Management of Cancer patients


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With thw evolution of the medicine and increasing of the survival rate of cancer patients , its commonly to be seen in dental clinics. OMFS must know about their patients conditions , treatments and how to manage them in order to provide them good care and good life.

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  • With the introduction of new advanced antineoplastic therapy ., With the increasing of survival of cancer patients More common for oral surgeon to deal with cancer patients. Knowledge of cancer progression, treatment modalities, the location of the available cancer therapy(hosp. out pt.). (whether surgery only,chemo or radio or combination)..
  • Today the treatment is one of the following…..are still the main stays of cancer therapy…in combination weighting combined therapy benefit.VS side effects. --
  • =In a presentation at the 2007 annual Multidisciplinary Head and Neck Cancer Symposium, Dr. Bonner described additional data on mucositis and dysphagia among cancer pt.=Dr. Bonner is chair of radiation oncology at the University of Alabama in Birmingham =These findings are important because they show that the addition of this monoclonal antibody therapy has lifesaving benefits without any additional length of suffering from the primary acute side effects,=Dr. Bonner and colleagues reported that the median duration of any mucositis or dysphagia was 12 to 13 weeks, and less than 10% of patients experienced mucositis or dysphagia for more than 15 weeks.
  • Today the treatment is one of the following…..are still the main stays of cancer therapy…in combination weighting combined therapy benefit.VS side effects. ---while immunotherapy, gene therapy and antiangiogenic therapy hold hope for the future as they are not yet established and not routelny used.
  • Highly dividing cells like neoplasic,endothelial, epithelia reticuloendothelial cells --interact with atoms and molecules to produce free radicals that damage DNA and affect all cell cycle phases. ==Radiation therapy has been used for over 100 years. It is a proven method for controlling malignancies and for prolonging the life of individuals who would otherwise die from their cancer
  • 1-emits beta particles tha splits H2O into free radicals. hyperfractionate radiotherapy to reduce ORN 2-the use of tiny radioactive isotopes called "seeds" that are permanently placed in the body. over a period of time, implanted seeds lose their radioactivity and can remain in the body=cont. energy emission.high risk ORN
  • 1-methotrexate.-bone suppression,stomatitis , rash 2-steroids.- tamoxifine (osteoporosis) antiestrogen nonsteroidal 5-dactinomycin,doxorubcin.(streptomyces)=bone marrow supression. 3-vincrestine.= bone marrow suppression. 4-cisplatine,= nephrotoxic,ototoxicity
  • A smaller percentage of pt. die from direct complication of treatment or from side effect of therapy. -- Surgery
  • Mucositis- s often a dose limiting factor in chemo. And a cause of dose interruption in radiotherapy. ---Pain may not be evident at first, but as oral mucositis escalates, pain can elevate accordingly. Activities such as eating, drinking, swallowing, and talking may become difficult
  • During radiation and chemotherapy , pt. are prone to 2ry infection. Because of xerostomia and decrease salivary flow, several microorganisms (bact.viral.fungal) opportunistically infect oral cavity.
  • So the only opportunistically infect oral cavity in pt undergoing cancer therapy -- that white plaques that easily scraped off leaving behind tiny peticheal hemorrages. Less common erythematous or atrphic==hypertrophic formcannot be scraped off
  • Systemic ketokonazole useed also if uncommon fungal infection like aspirogellosis, mucormycosis.
  • Minor trauma from tongue biting or tooth brushing.
  • Avoid sensory stimulation by putting strong perfumes. ==aversion of foods means doesn’t like the food
  • Pt may complaints of odontogenic pain caused by theese agents So proper Ex to rule out any dental cause and by understanding the effect of chemo. agents
  • 3-5 mm in size. Incidence 5-15% with an overall incidence 5.4% Bimodal incidence peaking @12 months and 24-60 monthes
  • Nonsurgical treatment , curettage cause reduction in blood supply to the region (vasoconstruction)result in ORN >7500cGy– ORN is almost 10X higher than for doses <5000cGy====so radiation dose is the most imp. Factor in the incidence of ORN.
  • Ct and bone scintigraphy are diagnostic aids to evaluate the extension and the behaivior of ORN.
  • Without the need of HBO or surgical intervention..this appraoch consist of:====
  • That will disolve the oxygen in interstitial tissue and blood. 100 % O2 via mask or ET Tube. In chamber with 2.4 atmosph. Absolute pressure for 90 min each session or dive.
