Dental Management of the patient undergoing radiotherapy or chemoterapy
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Transcript of Dental Management of the patient undergoing radiotherapy or chemoterapy
PATIENTMANAGEMENT UNDERGOING RADIOTHERAPY OR CHEMOTHERAPY
RADIOTHERAPY ON HEAD AND NECK
Radiotherapy has the ability to destroy neoplastic cells while sparing normal cells. However in practice, normal tissues experience some undesirable effect.
Radiation affected hematopoietic cells, epithelial cells, and endothelial cells soon after radiotherapy begins
Salivary glands and bone are relatively radioresistant, but intense vascular compromise may result in salivary glands and bone damage
RADIATION EFFECTS ON ORAL MUCOSA
Initial effect on oral mucosa (first 1 or 2 weeks) : erythema that may progress into severe mucositis
with or without ulceration
Pain
Dysphagia that may lead to inadequate nutritional intake
Loss of taste
Long term effect: Submucosal fibrosis, which make mucosal lining less pliable and less resilient. So, minor trauma may create ulcerations and take weeks or months to heal
RADIATION EFFECTS ON MANDIBULAR MOBILITY
Radiation may lead : Pterygomasseteric sling and periauricular
connective tissues become inflamed
Muscles become fibrotic and tends to contract
Articular surfaces degenerate
Usually occuring over the first year after radiation therapy and painless
TRISMUS
RADIATION EFFECTS ON SALIVARY GLANDS
Salivary glands damage will result to atrophy, fibrosis, and degeneration → Xerostomia
Xerostomia leads to: Difficulty with tasting, chewing, and swallowing
Sleeping difficulty
Esophageal dysfunction (including chronic esophagitis)
Nutritional compromises
Higher frequency of intolerance to medications
Increased incidence of glossitis, candidiasis, angular cheilitis, halitosis, and bacterial sialadenitis
Decreased resistance to loss of tooth structure from atrition, abrasion and erosion
Loss of buffering capacity
Increase susceptibility to mucosal injury
Inability to wear dental prostheses
Rampant (radiation) caries → decay around the entire circumference of the cervical portion
Increase in oral infections such as candidiasis
TREATMENT OF XEROSTOMIA
Replacement / Stimulation of saliva:
REPLACEMENT
Water
Glycerin (contains several ions in saliva, mimic the lubricating action of saliva)
Carboxymethylcellulose (mucin-based products which animal-derived)
STIMULATION
Sugar-free chewing gum
FDA approved:
Pilocarpine hydrochloride (4 x 5mg / day)
Cevimeline hydrochloride (3 x 30mg / day)
RADIATION EFFECTS ON BONE
Osteoradionecrosis is devitalization of the bone by cancericidal doses of radiation
The bone virtually nonvital from an endarteritis because of elimination of the fine vasculature within the bone.
Continual process of remodeling does not occur (e.g sharp areas will not smooth themselves)
Mandible is denser and poorer blood supply, so mandible is the most commonly affected with nonhealing ulcerations and osteoradionecrosis
Other effects of Radiation
Alteration normal oral flora
Overgrowth of anaerobic species and fungi
This may because of radiation and or xerostomia
Candida albicans commonly thrives, frequently needed nystatin or 0,1% chlorhexidine (Peridex) which has antibacterial and antifungal effects
EVALUATION OF DENTITION BEFORE RADIOTHERAPY SHOULD TEETH BE EXTRACTED? Consideration:
Condition of Residual Dentition
Poor prognosis teeth should be extracted before RT
Patient’s Dental Awareness
Excellent OH → Retain as many teeth as possible
Neglected OH → Will be more difficult
Immediacy of Radiotherapy
Immediate RT: maintain the dentition
Delayed RT: may give time for dental management, need to work closely with the patient
Radiation Location
The more salivary glands and bone involved, the more severe xerostomia and vascular compromise
Radiation dose
Higher radiation dose → more severe normal tissue damage
PREPARATION OF DENTITION FOR RADIOTHERAPY AND MAINTENANCE AFTER IRRADIATION Prophylaxis like topical fluoride application using fabrication
of custom trays
Stop smoking and alcohol consumption
During radiation treatment, should rinse the mouth at least 10x / day with saline
Chlorhexidine mouth rinse 2x / day
The Dentist should control 1x / week
Application of nystatin or clotrimazole (overgrowth Candida albicans)
Monitor ability of mouth opening → physiotherapy exercises
Weighed weekly to determine adequate nutritional status
May be necessary to feed via nasogastric tube
METHOD OF PERFORMING PREIRRADIATION EXTRACTIONS
Concepts of bone preservation are disregarded
Remove a good portion of the alveolar process along with the teeth (using burs or files to smooth the bony edges) and achieve a primary soft tissue closure
Prophylactic antibiotics are indicated
“ The Dentist is in a race against time. If the wound fails to heal, the radiotherapy will be delayed. If the radiation is delivered before the wound heals, healing will take months or even years ”
INTERVAL BETWEEN PREIRRADIATION EXTRACTIONS AND BEGINNING OF RADIOTHERAPY?
