Oral Side Effects of Cancer Treatment (PDF)

Oral Side Effects of Cancer Treatment Sehrish Javaid [email protected] x Cancer Therapies and Dental Considerations Cancer is common and overall cancer survival has increased  A dentist will likely encounter patients with history of canc...

Oral Side Effects of Cancer Treatment Sehrish Javaid [email protected] x Cancer Therapies and Dental Considerations Cancer is common and overall cancer survival has increased  A dentist will likely encounter patients with history of cancer/treatment “The National Cancer Institute (NCI) recommends that dental professionals be considered part of the cancer care team in individuals undergoing cancer treatment and that people see their dentist 4 weeks prior to initiating cancer treatment (if possible) to allow for healing if any dental work is required” https://www.ada.org/en/resources/research/science-and-research- institute/oral-health-topics/cancer-therapies-and-dental-considerations Oral Side Effects of Cancer Treatment Can be: Acute Caused by chemotherapy, radiation therapy Delayed onset For example, fibrosis post radiation Local At the site of treatment Systemic Nutritional compromise Functional dysgeusia (change in taste), dysphagia (difficulty swallowing) https://www.ada.org/en/resources/research/science-and-research- institute/oral-health-topics/cancer-therapies-and-dental-considerations  Direct For example radiation induced mucositis Indirect Bleeding or infections due to cytotoxic therapy https://www.ada.org/en/resources/research/science-and-research- institute/oral-health-topics/cancer-therapies-and-dental-considerations  Most common: immunocompromised Mucositis Opportunistic infection (viral or fungal) Salivary gland dysfunction Taste disturbance Pain https://www.ada.org/en/resources/research/science-and-research- institute/oral-health-topics/cancer-therapies-and-dental-considerations Review What is the MOA of cytotoxic chemotherapy? Targets rapidlyreplicating cells RBCs Epithet Review What can be clinically manifested as a result of myelosuppression? Review What can be clinically manifested as a result of myelosuppression? RBCs?anemia suppression of bonemarro WBCs?poorimmunity activity Platelets? a riskhemorrhage affectsbloodcells allcapableofmanifestinginoralcavity Review Do you think oral mucosa has high or low rate of turnover? High Review Radiation therapy would cause local _____ side effects localized Review How would cytotoxic chemotherapy and radiation effect development of teeth and bone? compromisebonedevelopment Osteonecrosis degradation  Case 1 15 M History of parameningial rhabdomyosarcoma at age 5 treated with surgery and radiation Susan Müller, DMD, MS 2016 ESTOP/WESTOP Susan Müller, DMD, MS 2016 ESTOP/WESTOP Susan Müller, DMD, MS 2016 ESTOP/WESTOP  Pt has been in remission for 10 years Radiation affected tooth development of permanent teeth Susan Müller, DMD, MS 2016 ESTOP/WESTOP Diagnosis Malformed teeth due to childhood chemotherapy Abnormal dental development High doses of chemotherapy and/or radiation in pediatric patients can cause abnormal dental development Altered tooth development Craniofacial growth or skeletal development Especially in children younger than 9 years of age Potential effects and recommendation A for Pediatric cancer patients Effinger KE, Migliorati CA, Hudson MM, McMullen KP, Kaste SC, Ruble K, Guilcher GM, Shah AJ, Castellino SM. Oral and dental late effects in survivors of childhood cancer: a Children's Oncology Group report. Support Care Cancer. 2014 Jul;22(7):2009-19. doi: 10.1007/s00520-014-2260- x. Epub 2014 Apr 30. PMID: 24781353; PMCID: PMC4118932. Case 3 15 yo F On treatment with immunoguppresent methotrexate Neutrophil count 0.36 x10^9/L Pain level = 8/10 Fiwek, P.; Emerich, K.; Irga-Jaworska, N.; Pomiecko, D. Photobiomodulation Treatment in Chemotherapy-Induced Oral Mucositis in Young Haematological Patients—A Pilot Study. Medicina 2022, 58, 1023. https://doi.org/10.3390/medicina58081023 Gussgard AM, Hope AJ, Jokstad A, Tenenbaum H, Wood R. Assessment of cancer therapy-induced oral mucositis using a patient-reported oral mucositis experience questionnaire. PLoS One. 2014 Mar 10;9(3):e91733. doi: 10.1371/journal.pone.0091733. PMID: 24614512; PMCID: PMC3948915. Mucositis Can occur throughout the GI tract, from mouth to anus, and symptoms manifest depending on the affected site Patients with mucositis have 2x risk of developing infections and 4x the risk of death compared with patients who do not develop mucositis Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Pathogenesis Mucositis Initiation Radiation and/or chemotherapy induces cellular damage  promotes reactive oxygen species formation within basal epithelium and submucosa Mucosa appears normal Primary damage response Cellular damage activates p53 and nuclear factor-κB (NF-κB) Signal amplification NF-κB activation ultimately results in the production of the inflammatory