“I have oral cancer – To Whom Should I Be Referred?”

Peter B. Lockhart, DDS, FDS RCPSChair, Department of Oral Medicine

Carolinas Medical Center

Dental Management of Medically Complex Patients

• Cancer• Radiotherapy• Chemotherapy

• Coagulopathy• Cardiovascular• Renal• Immunosuppression• Diabetes• Bacteremia issues

Who To See?Who To See?

Team approach! Team approach! The The whowho and the and the sequencesequence of care depends on: of care depends on:

anatomical location and TNM Stageanatomical location and TNM Stage medical and dental resourcesmedical and dental resources overall medical conditionoverall medical condition survival and quality of lifesurvival and quality of life organ preservation (larynx, tongue)organ preservation (larynx, tongue) training, experience, and time commitmenttraining, experience, and time commitment driven by the literature - RCTsdriven by the literature - RCTs

Evolving over timeEvolving over time

Tumor StagingTumor Staging

Stage 1Stage 1Stage 2Stage 2Stage 3Stage 3

Stage 4Stage 4

T1T1 NONO MOMOT2T2 NONO MOMOT3T3 NO NO MOMOT1, T1, T2 or T3T2 or T3 N1 MON1 MOT4T4 NO or N1NO or N1 MOMOAny T Any T N2 or N3 MON2 or N3 MOAny TAny T Any NAny N M1M1

Changes in H&N Cancer TherapyChanges in H&N Cancer Therapy

Surgical skills and medical oncology protocolsSurgical skills and medical oncology protocols Radiotherapy technology and methodologyRadiotherapy technology and methodology

IMRT and IGRTIMRT and IGRT altered fractionationaltered fractionation

Concomitant chemo/RTConcomitant chemo/RT Return to neo-adjuvant chemo (TPF)Return to neo-adjuvant chemo (TPF) Emphasis on feeding tubes, swallowing functionEmphasis on feeding tubes, swallowing function

Estimated New Cases*

Jemal A, et al. CA Cancer J Clin 2008; 58:71-96

Oral cavity & pharynx 25,310 3%

Jemal A, et al. CA Cancer J Clin 2008; 58:71-96

A Tale of Two CitiesA Tale of Two Cities BostonBoston (Brigham and Women’s Hospital 1977-1987) (Brigham and Women’s Hospital 1977-1987)

Large medical school-based academic medical centers Large medical school-based academic medical centers including Dana Farber Cancer Instituteincluding Dana Farber Cancer Institute

Full time staff physicians and dentistsFull time staff physicians and dentists Twice weekly multi-disciplinary H&N clinicsTwice weekly multi-disciplinary H&N clinics

CharlotteCharlotte (Carolinas Medical Center 1987-2008) (Carolinas Medical Center 1987-2008) Non-medical school, community-based teaching Non-medical school, community-based teaching

hospitalhospital Community-based physicians and dentistsCommunity-based physicians and dentists No H&N clinicsNo H&N clinics

Dana Farber Cancer Institute (DFCI) Dana Farber Cancer Institute (DFCI) Head and Neck ServiceHead and Neck Service

Director (Medical Oncologist)Director (Medical Oncologist) Large referral baseLarge referral base NIH funded protocolsNIH funded protocols 2 half day/week clinics (10+ hrs)2 half day/week clinics (10+ hrs) 2 exam. rooms and a conference room2 exam. rooms and a conference room

DFCI Head and Neck Cancer TeamDFCI Head and Neck Cancer Team

3 rotating head and neck surgeons (ENT)3 rotating head and neck surgeons (ENT) Radiation oncologistRadiation oncologist 2 medical oncologists2 medical oncologists DentistDentist 2 oncology nurses2 oncology nurses NutritionistNutritionist Social workerSocial worker Speech pathologistSpeech pathologist Various house officersVarious house officers

Data CollectionData Collection

Baseline oral statusBaseline oral status Chemo. & RT comps.Chemo. & RT comps. Surgery issuesSurgery issues Long term F/ULong term F/U Clinical trialsClinical trials

Carolinas Medical CenterCarolinas Medical Center

No structure to H&N cancer care initiallyNo structure to H&N cancer care initially Dental service oncology research nurseDental service oncology research nurse Failed attempt at multidisciplinary clinicsFailed attempt at multidisciplinary clinics Evolved over time to suit the systemEvolved over time to suit the system Bi-monthly, multidisciplinary tele-conferencesBi-monthly, multidisciplinary tele-conferences Improved communication – Letters and emailImproved communication – Letters and email

