PREVENTION, ORAL HEALTH AND DISEASE AND TREATMENT PLANNING IN RADIOTHERAPY

Oedijani Santoso Bagian/SMF Gigi dan Mulut FK Undip/RSUP Dr Kariadi Semarang

Introduction
Clinics ( surgeons, oncologists) and support staff agreed treatment policy the best outcomes. Oral squamous cell carcinoma (OSCC) treated by surgery and/or irradiation Important factors quality of life and patient education

In one study, at least 6 months after the diagnosis of oral cancer, 47% of participants still smoked and 36% drank alcohol to excess. Only one third of the participants were aware that these habits were important in the development of oral cancer.

The prognosis of OSCC site dependent. Intraoral carcinoma the 5-year survival rate < 30% for posterior lesions presenting late Lip carcinoma the 5-year survival rate > 70%.

Radiotherapy
Advantages of radiotherapy include : (1) normal anatomy and function are maintained (2) general anesthesia is not needed (3) salvage surgery is available if radiotherapy fails.

Disadvantages mainly include : (1) adverse effects are common (2) cure is uncommon, especially for large tumors (3) subsequent surgery is more difficult and hazardous and survival is reduced further.

The Role of Pretreatment Oral Care

Reduces the risk and severity of oral complications. Allows for prompt identification and treatment of existing infections or other problems. Improves the likelihood that the patient will successfully complete planned cancer treatment. Prevents, eliminates, or reduces oral pain.

Minimizes oral infections that could lead to potentially serious systemic infections. Prevents or minimizes complications that compromise nutrition. Prevents or reduces later incidence of bone necrosis

Preserves or improves oral health. Provides an opportunity for patient education about oral hygiene during cancer therapy. Improves the quality of life. Decreases the cost of care.

Prevention and treatment planning before cancer therapy

Prevention of oral disease and careful treatment planning minimize oral disease and the need for, and possible adverse consequences of operative intervention Adults with malignant head and neck disease have poor oral hygiene and care. 97% need oral health care before radiotherapy or chemotherapy

Psychosocial counseling to ensure they can adjust the complications of cancer therapy Postoperative complications predicted by preoperative assessment : alcohol abuse, and a platelet count thrombocytosis risk for wound infection

Fruits and vegetables protective effect. The potential of topical gel formulations for local delivery of chemopreventive plant anthocyanins is being investigated. oral hygiene before radiotherapy or chemotherapy

Dietary control and topical fluoride therapy are essential and must be continued best to the entire surface of all teeth to have the maximal protective effect A gel 1% sodium fluoride, applied to the teeth for 5 min. Sodium fluoride mouth rinses with chlorhexidine diacetate

Teeth should be cleaned and restored before radiotherapy begins The only teeth that need to be extracted before radiotherapy include : - non vital - root filling - periodontal disease

Extractions should be : - atraumatically - the tissues sutured to promote rapid healing - antimicrobial therapy Dental extractions typically are best performed judiciously and a minimum of 2-3 weeks before commencement of irradiation therapy

Oral health and disease in cancer therapy

Complications of cancer therapy depend on : the type of malignancy and location the treatment modality used ( agents, sequencing, rate of delivery, dosage) host factors.

Manifestations of cancer therapy :

mucositis and oral ulceration infections bleeding pain xerostomia Osteoradionecrosis (ORN) taste loss trismus caries

Oral complications common to both chemotherapy and radiation

Oral mucositis: inflammation and ulceration of the mucous membranes; can the risk for pain, oral and systemic infection, and nutritional compromise. Infection: viral, bacterial, and fungal; results from myelosuppression, xerostomia, and/or damage to the mucosa from chemotherapy or radiotherapy.

Taste alterations: changes in taste perception of foods, ranging from unpleasant to tasteless. Nutritional compromise: poor nutrition from eating difficulties caused by mucositis, dry mouth, dysphagia, and loss of taste. Abnormal dental development: altered tooth development, craniofacial growth, or skeletal development in children

Xerostomia/salivary gland dysfunction: dryness of the mouth due to thickened, reduced, or absent salivary flow; the risk of infection and compromises speaking, chewing, and swallowing. Medications other than chemotherapy can also cause salivary gland dysfunction. Persistent dry mouth the risk for dental caries. Functional disabilities: impaired ability to eat, taste, swallow, and speak because of

Other complications of chemotherapy

Neurotoxicity: persistent, deep aching and burning pain that mimics a toothache, but for which no dental or mucosal source can be found. This complication is a side effect of certain classes of drugs, such as the vinca alkaloids. Bleeding: oral bleeding from the platelets and clotting factors associated with the effects of therapy

Other complications of radiation therapy

Radiation caries: lifelong risk of rampant dental decay that may begin within 3 months of completing radiation treatment if changes in either the quality or quantity of saliva persist. Trismus/tissue fibrosis: loss of elasticity of masticatory muscles that restricts normal ability to open the mouth. Osteonecrosis: blood vessel compromise and necrosis of bone exposed to high-dose

Oral Care During Cancer Treatment

Careful monitoring of oral health is especially important during cancer therapy to prevent, detect, and treat complications as soon as possible. When treatment is necessary, consult the oncologist before any dental procedure, including dental prophylaxis.