  • The use and efficacy of HBO prior to tooth extraction has been debated in the literature. Those who argue against the use of HBO prior to tooth extraction state that the
  • As prophylactic before any surgical procedure within the field of radiation.
  • 1-HBO with surgery is indicated in … 2-according to marx university of miami protocol depend on the extent of the disease ,,its consists of 3 ttt stages of advanced clinical severity; stageI,II, we will see in the coming slides.
  • Stage I – with rigorous wound care- after 30 treatments, the wound is reevaluated for definitive improvement like: decrease bone exposure, resorbtion or spontaneous sequestration—then pt receives another 10 treatments for a full course of 40 treatments. stagII-e’ chronic,persistent(nonprogressive form of ORN-surgical debridement (transoral alveolar squestrectomy)of all necrotic bone to a bleeding bone and 1ry closure in a layered fashion.-if no improvement can be seen or wound break down exposing larger area of bone, te pt. is non responder and advanced to stageiii. Who is candidate for stageIII treatemnt of ORN?? Who has still bone exposure (not respond to stage II) or has initially or after ttt of ORN e’ one of the following:..
  • After resection of nonviable bone, vascular free tissue transfer offers immediate reconstruction and restoration of mandibular continuity. Free tissue transfers offer patients a shorter treatment course, often without the need for HBO.
  • Despite ongoing contraversery, still HBO used in many clincal situation propably because of the unique atmospheric condition to which the pt. is exposed to . Yet a major concern regarding the safety aspects of this thereapy. Possible complications including:::: ---ear prob. Is due to equalizing the pressure--- three cases reported regarding loss of hearing=== ==knowledge about the incidence of each complication allows you to wieght the benift versus risk ration in certain cases.
  • Lung;; dry cough or burning sensation substernally—hyperoxia can cause pulmonary exudation and edema
  • =exclude pt who has FVC<70% of normal individual 1-exclude pt with acute ischemia or bradicardia 2-eclude pt with pulmonary adhesion or interpulmonary irrigularities. 3-evaluate healthy tympanic memb.—further Dx in middle ear infection.
  • Bone remodeling is a physiological function— By the time bone turnover become profoundly suppressed &overtime bone show little physiologic remodeling
  • Which occur
  • … after bone exposure.
  • To educate and reassure each patient regarding potential ONJ complications; dietary counseling and advice regarding appropriate supplements and/or tube feeding for patients with limited ability to eat due to the oral lesions.
  • To eliminate discomfort, pain, and secondary infection: baking soda with water or an antimicrobial mouth rinse to clean and irrigate the exposed sites is advised.Microbiological culture for secondary infection has been suggested.
  • Recommendations include a 3-week course of penicillin V potassium (Pen V-K) with the addition of metronidazole as necessary, in addition to 0.12% chlorhexidine mouth rinse.
  • Cancer pt has one of two ways either short that end it safely or a very long way of suffering….
  • Management of Cancer patients

    1. 1. Management of Patients Undergoing Cancer T herapyHanan Shanab
    2. 2. • Few information obtained from cancer pt. which is relevant to the surgeon. .. Like: – The type of treatment. – The duration of treatment . – Whether he is an outpatient or inpatient
    3. 3. There are three treatment modalities involved ineradicating head and neck cancer: (1) surgery; (2) radiation therapy. (3) Chemotherapy.
    4. 4. Combination Chemoradiotherapy• Cetuximab is a chimeric monoclonal antibody that targets epidermal growth factor receptor. The FDA approved cetuximab for treatment of squamous cell carcinoma of the head and neck in March 2006.
    5. 5. Treatment modalities involved in eradicating head and neck cancer:(1) surgery;(2) radiation therapy.(3) Chemotherapy.(1) Immunotherapy(2) Gene therapy.(3) Antiangiogenic therapy.
    6. 6. Pt . Evaluation before cancer therapy:– Age of the pt.– Condition of dentition.– Level of oral hygiene and pt. attitude.– Radiation field and dose.
    7. 7. Guidelines for extraction before RTx• All questionable ,carious teeth in the field of radiation (>6000 cG) must be extracted.• Optimal time for extraction is 21 days before the beginning of RTx (not less than 2 w).
    8. 8. • Less optimally, extraction can be done within 4 months after completion of RTx. (after HBO)• Perform radical alveolectomy with primary soft tissue closure following extraction .
    9. 9. Radiotherapy• More effective on well oxygenated and mitotically active.. – Induce cell necrosis . – Microvascular damage. – Parenchyma and stromal damage.