Critical Differences by Medical CenterCritical Differences by Medical Center

LeadershipLeadership Financial considerationsFinancial considerations Territorial instinctsTerritorial instincts Formal multidisciplinary clinics - facilitiesFormal multidisciplinary clinics - facilities Institutional commitment (e.g., dental service)Institutional commitment (e.g., dental service) Support staffSupport staff Communication and coordinationCommunication and coordination Emphasis on science and researchEmphasis on science and research TraineesTrainees

Communication and Coordination

Head & Neck Surgery

Dentistry

Radiation Oncology

Medical Oncology

Head & Neck Patients

Interdisciplinary Team ApproachInterdisciplinary Team Approach

Critical to successful patient managementCritical to successful patient management Portals to head and neck cancer carePortals to head and neck cancer care CoordinationCoordination

sequence of caresequence of care timing of dental involvementtiming of dental involvement

Time commitmentTime commitment Importance of understanding our role and that of Importance of understanding our role and that of

other disciplines – formal trainingother disciplines – formal training General dentist – medical center-basedGeneral dentist – medical center-based

Dentist’s Role in OncologyDentist’s Role in Oncology

Identification of malignancyIdentification of malignancy Prevention and management of problemsPrevention and management of problems

pre-cancer treatmentpre-cancer treatment during treatmentduring treatment post-treatment – especially RTpost-treatment – especially RT

Presenting SignsPresenting Signs

Systemic:Systemic: InfectionInfection MalaiseMalaise Slow healingSlow healing FeverFever

Local:Local: UlcerationUlceration BleedingBleeding Loose teethLoose teeth ParaesthesiaParaesthesia

BoneBone

AcellularityAcellularity

Poor repairPoor repair

VascularityVascularity

EndarteritisEndarteritis

IschemiaIschemia

GlandsGlands

XerostomiaXerostomia

Bacterial flora/pHBacterial flora/pH

MucosaMucosa

ThinningThinning

MucositisMucositis

InfectionInfection

Teeth/BoneTeeth/Bone MucosaMucosa

Radiotherapy SequelaeRadiotherapy Sequelae

Additional Radiotherapy Additional Radiotherapy SequelaeSequelae

TasteTaste NutritionNutrition FunctionFunction

Trismus Musculature (TMD) Growth & development

Interim vs. Early vs. LateInterim vs. Early vs. Late

Patient-related:Patient-related: MalignancyMalignancy AgeAge Medical statusMedical status Previous RTPrevious RT

Factors Influencing Frequency and Severity of Oral Complications

Pre-treatment oral status Level of oral care during

chemo. and RT Genetics?

Factors Influencing Frequency and Factors Influencing Frequency and Severity of ComplicationsSeverity of Complications

Therapy-related:Therapy-related: Chemo agents and Chemo agents and

# rounds# rounds Total dose (RT)Total dose (RT)

Concomitant therapyConcomitant therapy Degree and duration of Degree and duration of

neutropenianeutropenia

Pre-chemo./RT Oral StatusPre-chemo./RT Oral Status

AnatomyAnatomy Poor oral hygienePoor oral hygiene Perio. / pupal diseasePerio. / pupal disease Ill-fitting prosthesisIll-fitting prosthesis Defective restorationsDefective restorations

Restorations – Crowns, etc.

Trauma

Level of Oral Care

Frequency of Care

0

10

20

30

40

50

1

Perc

en

t Every 6

Every 12

Infrequent orEmergency

Hygiene

0

20

40

60

Per

cen

t

Excellent

Good

Fair

Gross Debris

Periodontal Status

0

20

40

60

Per

ce

nt

Excellent

Gingivitis

Sig. Bone Loss

AdvancedDisease

Dentition: State of Repair

0

20

40

60

Pe

rce

nt

Excellent

OldRestorations

RecurrentCaries

Clinical Caries

0

10

20

30

40

Pe

rce

nt None

Incipient

Obvious

Pre-Treatment Needs

0

20

40

60

80

100

Pe

rce

nt

Prophy/Scaling

Restorations

Extractions

PeriodontalSurgery

Endodontics

0

50

100

Percent

Pre-Tx vs Resolved Needs

Yes

No

Yes

No

Pre-Radiotherapy Dental Treatment Planning

Patient Factors – Medical

Cancer prognosis Planned treatment regimens Compliance with medical therapy Risk / Benefit issues Psychological factors Tobacco use

Patient Factors - Patient Factors - Preventive ConsiderationsPreventive Considerations