Examine the soft tissues for inflammation or infection and evaluate for plaque levels and dental caries. Review oral hygiene and oral care protocols; prescribe antimicrobial therapy as indicated.

Provide recommendations for treating dry mouth and other complications:

Sip

water frequently. Suck ice chips or sugar-free candy. Chew sugar-free gum. Use a saliva substitute spray or gel or a prescribed saliva stimulant if appropriate. Avoid glycerin swabs.

Take precautions to protect against trauma. Provide topical anesthetics or analgesics for oral pain.

Mucositis
Mucositis 3-15 days after cancer treatment, earlier with chemotherapy than radiotherapy Pain interferes with eating quality of life. Occasionally, tx must be stopped for several days to allow healing To causing local pain and ulceration Mucositis microbial entry local and systemic infection.

Mucositis

The acute mucosal reaction to radiotherapy mitotic death of cells in the epithelium Mucosal erythema a few days appearance of a patchy fibrinous exudate. If a high dose of radiation is given over a short time ulceration + a thick fibrinous membrane covering the denuded surface

Fase II & III Fase I Epitel normal Inisiasi

Fase IV Fase V Healing

Messaging, Ulserasi Signaling, & Amplification (mukositis)

Radiasi Lapisan epitel

Submukosa

Kemoterapi Basal Cell

Pembuluh darah

Sel inflamasi

Fibroblas

The duration mucositis takes to heal depends on the dose intensity of the radiotherapy, but usually, healing is complete within 3 weeks after the end of treatment. Tobacco smoking delays resolution.

Oral ulceration a portal for infection and septicemia. Preventing mucositis not only exposure radiation, but also by taking active measures. Radiotherapy oral gram-negative enterobacteria and pseudomonads mucositis microorganisms release endotoxins cause systemic and local effects on the host.

KLASIFIKASI BERDASARKAN WHO

Oral Mucositis Grade 0 Grade 1 Tidak terdapat Eritema dan perubahan, nyeri (tanpa fungsi baik ulserasi) Severe Oral Mucositis Grade 2 Grade 3 Grade 4 Eritema dan Eritema dan Eritema dan ulserasi (bisa Ulserasi ulserasi makan (hanya dapat (tidak dapat makanan diet cairan) makan padat) apapun)

Management of mucositis
Diluting agent : saline, bicarbonate rinses, frequent water rinses Coating agents : kaolin-pectin, Al chloride, Mg hydroxide Lip lubricants : lanolin, water based lubricants Topical anesthetics : dyclonine HCl, xyclocaine HCl, benzocaine HCl, diphenhydramine HCl

Topical anesthetics Benzydamine HCl, doxepin HCl Maintain OH brushing the teeth, rinses Systemic analgesics Maintain nutrition and hydration to eat a soft, bland diet and avoid irritants such as smoking, spirits, or spicy foods.

2 clinical trials : polymyxin E and tobramycin applied locally (lozenge) 4 times daily Rat model : use of TGF3 and IL-11 significant reduction mucositis

Oral Infections
Streptococcus mutans, Lactobacillus and candidal after radiotherapy. These changes are maximal from 3-6 months after radiotherapy, after which no further change or a partial return towards the baseline florae occurs.

Herpetic Gingivostomatitis

Herpes Zoster

Candidiasis

The frequency and severity of oral infections with virus, bacteria, and fungi significantly The primary symptomatic viral infections : herpes simplex virus (HSV) and herpes varicella-zoster virus infections. Acyclovir primary treatment, but new agents : famciclovir, penciclovir, sorivudine, foscarnet, and other agents

Candidiasis oral fungal infection in patients with cancer soreness, occasionally responsible for dissemination of infection. Xerostomia, dental prostheses, alcohol use, and tobacco smoking predispose patients to oral candidiasis. A meta-analysis prophylactic clotrimazole or fluconazole

Xerostomia
Salivary tissue, serous acini, is highly vulnerable to radiation damage, and the parotid glands are damaged most readily. the conventional treatments for oral carcinoma a rapid decrease in flow occurs during the first week of radiotherapy, with an eventual approximate 95%

Salivary Gland

After 5 weeks of radiotherapy salivary flow virtually ceases and rarely completely recovers. The sensation of dry mouth after a few months - year a result of compensatory hypertrophy of unirradiated salivary gl tissue. After 1 year, little further improvement occurs.

