1. Surgical treatment 2. Chemotherapy: causes neutropenia. 3. Radiotherapy 4. Biological targeted therapies: medications that target certai...

Lecture VIII Dental management of cancer patients A patient having cancer is treated by one or more of the following modalities: 1. Surgical treatment 2. Chemotherapy: causes neutropenia. 3. Radiotherapy 4. Biological targeted therapies: medications that target certain pathways in the tumor cells only; not in normal cells. 5. Hematopoietic stem cell transplantation (HSCT) 6. Bone modifying agents. Treatment side effects: But these treatment modalities cause some unavoidable oral complications that may be severe enough to affect the patient's life. At this stage, cancer treatment should be interrupted. And so, the prognosis of the treatment is worsened. Oral complications of cancer treatments: 1. Oral mucositis 2. Stomatitis (aphthous-like ulcers) 3. Infection: a. fungal infections b. viral infections c. Bacterial infections 4. Oral pain 5. Salivary gland hypofunction or xerostomia 6. taste alteration (dysgeusia) 7. halitosis 1  8. trismus 9. osteonecrosis: a. Osteo-radionecrosis (ORN) b. Medication-related osteonecrosis of the jaw (MRONJ) 10.Graft-versus-host disease (GvHD) Incidence of oral complications with different treatment modalities: Biological Bone Chemo- Radio- Surgery targeted HSCT modifying therapy therapy therapies agents Mucositis √ √ Stomatitis √ Infections √ √ √ √ √ Oral pain √ √ √ √ √ Xerostomia √ √ √ √ √ Dysgeusia √ √ √ √ √ Halitosis √ √ √ √ √ Trismus √ √ ORN √ MRONJ √ GVHD √ Basic oral care: Routine care must be performed before, during and after cancer therapy to prevent and reduce the severity of oral complications. So, interrupting cancer treatment is avoided. ▪ Education of the patient, the family and caregivers of the expected complications. ▪ Regular oral assessment. ▪ Eliminate sources of trauma. ▪ Eliminate pre-existing infections (decontamination): dental, periodontal and mucosal.  Professional scaling and subgingival debridement. 2   toothbrushing with a soft or ultra-soft tooth brush 2-3 times daily.  dental flossing in an atraumatic way once daily  fluoridated toothpaste  fluoride application using fluoride tray if high caries index  Antiseptic mouthwash (0.12% Chlorhexidine gluconate)  Restorative treatment of carious lesions  endodontic treatment or extraction of cases of pulpitis  extraction of hopeless teeth at least 7-10 days pre-cancer ttt. ▪ Oral hydration to reduce the risk of friction and traumatic injuries.  frequent sipping of water  mouth rinses: as much as needed. (1 teaspoon salt + 1 teaspoon baking soda + 1 liter of water) decontaminates, hydrates and neutralize PH  saliva substitutes (mouthwash, spray or gel)  Lubricating the lips to avoid crusting and ulceration.  Pharmacological stimulation of residual salivary gland. ▪ pain management ▪ Early diagnosis of emerging complications. ▪ Adequate management of the detected problems. 3 I. ORAL MUCOSITIS: Inflammation in the oral mucosa secondary to cancer therapy. Cancer therapy impairs the blood supply to the oral mucosa. So, it gets atrophied. The condition is worsened by the neutropenia caused by chemotherapy. ▪ It allows secondary infection of the lesions and retards its healing. ▪ It may be source of a systemic infection Oral mucositis clinical stages: erythema, ulceration (necrotic ulcers), and then healing after stoppage of cancer treatment. It reaches the stage of ulceration at week 2 after treatment; and heals after 4 weeks of stopping treatment. Management (based on the 2019 guidelines): 1. Intravenous keratinocytes growth factor-1 (KGF-1) [Palifermin] for prevention 2. topical use of honey 3. topical morphine 0.2% mouthwash 4. oral cryotherapy for prevention (Sucking ice cubes before and during the treatment sessions to cause vasoconstriction and prevent the chemotherapeutic agent to reach the mucosa) 5. Basic oral care including the saline and sodium bicarbonate mouthwash. 