cytokines tumor necrosis factor-α, interleukin-1β (IL-1β), and IL- 6  Tissue damage and cell deat May still be subclinical or only subtle Ulceration Becomes clinically apparent High risk for bacterial colonization and the development of sepsis. Healing Occurs once there is cessation from ongoing tissue damage that initiated the mucositis Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Risk factors atop a Patient related Smoking, poor oral hygiene, younger age, female sex, pretreatment nutritional status, and pretreatment neutrophil counts Treatment related Type of chemotherapy, dose and field of radiation Frequency and duration Patients at high risk are referred to the dentist Education on sign and symptoms Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Prevention Preventive measures for chemotherapy Soft tooth brush, gentle flossing Bland mouth rinse (Normal saline, sodium biocarbonate ~ 4x/day) Prophylactic dental care Rx of caries, extraction of compromised teeth Aggressive prophylactic care reduces risk by 25% Cryotherapy (ice chip therapy) Pt holds ice chips in mouth for 30 minutes before infusion (of 5-fluorouracil) Mucoadhesive hydrogel rinse Not endorsed yet Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Prevention Preventive measures for radiation therapy to head and neck Make oncology team aware of metal in oral cavity Adequate oral care Delivery of radiation should be optimized to limit oral exposure Shielding Laser therapy: 632.8 nm laser (low level laser therapy) Zinc supplements Prophylactic placement of a percutaneous endoscopic gastrostomy tube in patients at high risk for mucositis to prevent the onset of dehydration or weight loss Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926.  commit to Grading of Oral Mucositis She said memory Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Management of Chemotherapy induced mucositis Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Management of radiation therapy induced mucositis Occurs in up to 91% of patients with head and neck cancer who receive radiotherapy Often a dose-limiting toxicity, and can lead to the early discontinuation of radiotherapy with the possibility for worse outcomes Management is fairly similar to chemotherapy induced mucositis i Bland rinses, such as normal saline and salt-and-soda mouthwashes, swish and spit, up to four times a day Topical anesthetics, such as 2% viscous lidocaine sswish and spit. Low-level laser therapy Systemic agents, including opiates Alteration of diet (avoid trauma to mucosa) Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926. Salivary gland dysfunction Radiation-induced xerostomia has been reported in the first days of RT, with dose between 2 and 10 Gy Decreased salivary secretion Increase in salivary viscosity Residual saliva “ropey” or Clinical foamy features Examining gloves may stick to dry mucosal surfaces Increases risk for secondary infections Jaguar, G.C., Prado, J.D., Campanhã, D. et al. Clinical features and preventive therapies of radiation- induced xerostomia in head and neck cancer patient: a literature review. Appl Cancer Res 37, 31 (2017). https://doi.org/10.1186/s41241-017-0037-5 Salivary gland dysfunction Risk Treatment Oral fungal infection Artificial saliva Caries Sialagogues (Only work if Difficulty with there is residual salivary mastication gland) Prevention Amifostine (Ethyol) FDA approved for xerostomia caused by radiation therapy Protects cells by scavenging oxygen-derived free radicals Controversial because of its toxicity, compromised tumor control and cost Systemic sialogogues Pilocarpine: Evidence that causes depletion of secretory granules and decreases radiation induced damage Intensity modulated radiation therapy (IMRT) Spares parts of salivary glands Conflicting results Jaguar, G.C., Prado, J.D., Campanhã, D. et al. Clinical features and preventive therapies of radiation- induced xerostomia in head and neck cancer patient: a literature review. Appl Cancer Res 37, 31 (2017). https://doi.org/10.1186/s41241-017-0037-5 Opportunistic infection (viral or fungal) Etiology Viral, bacterial, fungal Caused due to Myelosuppresion, xerostomia, damage to mucosa Suppression of bone 4h mucositis marry MRONJ Complication in patients who are on anti-bone resorptive drugs Prescribed for patients with multiple myeloma, osteoporosis, metastatic carcinoma and Paget's disease Bisphosphonate and monoclonal antibodies such as denosumab Cause osteomyelitis of the jaw Muthukrishnan A, Bijai Kumar L, Ramalingam G. Medication-related osteonecrosis of the jaw: a dentist's nightmare. BMJ Case Rep. 2016 Apr 6;2016:bcr2016214626. doi: 10.1136/bcr-2016- 214626. PMID: 27053542; PMCID: PMC4840656. GVHD raft VersusHostDisease History of a previous bone marrow transplantation Dean D, Sroussi H. Oral Chronic Graft-Versus-Host Disease. Front Oral Health. 2022 May 20;3:903154. doi: 10.3389/froh.2022.903154. PMID: 35719318; PMCID: PMC9205403.