No categoric answer
Traditionally: 7-14 days between tooth extraction and radiotherapy
If possible: 3 weeks after extractions
If wound dehiscence has occured, the radiotherapy should be delayed if possible
Daily local wound care with irrigations and post op Antibiotics until soft tissues have healed
IMPACTED THIRD MOLAR REMOVAL BEFORE RADIOTHERAPY
Partially erupted: removal may be prudent, to prevent pericoronal infections
Totally impacted: Keep it remain in place is more expeditious
METHODS OF MANAGING CARIOUS TEETH AFTER RADIOTHERAPY
Must be immediately cared
Full crowns are not warranted because recurrent caries is more difficult to detect
Flouride application
Endodontic intervention with systemic antibiotics
TOOTH EXTRACTION AFTER RADIOTHERAPY
Post irradiation extractions is most undesirable, because the outcome is uncertain
If the tooth is needed to be extracted, perform routine extraction without primary closure or surgical extraction with alveoloplasty and primary closure, both has similar results: a certain concomitant incidence of osteoradionecrosis
Use of antibiotics is recommended
Use of hyperbaric oxygen (HBO) before and after tooth extraction
HBO dives 20-30 before extraction and 10 more after extractions
Usually 1x / day. So, it takes 4-6 weeks to get the 20-30 treatments and 2 weeks of treatment after surgery
Marx et al: Incidence of Osteoradionecrosis of group with use of AB only : AB+HBO = 30% : 5,4%
DENTURE WEAR IN POSTIRRADIATION EDENTULOUS PATIENTS
With denture, patient has the risk of causing ulceration of the mucosa
Soft denture liner may be a solution
Denture fabrication is made once the acute effects of irradiation have subsided
Denturers fabrication must be certain that denture base and occlusal table are designed so that forces aare distributed evenly throughout the alveolar ridge and that lateral force on the denture are eliminated
USE OF DENTAL IMPLANTS IN IRRADIATED PATIENTS The more radiation delivered, the higher the failure rate
for endosseous implants
The longer the duration betweenn radiation treatment and implantation, the higher the failure rate
When implants in irradiated patiens fail, they usually fail early, before prosthetic reconstruction indicating a failure of osteointegration
The combination of radiation and chemotherapy has a particularly negative effect on the outome for osseointegration
Implant survival in irradiated patients tends to he higher in the maxilla than in the mandibule
Shorter implants have the worst prognosis
HBO treatment reduces implant failure rates
MANAGEMENT OF PATIENTS WHO HAVE OSTEORADIONECRIOSIS
Patient should discontinue wearing any prosthesis
Decreased vascularity of the tissues and do not gain ready access to the area to perform the function of Antibiotics
Nonhealing wounds or extensive areas of osteoradionecrosis is needed surgical intervention.
HBO can improve results greatly in conjunction with surgical intervention
DENTAL MANAGEMENT OF PATIENTS RECEIVING SYSTEMIC CHEMOTHERAPY FOR MALIGNANT DISEASE
Antitumor effect of cancer chemotherapeutic agents is based on their ability to destroy or retard the division of rapidly proliferating cells
Normal host cells that have a high mitotic index are affected. Most affected are the epithelium of the gastrointestinal tract and the cels of the bone marrow
EFFECTS ON ORAL MUCOSA
Reduce the normal turnover rate of oral epithelium → atropic thinning, which manifested clinically as painful, erythematous, and ulcerative mucosal surfaces in the mouth.
