Pre R/T Dental Management Presenter: R1 鄭瑋之 Instructor: VS 陳靜容醫師 Date: 2012/3/16
Oral Assessment before R/T• Acute effects of RT: mucositis, altered salivary gland function and risk of mucosal infection.• Long-term effects of RT: hypovascularity, hypocellularity and hypoxia of the tissues, damage to the salivary glands and increased collagen synthesis resulting in fibrosis. The affected bone and soft tissue have a reduced capacity to remodel.• A consultation with a dental teamshould be completed before the start of therapy.
Oral Assessment before R/T1. A complete dental examination to identify preexisting problems.2. Prior to treatment, potentially complicating diseases should be corrected.3. Patient adherence to hygiene protocols are critical.
StrategiesBefore R/TMedical history Prior cancer history, risk factorsDeﬁnitive diagnosis Tumour size and typeDental knowledge Past and current dental careOral hygiene Current practicesComplete dental examination Mucosa, dentition, periodontium, TMJRadiographic examination Panoramic, selected periapical, bitewing Resting (> 0.1 mL/minute),Whole salivary ﬂow rates stimulated (> 1.0 mL/minute) Pulp tests, speciﬁc cultures (fungal, viral,Adjunctive tests as indicated bacterial)Prognosis (cure or palliation)Proposed radiation therapy Timing, dose, ﬁelds
Oral Assessment before R/T• All teeth, but especially those located within the radiation ﬁelds, should be closely evaluated.• Only 11.2% of patients required no dental treatment before RT.• The criteria for extractions before R/T are not universally accepted and are subject to clinical judgement.
Criteria for pre R/T extractions• Teeth in the high-dose radiation ﬁeld and – Caries (nonrestorable) – Active periapical disease (symptomatic teeth) – Moderate to severe periodontal disease – Lack of opposing teeth, compromised hygiene – Partial impactions or incomplete eruption – Extensive periapical lesions (if not chronic or well localized• A more aggressive dental management strategy should be considered for patients with limited previous dental care, poor oral hygiene and past dental or periodontal disease
Guidelines for extractions• At least 2 weeks, ideally 3 weeks, before R/T.• Trim bone at wound margins to eliminate sharp edges.• Primary closure should be done.• Intra alveolar hemostatic packing agents should be avoided that can serve as a nidus of microbeal growth.• If the platelets count is < 50000/mm3 than transfusion is mandatory.• Delay the extraction if the WBC < 2000/mm3 or absolute neutrophil is < 1000/mm3. Prophylatic antibiotics .
During R/T• Monitoring of the oral cavity• Systematically applied oral hygiene protocols may reduce the incidence, severity and duration of oral complications.• Frequent brushing with a soft-bristled toothbrush and ﬂuoride toothpaste or gel to help prevent plaque accumulation and demineralization or caries of the teeth.
StrategiesDuring R/T Brushing 2 to 4 times daily withMaintenance of good oral hygiene soft-bristled brush; ﬂossing daily Custom trays, brush-onDaily topical ﬂuoride prescription-strength ﬂuorideFrequent saline rinsesLip moisturizer (non-petroleum based)Passive jaw-opening exercises toreduce trismus
Side Effects of R/T• Directly affects the salivary glands, the mucosal membranes, the jaw muscles and bone.1. Dry mouth (xerostomia): loss of saliva periodontal disease, rampant caries, and oral fungal and bacterial infections.2. Oral Infection (Candida)3. Oral Mucositis: by the 3rd week of treatment4. Fibrosis around the mastication m. trismus5. Bone: blood flow↓, loss of osteocytes limited remodelling of bone and limited healing potential
If >40Gy , permanent Xerostomia dysfunction of the salivary glands should be expected. • Sialagogues residual functionSjogren’s disease • No optimal substitute for saliva: without rheologic and antimicrobial factors • Sugarless gum or lozenges, ice cubes or ice water, eating foods high in ascorbic acid, malic acid or citric acid, but not recommended in dentate patients
Xerostomia• For the prevention of rampant caries 1. Apply 1.1% neutral sodium fluoride gel daily (for at least 5 minutes) with a custom fitted vinyl tray. 2. Started on the first day of R/T and continued daily as long as salivary flow rates are low. 3. High-potency fluoride brush-on gels and dentifrices in those who are unable or unwilling to comply with the use of fluoride trays.