    10. 10. Types of Radiation therapy1-External beam radiation. – (tumoricidal dose is 6000-7600 cGy) – Hyperfractionated to 200 cGy for 5 days/week. – 150-180 cGy twice daily-3-4 days/week2- Interstitial Radiotherapy (brachytherapy).RadiumIridium- ½ life 74 days-no gaseous by product3-Neutron Beam Radiotherapy.Rarely used today
    11. 11. Chemotherapy TYPES: CCS CCNS•Antimetabolites. • Alkylating agents•Hormons. • Antibiotics.•Mitotic inhibitors
    12. 12. Complication of Cancer Therapy
    13. 13. Complication of Cancer Therapy• 1-Mucositis.• 2- Xerostomia.• 3-secondary infection.• 4- bleeding.• 5-Muscle Trismus.• 6-osteoradionecrosis.• 7-alopecia.
    14. 14. 1-Mucositis. – More in non keratinized tissues like palatal , buccal mucosa , ventral tongue .. – Started by the second week of radiation therapy.(if the dose 200 cGy/week) – 7th -14th day after chemotherapy.Complications of Cancer Therapy
    15. 15. • More higher in young pt…high division rate.• Produce red,raw, tender oral mucosa with sloughing epi. ..Like burn..• Pt. has dysphagia, pain, loss of taste difficulty in eating which increase systemic infection. Its generally subsides 1-2 weeks after completion of treatment. Complication..Mucositis.
    16. 16. WHO Scale for Oral Mucositis• Degree 0:is when there are no signs or symptoms.• Degree 1 :is when the mucosa is erythematose and painful.• Degree 2 :is characterized by ulcers, and the patient can eat normally.
    17. 17. • Degree 3 :is when the patient has ulcers and can only drink fluids.• Degree 4 :is when the patient cannot eat or drink.
    18. 18. Phases of Mucositis
    19. 19. Phase 1 (Initiation): radiation or chemotherapy causes DNA damage inbasal epithelial cells and generates reactive oxygen species (ROS), whichfurther damage cells and blood vessels in the submucosa.
    20. 20. Phase 2 (Signaling): chemotherapy, radiation,induce apoptosis and upregulated inflammatorycytokines in cells.
    21. 21. Phase 3 (Amplification): inflammatory cytokines producefurther tissue damage, amplifying signaling cascades and theinjury process.
    22. 22. Phase 4 (Ulceration): loss of mucosal integrity produces extremely painful lesions, providing portals of entry for bacteria, viruses, and fungi.
    23. 23. • Phase 5 (Healing): proliferation, differentiation, and migration of epithelial cells to restore the integrity of the mucosa.
    24. 24. Management of Mucositis• 1-A bland mouth rinse (salt and water).. To keep ulcerated areas clean as possible.• 2-Topical anesthesia and /or antihistamine solution or with coating agents (milk of magnesia).
    25. 25. • 3-Anti microbial- Chlorohixidine.12%• 4-Anti-inflammatory or topical steroids.• 5-Diet consisting of soft food, proteins, and vitamins supplements at therapeutic level.Management of Mucositis
    26. 26. • 6-Oral lubricants and lip palm ..containing (beeswax).• 7-Avoidance of alcohol, tobacco and irritant foods
    27. 27. 2-Xerostomia• If major salivary gland have been irradiated.• Occur following the onset of mucositis. – Altered taste sensation. – Increase susceptibility for caries and mucosal inflammation. – Difficult in swallowing, speech.
    28. 28. • Side effects of pain medicine: Opioids for painful swallowing may cause dry mouth and constipation.
    29. 29. Management of Xerstomia• Recommended sugarless lemon drops.• Sorbitol-based chewing gum.• Buffered solution of glycerine and water or salivary substitutes.
    30. 30. 3-Secondary infection:Causes:• Decrease in quantity of salivary flow.• Immunosuppressed (WBC<2000/mm3).• In pt. receiving chemotherapy and antibiotics.
    31. 31. Fungal infection• Candida albicans• Candidal infection produce pain, burning taste and intolerance to certain foods.• The most common type is pseudomembranous candidiasis.. Curdled milk• Other forms (angular cheilosis and less common hypertrophic form.
    32. 32. Bacterial infection• Shift occurs in the oral flora to gram –ve that’s Normally inhabit the GIT or respiratory tract like Pseudomonas, Klebsielaa, Proteus, E coli, Enterobacter.