The degree of xerostomia degree of exposure of the salivary tissue. Xerostomia the parotid glands are involved. Mantle, unilateral, and bilateral fields of radiation can be associated with a reduction in salivary flow of 30-40%, 50-60%, and approximately 80%, respectively.

Radiotherapy to the nasopharynx damages both of the parotid gl severe and permanent xerostomia. Radiotherapy to a salivary tumor avoid the contralateral gland and not cause severe xerostomia. Radiotherapy of oral cancer normally avoid at least part of the parotid glands xerostomia tends not to be severe

Xerostomia discomfort and loss of taste and appetite. Residual salivary tissue stimulated pharmacologic stimuli (cholinergic agents) Pilocarpine ophthalmic drops placed intraorally or tab relieving symptoms and improving salivation (5 mg/3x daily) Sugar-free chewing gum may be a useful stimulus

Individuals with dry mouth frequently sip water during eating, and often need to keep water by their bedsides. Several saliva substitutes or mouth-wetting agents are currently contain carboxymethylcellulose, mucins and constituents enamel remineralization

Advise xerostomia patients : to avoid agents such as medications, tobacco, and alcohol that may further impair salivation.

Dental Problems
Xerostomia Periodontal disease <caries Xerostomia foods with high sucrose & carb cariogenic oral microflora caries Most involving incisal edges and cervical areas. The direct effect of radiation on tooth structure < the indirect effect

Caries :
- Cervical - Incisal

Loss of Taste Sensation

Patients receiving radiotherapy disturbance or loss of taste sensation. The taste receptor cells relatively radioresistant mechanism ? Xerostomia probably contributes disturbance of taste is common after irradiation of the parotid gl

Patients with distress syndrome & poor nutrition Recovers slowly a few months after the end of radiotherapy sometimes loss is permanent. Zinc sulphate may help improve taste sensation

Osteoradionecrosis
Radiation thrombosis of small blood vessels Radiation therapy fibrosis of the periosteum and mucosa damage to osteocytes, osteoblasts, fibroblasts bone cell may not divide for months or years after irradiation

slow protracted loss of bone cells occurs after radiotherapy slowing of remodeling thinning and reduced bone strength. The mandible compact bone with a higher density than the maxilla absorbs more radiation than the maxilla.

Osteoradionecrosis

ORN in dentate 3x in edentulous patients as result of infection from periodontal disease and trauma from tooth extraction. if dental extraction is performed shortly after radiotherapy, when devascularization occurs in addition to damage to the osteoblasts, the risk of ORN is

The highest rate of mandibular ORN occurs in patients who have dental extractions immediately prior to radiotherapy or immediately after. Many authors agree that postradiation extractions should be avoided if possible.

ORN Therapy
Conservative approach is indicated >60% ORN resolve with conserv tx Therapeutic approaches : - local wound care, - topical or systemic antibiotics, - ultrasound, - hyperbaric oxygen (HBO) - minor-to-extended surgery with reconstruc

 oral hygiene 0.02% chlorhexidine mouthwashes after meals Irrigate debris and sequestra Any sequestrum that becomes loose should be removed gently along with any sharp edges of spicules of bone

Antimicrobials not especially effective because the tissues are avascular Tetracyclines 250 mg of tetracycline 4 times/day for 10 days, followed by 250 mg twice daily continued for several months Add metronidazole 200 mg 3 times/day in cases of severe infection or when anaerobes are implicated.

HBO therapy to promote healing. Therapeutic ultrasound frequency of 3 MHz pulsed 1 in 4 at an intensity of 1 W/cm2 Surgical management include : - sequestrectomy - alveolectomy with primary closure - closure of orocutaneous fistulae - hemimandibulectomy

Medications
The goals of pharmacotherapy for OSCC reduce morbidity associated with secondary infection and to prevent complications. Antiviral agents : Nucleoside form a nucleoside triphosphate inhibit HSV polymerase with 30- to 50-times the potency of human

Antibiotics : Antimicrobials are not especially effective because the tissues are avascular; therefore, prolonged treatment is necessary. Antifungal agents : Mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal

SELAMAT BELAJAR SUKSES SELALU