Oral Infection • A fungal, bacterial or viral culture • Candida ↑ during R/T (pseudomembranous, , chronic hyperplastic, chronic cheilitis) contraindications liver toxicityunpleasant flavour, may cause nausea and vomiting, high sucrose content.antifungal, antibacterial and antiplaque
Oral Infection• If CHX is used, it is important to note that nystatin and CHX should not be used concurrently, because chlorhexidine binds to nystatin, rendering both ineffective.• CHX should be used at least 30 minutes before or after the use of any other topical agents with which it may bind.• Viral infections, such as Herpes simplex 1 acyclovir or penciclovir (newer, with increased tissue penetration)
Mucositis• Combinations of rinses: interfere dilution• Isotonic saline/sodium bicarbonate• Prophylactic rinses with CHX Candida counts↓ but has no effect on mucositis.• Cheapest and easiest: a teaspoon (10 mL) of salt + a teaspoon (10 mL) of baking soda (sodium bicarbonate) in 8 ounces (250 mL) of water.• Oral rinses should be discontinued because of their drying and irritating effects.• The discomfort can be reduced with coating agents, topical anesthetics and analgesics.
Mucositis •occurs 12- 17 days after the initiation of therapy contraindications Risk of aspiration↑ Systemic absorption cardiac effectsLack of saliva and damaged taste buds Alter the sensation of taste (transient phenomenon) compensate by increasing intake of sugar
After R/T• After the completion of R/T, acute oral complications usually begin to resolve.• Oral exercises should be continued to reduce/prevent trismus.• Additional dietary adaptations• Long-term management and close follow-up of patients after radiation therapy is mandatory.• Excellent time to resolve any deferred dental care.
StrategiesAfter R/TComplete dental work that wasdeferred during radiotherapyMaintain integrity of teeth Especially those in radiation ﬁelds Check for oral hygiene, xerostomia, decalciﬁcation, decay, ORN,Frequent follow-up appointments metastatic disease, recurrent disease, new malignant disease
Osteoradionecrosis• Irreversible, progressive devitalization of irradiated bone• Most in the mandible, where vascularization is poor and bone density is high.• Symptoms: pain, orofacial fistulas, exposed necrotic bone, pathologic fracture and suppuration• One-third of cases occur spontaneously.• The majority result from extraction of teeth.• Incidence: dentate = edentulous*2• Poor oral hygiene and continued use of alcohol and tobacco may also lead to rapid onset of ORN.• Hyperbaric oxygen therapy in conjunction with surgery has better success rates.
Conclusion• The complications of radiotherapy must be considered thoroughly so that every effort is undertaken to minimize the oral morbidity of these patients before, during and after cancer treatment and throughout the patient’s lifetime.
Referrence1. Pamela J. Hancock, BSc, DMD, Joel B. Epstein, DMD, MSD, FRCD(C), Georgia Robins Sadler, BSN, MBA, PhD. Oral and Dental Management Related to Radiation Therapy for Head and Neck Cancer. J Can Dent Assoc 2003; 69(9):585–90.2. Jay Lucas, DMD, MD, David Rombach, DMD, MD, Joel Goldwein, MD. Effects of Radiotherapy on the Oral Cavity. November 1, 2001.3. Virendra Singh M.D.S., Sunita Malik M.D.S. Oral Care Of Patients Undergoing Chemotherapy And Radiotherapy: A Review Of Clinical Approach. The Internet Journal of Radiology ISSN: 1528- 8404.