Changes are seen within 1 week of the onset of antitumor agents
Effects are usually self limiting, spontaneous healing within 2-3 weeks after cessation of the agent
EFFECTS ON HEMATOPOIETIC SYSTEM
Myelosuppression : Leukopenia, Neutropenia, Thrombocytopenia and Anemia
Within 2 weeks the white blood cell count falls to an extremely low level
The oral effect: Marginal gingivitis, and bleeding from the gingiva is common
Overgrowths of oral flora, especially fungi
Thrombocytopenia can be significant, and spontaneous bleeding may occur
Recovery from myelosuppresion is usually complete 3 weeks after cessation of chemotherapy
EFFECTS ON ORAL MICROBIOLOGY
Chemotherapeutic agents → Immunosuppressive side effect → overgrowth of microbes, superinfection with gram (-) bacili, and opportunistic infections
Most patients with chemotherapy are treated with sytemic antimicrobial agents
Frequent overgrowth organism: Candida species
GENERAL DENTAL MANAGEMENT
Chemotherapy has minimal effects on the vasculature, so dental management is easier
Primary concerns: bone marrow suppression
Patient being treated for hematologic neoplasm (e.g leukemia) both the disease and chemotherapy lead to decrease in functional blood elements → risk of infection & hemorrhage
In non hematologic neoplasm, risk of infection & hemorrhage only during the course of chemotherapy
Prechemotherapy dental measures: Prophylaxis
Fluoride treatment
Necessary scaling
Removal of unrestorable teeth
GENERAL DENTAL MANAGEMENT
Dental procedures requirement: WBC ≥ 2000/mm3
At least 20% PMN
Platelet ≥ 50.000/mm3
Prophylactic Antibiotics should be given if chemotherapy within 3 weeks of dental treatment
Removable dental appliance should be left out (to prevent ulceration of fragile mucosa)
TREATMENT OF ORAL CANDIDIASIS
Topical application of antifungal
Or oral rinses, oral tablets, and creams Oral rinses are less efficacy
tablet are most accepted forms
creams are helpful for oral commissures or prosthetic device surfaces
Most common topical medications: Clotrimazole and Nystatin. 4x daily for 2 weeks
Clotrimaazole troches 4 x 5 times a day
Stronger drugs: Ketoconazole or Fluconazole
Other : Chlorhexidine mouth rinse
DENTAL MANAGEMENT OF PATIENTS WITH BIPHOSPHONATE-ASSOCIATED OSTEONECROSIS OF THE JAW (BOJ)
BOJ is a condition of chronically exposed necrotic bone (painful and often infected)
Bone exposure might occur spontaneously or more commonly following an invasive dental procedure
Complains: halitosis, difficulty eating & speaking, extreme pain
The lesions are persistent and do not respond to debridement, antibiotic, or HBO therapy
BIPHOSPHONATES
Biphosphonates are used to treat osteoporosis, malignant bone metastasis, Paget’s disease of bone, and hypercalcemia of malignancy
Biphosphonates also have antiangiogenic properties → tumoricidal
Biphosphonates bind to bone and incorporate in osseous matrix. During bone remodelling the drug is taken up by osteoclasts and internalized in the cell cytoplasm → inhibit osteoclastic function and induces apoptotic cell death
The result: bone becomes suppressed and shows little physiologic remodelling → becomes brittle and unable to reapir physiologic microfractures
CLINICAL SIGNS AND SYMPTOMS OF BOJ
Exclusively affects the jaws
Clinical: ulcer with exposed bone in a patient who has had a dental extraction
May be asymptomatic
May have severe pain (if necrotic bone becoming infected and exposed)
Osteonecrosis often progressive and lead to extensive areas of bony exposure and dehiscence
DENTAL CARE FOR PATIENTS START TAKING BIPHOSPHONATES
Minimize the risk of occurence of BOJ
Provide dental care early in the treatment
Teeth with poor prognosis should be removed before or as early as possible after administration of biphosphonates
Should be delayed for 4-6 weeks after invasive procedures (e.g tooth extraction)
Elimination of all potential sites of infections
Restorative dentistry
Evaluation on prosthodontic appliances (fit, stability, and occlusion)
DENTAL CARE FOR PATIENTS WITH BOJ
Treatment directed for elimminating or controlling pain and preventing progression of exposed bone
Eliminating sharp edges using bur
Attempts to cover exposed bone with flaps may cause more bone exposure and worsening of symptoms with risk of pathologic fracture
NONE are successful : Major surgical sequestrectomies, marginal and segmental mandibular resections, partial and complete maxillectomies and HBO therapy
Use of Chlorhexidine 3-4x/day
If the tooth is unrestorable because of caries → root canal treatment and amputation of the crown may be a better option than removing the tooth unless it is very loose
Relining a denture with soft liner to promote a better fit and to minimize soft tissue trauma
Odontogenic infections treated aggressively with systemic antibiotics
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