Thorough examThorough exam Full series filmsFull series films CleaningCleaning Education:Education:

HygieneHygiene FluorideFluoride DietDiet RestorationsRestorations

Patient Factors – Dental StatusPatient Factors – Dental Status

Gingival recession, exposed dentinGingival recession, exposed dentin Caries and periodontal diseaseCaries and periodontal disease Periapical diseasePeriapical disease MobilityMobility Removable appliancesRemovable appliances Orthodontic appliancesOrthodontic appliances

Dental Treatment PlanningDental Treatment Planning

Tooth by tooth - need/prognosis for eachTooth by tooth - need/prognosis for each Single vs. multi-rooted toothSingle vs. multi-rooted tooth Mandible vs. maxillaMandible vs. maxilla Anterior vs. posterior toothAnterior vs. posterior tooth Prosthetic needsProsthetic needs Eliminate existing and potential sources of Eliminate existing and potential sources of

trauma and infectiontrauma and infection

On the one hand…

On the other hand…….

Periodontal Disease

Pericoronitis

Dental ManagementDental Management

Ranges from no treatment to full mouth Ranges from no treatment to full mouth extractionsextractions

Problems Problems DuringDuring Radiotherapy Radiotherapy

MucositisMucositis Direct and indirectDirect and indirect

Taste alteration/lossTaste alteration/loss XerostomiaXerostomia InfectionInfection

FungalFungal PeriodontalPeriodontal

Mucositis Complications Mucositis Complications and Sequelaeand Sequelae

PainPain Oral infectionOral infection Systemic infectionSystemic infection SepsisSepsis Oral bleedingOral bleeding

Taste Hydration/Nutrition Fatigue Interrupted cancer

treatment

Concomitant Therapy

Irritation and Trauma

Poor Appetite and NutritionPoor Appetite and Nutrition

MucositisMucositis XerostomiaXerostomia HypogeusiaHypogeusia Taste lossTaste loss

Causes: Outcomes:

Weight loss Dehydration Stomatitis (nutritional) 2° oral infection

Xerostomia – Saliva FunctionsXerostomia – Saliva Functions

DysphagiaDysphagia SpeechSpeech ProsthesesProstheses Taste alterationTaste alteration AntimicrobialAntimicrobial RemineralizationRemineralization BufferBuffer

Lubrication Cleansing Digestive

Enzymes Chewing and swallowing

Mucosal integrity

Infection

““Late” RT ProblemsLate” RT Problems

Persistent xerostomiaPersistent xerostomia Oral prostheticsOral prosthetics Infection – bacterial and fungalInfection – bacterial and fungal Trismus – 45%*Trismus – 45%* Necrosis – Bone and soft tissueNecrosis – Bone and soft tissue Growth and developmentGrowth and development

* Kent ML Support Care Cancer 16:305-309, 2008

Caries

Pulp Necrosis

Soft Tissue Necrosis

Osteonecrosis

TrismusTrismus

Unpredictable frequency and severityUnpredictable frequency and severity Muscle/ligament fibrosisMuscle/ligament fibrosis TMJ capsuleTMJ capsule Primary tumor sitePrimary tumor site 3-6 months after RT3-6 months after RT Effects on nutrition/hygieneEffects on nutrition/hygiene ExercisesExercises PreventionPrevention

Patient ManagementPatient ManagementControversiesControversies

Fluoride traysFluoride trays DenturesDentures Pre vs. post RT extractionsPre vs. post RT extractions Endodontics vs. extractionsEndodontics vs. extractions 7-21 days for healing7-21 days for healing Hyperbaric oxygen pre and post RTHyperbaric oxygen pre and post RT

Dentures

Long Term Follow-Up Care – RTLong Term Follow-Up Care – RT

Daily Daily fluoridefluoride DietDiet – low refined carbohydrate – low refined carbohydrate Oral Oral hygienehygiene - meticulous - meticulous Frequent dental Frequent dental recall visitsrecall visits

Institute for Oral MedicineInstitute for Oral MedicineCarolinas Medical Center, Charlotte, NCCarolinas Medical Center, Charlotte, NC

Jen-Luc Mougeot, PhDJen-Luc Mougeot, PhD Farah Mougeot, PhDFarah Mougeot, PhD Peter Lockhart, DDSPeter Lockhart, DDS Michael Brennan, DDSMichael Brennan, DDS Philip Fox, DDS Philip Fox, DDS Louise Kent, RNLouise Kent, RN Jenene Noll, RNJenene Noll, RN