6. Benzydamine mouthwash (anti-inflammatory) is effective in prevention; but Chlorhexidine is not. 7. pain control using systemic narcotics 8. nutritional support II. Stomatitis: (aphthous-like ulcers) ▪ arise due to oral mucosal toxicity secondary to targeted cancer therapies ▪ Clinically similar to aphthous ulcers and does not arise on the keratinized mucosa too. ▪ appear after few days of the 1st cycle of therapy 4  ▪ Managed like aphthous ulcers: topical, intralesional or systemic steroids depending on the severity of the lesions. III. Infection: secondary to bone marrow suppression a. Fungal infection: -predisposing factors: xerostomia, antibiotics administration. -Types of candidosis occurring in cancer patients: pseudomembranous, erythematous, chronic hyperplastic, angular chelitis -Management: topical antifungal: Nystatin or amphotericin rinses 4 times/day b. Viral infection: ▪ reactivation of viruses: Herpes simplex, Varicella zoster, cytomegalovirus and Epstein Barr virus ▪ prevention of HSV by prophylactic Thymidine Kinase inhibitors (Acyclovir) c. Bacterial infection: acute flare up of dental, periodontal and periapical infections Bacterial Sialedinitis of major salivary glands. Management: ▪ mechanical plaque control ▪ fluoride supplements to prevent dental caries. ▪ broad spectrum antibiotics IV. Oral pain: caused by both mucosal irritation (nociceptive) and neuropathic pain. Mucosal irritation is treated as oral mucositis. Neuropathic pain is treated by NSAIDs. In more severe pains, it can be combined with opioids. topical anaesthetic rinses can be used. V. Salivary gland hypofunction/ xerostomia: 5 Severe decline in salivary secretion occurs after the first week of treatment. ▪ Continues to decline to reach scarce amount at the 6th week. ▪ Continues to decline till 3 months after stoppage of treatment. ▪ May recover within 1-2 years ▪ Xerostomia is the most common LATE adverse effect of cancer therapy. ▪ causes discomfort, inability to swallow, affects food intake, high risk of caries, oral candidosis and increase mucosal sensitivity. VI. Dysgeusia Alteration in taste sensation occurs due to toxic effect of treatment on taste buds, salivary gland hypofunction or oral infections. It may become permanent. VII. Halitosis Caused by local factors: poor oral hygiene, oral mucositis, candidosis, periodontal infections and salivary gland hypofunction. It may have systemic causes as diseases in GIT, liver, kidney and upper respiratory tract. reduced by: o basic oral care o mechanical tongue rinsing o antiseptic mouthwash VIII. Trismus Surgery and radiotherapy causes fibrosis of the submucosa and TMJ. Radiation-induced trismus can start any time after treatment; even years after stoppage of treatment. Prevented by daily exercise of TMJ. IX. Osteonecrosis: 6 a. Osteoradionecrosis (ORN): It is bone death secondary to radiotherapy. It manifests as non-healing area of exposed bone. Mandible is more common than maxilla. The patient is at lifelong risk for the lesion. Prevention by comprehensive oral and dental care before radiation therapy and close follow up afterwards. Management depends on the degree of the lesion's severity: o mild lesions: conservative treatment with antibiotics o advanced or refractory lesions: surgical removal of necrotic bone sequestrate. b. Medication-related osteonecrosis of the jaw (MRONJ): Bone death secondary to administration of bone modifying or antiangiogenic agents. Bone modifying agents are medications taken to reduce bone resorption as Bisphosphonates. MRONJ is diagnosed if the following 3 criteria exist: 1. Current or previous treatment with a bone-modifying or antiangiogenic agent 2. Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks. 3. No history of radiation therapy to the jaw or metastatic disease to the jaw. Prevented by oral and dental evaluation and care before starting the medication. Caries, pulpitis and periodontal diseases should be managed before treatment. Management depends on the degree of the lesion's severity as ORN 7 X. Graft-versus-host disease (GvHD) A complication commonly occurring after hematopoietic cell transplantation. The transplanted immunocompetent tissue tries to attack the tissues of the host as it recognizes them as non-self. Chronic GvHD may cause: o Oral lichenoid reaction with or without desquamative gingivitis, o Sjogren syndrome-like reaction (Kerato-conjunctivitis sicca syndrome) or o Scleroderma-like reaction: with limited mouth opening and tongue movement. cGvHD affects at least one organ of the skin, mouth, eyes, GIT, liver, lungs, genital organs and joints. When the diagnostic criteria of cGvHD are not totally fulfilled, acute GvHD is diagnosed. The oral manifestations may be the first symptom of the disease. cGvHD is managed using systemic immune suppressives. Symptomatic Management of oral lesions: o Lichenoid reaction is managed using topical steroids. o Xerostomia is managed by oral hydration and pilocarpine 8