    33. 33. Viral infection• Recurrent herpes simplex (HSV).• Occur often during chemotherapy and less frequent with radiotherapy.• Takes longer to heal.• Mimic aphthous ulcer on nonkeratinized mucosa.
    34. 34. Management of Infection• Cytology study.• Culture any non healed ulcerations for Dx and for accurate treatment.
    35. 35. For Candida infection : – Oral nystatin suspention 100,000 IU/ml 4-5 times daily. – Cotrimazole (10mg 5 times daily). – Systemic ketoconazol(Nizoral). – Alternatively, putting pt. on granulocyte (monocyte) colony-stimulating factor to elevate neutrophil count to normal.Management of Infection
    36. 36. For Viral infection:• Enzyme-linked immunoassay for accurate Dx.• For HSV antibody-positive pt: – Acyclovir, famcyclovir, valcyclovir. – Daily dose of at least 1 g.Management of Infection
    37. 37. 4- Bleeding• Pt. undergo total body irradiation• High dose chemotherapy. Thrombocytopenia
    38. 38. • Clinical signs: – Plat. <50,000 cells/mm3 – Petechia, purpra on lateral margin of tongue. – Gingival bleeding. – Submucosal hemorrhage… from minor trauma
    39. 39. Management of Bleeding• Avoid trauma to the oral cavity.• Control bleeding by local measures by – Pressure. – Gelatine sponge. – Thrombin or microfibrillar collagen. – Antifibrinolytic rinse .. Amicar syrup 250mg/ml. on soft vinyl mouth guard.• Platelet transfusion in sever cases.
    40. 40. 5-Neural and chemosensory changes• Diminshed taste sensation… damage of microvilli of taste cells.• Pt on chemotherapy complaints of – bitter taste, – unpleasent odors – conditioned aversion of foods
    41. 41. • Neurotoxicity effect from chemotherapy (vincristine and vinblastin).• Occur in peripheral nerves.• Pt. experience pain in molar area bilateral.
    42. 42. Management• 1-Restore taste sensation within 3-4 months after completion of radiotherapy.• 2-In chronic loss of taste, zinc supplementation. Silverman recommends 220 mg of zinc 2x/day.• 3-No effective treatment for completely restores damagedtaste.
    43. 43. 6-Muscle Trismus• Caused by radiation therapy.• Damage to the vasculature of ms.(obliterative endoartritis).
    44. 44. – Progressive later dysphagia from fibrosis in the pharyngeal musculature – reduces nutritional intake – promotes aspiration.Muscle Trismus
    45. 45. • Pneumonia and respiratory failure: Patients who have trouble swallowing may aspirate when trying to eat or drink.• Poor nutrition: Being unable to swallow normally makes it hard to eat well. Wounds heal more slowly and the body is less able to fight off infections.• Use of tubefeeding: A patient who is not able to take in enough food by mouth may be fed through a tube.
    46. 46. management• Mouth block should be placed during radiotherapy.• Perform daily stretching exercises to improve trismus. By using tongue plates for 3 times aday for 10 min• Apply warm, moist heat onthe area. Muscle Trismus
    47. 47. 7-Osteoradionecrosis• Exposed bone for 6 months after high dose of radiation.• Results from: – Radiation. – Three-H tissue.(hypocellularity,hypoxia, hypovascularity) – Tissue breakdown..necrosis – nonhealing wound.
    48. 48. When the radiation dose is >7500 cGy.• The mandible more affected than maxilla
    49. 49. • Clinically.. – Exposed bone, loss of soft tissue and bone. – Pain (dysesthesia/anasthesia). – Pathological fracture and orocutaneous fistula. – Trismus. – Soft tissue necrosis.
    50. 50. • Radiographic.. – Diffuse radiolucency without sclerotic demarcation. – Mottled osteoporosis and sclerotic areas after bone sequestra are formed.
    51. 51. Management of ORN
    52. 52. Conservative management• Daily local irrigation..salineor chlorohixidine.2%• Systemic antibiotics.• Avoidance of irritants..tobaco,alcohol,denture.• Good oral hyigene instructions.• General removal of sequestrum in sequestrating lesions.
    53. 53. HBO protocol– It is esablished protocols of the Undersea and Hyperbaric Medicine Society.– Either monoplace or multiplace chamber.– Each session 100% O2 @ 2.4 ATA for 90 min.– Increase the vascularity by 75%
    54. 54. • Allow healing ….– Angiogenesis.– Inducing fibroplasia and neocellularity.– Promoting survival of osteoprogenitor cells.– Promoting the formation of functional periosteum. HBO Protocol
    55. 55. Indication of HBO 1. Prophylaxis.. In surgical procedure in irradiated field. 2. Treatment of ORN. 3. Before bony and soft tissue reconstruction and before placement of dental implants in irradiated bone. 4. Treatment of Necrotizing Fascitis, gas gangrene and chronic refractory osteomyelitis.HBO Protocol
    56. 56. Prophylactic HBO before oral surgical procedureMarx et al 1991  300 pts  Incidence of ORN in non –HBO 30% compared with 5.4% in – HBO group.  HBO is very cost effective
    57. 57. Against:× overall risk of developing ORN with preradiation or postradiation extractions is quite low.× HBO therapy is expensive.× it is time consuming.× HBO has not definitely been shown to prevent the development of ORN, and it does not reverse established ORN.
    58. 58. Prophylactic HBO before oral surgical procedure• 20 sessions before • 100% O2 @2.4ATA-90 min. • Once daily treatment 5 days/week.• 10 sessions post op. 20/10
    59. 59. Prophylactic HBO before dental implantsAnimal and clinical studies treated with HBO showed:• Improved soft tissue wound healing .• Decreased dehiscence after implants with HBO.This study also showed:• Improved torque removal forces of implants.• Greater quantity of bone-implant contact in irradiated rabbit tibias treated with HBO compared with that not treated.
    60. 60. Against:The potential benefit of HBO therapy balanced against itscost and potential complications doesn’t justify its use.In 1997, the Journal of Oral and Maxillofacial Surgeryhighlighted a similar controversy. Keller and Larsen tookopposing views. Keller examined 14 studies of implants inradiated tissue without HBO, which had remarkable success.
    61. 61. Evidence supports enhanced long-term survival in all sites, but the clinician must weigh the availability, complications, andadded cost in the decision-making process.
    62. 62. Protocol for HBO therapy before implant placement• Good oral hygiene before &after implantation.• The use of the longest &widesttype and maximum no. of implants.• Implant delay until 6 months after radiation.
    63. 63. • Cessation of smoking.• Preop. HBO ( increase integration time by 3 months).• This protocol is the same for maxilla and the mandible.Protocol for HBO therapy before implant placement
    64. 64. • Previously integrated implants should be buried before irradiation and subjected to 20 HBO ttt before uncovering.Protocol for HBO therapy before implant placement
    65. 65. Gidlines of using HBO
    66. 66. Osteoradionecrosis TreatmentExposed Bone Exposed Bone with: Continued exposure A- not respond to stageII. B-pt who presents with: Stage I Stage I 1-pathologic Fx or 30 Session HBO Nonresponder 2-orocutaneous Fistula or 3-osteolysis to inferior border of 1-Bone softens. the mandible (radiographic). 2-Granulation tissue develops Dehiscence, cont. bone exposureStage I Responder Stage II Stage III Local debridment Surgical debridement 30 Session HBO 10 Session HBO 10 Session HBO 1-continuity resection. 2-Jaw stabilization. Bone and mucosa healed 3-Soft tissue flap if needed. 10 Session HBOResolution of ORN Resolution of ORN Resolution of ORN
    67. 67. • However, several studies have shown some benefit in using HBO in the management of Stage I and II ORN.• Most reconstructive surgeons currently usevascularized free tissue transfers instead of HBOtherapy in the management of stage III ORN.
    68. 68. Early criticism of microvascular reconstruction of the mandible included:• inadequate bone stock for prosthetic dental reconstruction,• prolonged ICU stay and hospitalization,• increased donor site morbidity. Experience with microvascular reconstruction has lessened these concerns.
    69. 69. Complication of HBO1-Barotrauma: Middle ear. Nasal sinus. Inner ear . Lung. Teeth.
    70. 70. 2-oxygen toxicity: CNS..seizur . Lung.. Pneumothorax &air embolism. Complication of HBO
    71. 71. 3- confinement anxiety.4- Ocular defect..myopia and catarct growth Complication of HBO
    72. 72. Contraindication of HBO
    73. 73. Guidelines for tooth extraction in Radio. or chemotherapy pt.• Perform extraction with minimal trauma.• Within first 4 months of radiotherapy ‘’Golden Window’’.
    74. 74. • Trim bone at wound margins to eliminate sharp edges.• Obtain primary closure.• Avoid intraalveolar haemostatic packing agents that can serve as nidus of microbial growth. Guidelines for tooth extraction in Radio. or chemotherapy pt.
    75. 75. • Transfuse if the platelet count is less than 50,000/mm3.• Delay if WBC < 2000/mm3. or absolute neutrophil is <1000/mm3. or expected to be this level within 10 days.• Prophylactic antibiotics (cephalosporin) may be used with extractions are mandatory. Guidelines for tooth extraction in Radio. or chemotherapy pt.
    76. 76. • Prophylaxis: – Penicillin V 500mg q4h one day pre op. – Continue for at least 3 days post op.
    77. 77. Bisphosphonate• It is a synthetic analog of inorganic pyrophosphate.• Which has high affinity to calcium.• Accumulate over extended periods in mineralized bone matrix.
    78. 78. • Used in : – Paget’s disease. – Osteoporosis. – hypercalcemia of malignancy. – Multiple myeloma in bone. – metastatic solid cancer like breast.
    79. 79. • Action : – Arrest bone loss. – Increase bone density. – Decrease bone fracture.
    80. 80. Rout of Administration •Etidronate (Didronell) •Pamidronate (Aredia) •Zoledronic acid (Zometal)
    81. 81. What does it do?• Bisphosphonate alter bone remodeling.• The drug is taken up by osteoclasts (cytoplasm). • Inhibit its function. • Induce apoptotic cell death.• Inhibits osteoblast mediated osteoclast resorbtion.• Antiangeogenic properties.
    82. 82. • In oral cavity, the maxilla and mandible are subjected to constant stress from masticatory forces.• The bone becomes brittle and unable to repair physiological micro-fractures occur in human skeleton.
    83. 83. • So a result from: – Low bone metabolism. – Local trauma – Increase demand for bone repair. – Infection – Hypovascularity.
    84. 84. Table 3. Dental risk factors for osteonecrosis of the jaw (ONJ).° Clinically and radiographically evident periodontitis17,38: severe periodontitis with chronic infection andinflammation of the supporting alveolar bone is a major risk factor for ONJ. This condition may be present in3%–5% of seventh-decade and older adults who still have teeth17° Tooth extraction: up to 60% of cases of ONJ have been reported in patients having had a recent toothextraction1,2,17,35,38,50,66° Concomitant or past oral infection35,48,66,77,78° Failing root canal treatment with retained periapical infection35° Trauma caused by removable dentures2,35,38,77° Implant placement, past or current1,2,17,78: newly placed implants have a poor healing rate in patients receivingIV bisphosphonates and hence are contraindicated1. Previously placed implants may have a higher rate offailure. This warrants further studyTable 4. Systemic and other risk factors for osteonecrosis of the jaw (ONJ).° Concomitant malignant disease and chemotherapy1,17,38,66,79° Glucocorticoid therapy1,17,35,66,80° Diabetes1,38,81° Advanced age: in review of cases of ONJ in patients with multiple myeloma, there was a 9% increase in therisk of developing ONJ with each decade of life82° Smoking and alcohol need to be evaluated further
    85. 85. Clinical picture of BRONJIn early stage:• No radiographic manifestation.• Bone exposure• Soft tissue dehiscence. Sever pain• Secondary infection.• Parasthesia from peripheral nerve compression
    86. 86. BRONJ Staging and Treatment• At RiskNo apparent exposed/necrotic bone in pt. treated with oral or I.V bisphosphonate.• Treatment: – No treatmen.t – Pt. education.
    87. 87. Stage 1:•Exposed /necrotic bone.•Asymptomatic.•No evidence of infection.Treatment: •Antibacterial mouth rinse. •F/U every 3 months. •Review indication for continued bisphosphonate therapy. •Pt. education.
    88. 88. Stage2:•Exposed/necrotic bone.•Pain and erythema. In the area of exposed bone.•With/without purulent drainage.•Treatment: •Symptomatic treatment. •Broad spectrum A/B. •Pain control. •Superficial debridement to relieve soft tissue irritation.
    89. 89. Stage3:•Exposed/necrotic bone.•Pain and infection•One or more of the following:•Extraoral fistula.•Osteolysis extending to the mandibular border.•Treatment: •Broad spectrum A/B. •Pain control. •Superficial debridement/resection for palliation and pain.
    90. 90. Full understanding of the behavior of the cancer as well as the treatment modality available will help you in optimal management of those patient
    91. 91. THANK YOU