MANAGEMENT OF HEAD

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MANAGEMENTOF HEAD NECK RADIOTHERAPY PATIENTS

• Dr. Gillian Soskin
• General Medicine D344/QP344
• March 11, 2005

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Head Neck Cancer Diagnosis
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Squamous Cell Carcinoma

• 90 of all oral cancers
• 50 5-year survival
• can occur in
• tongue
• skin
• throat
• soft palate

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Radiation Treatment Centres In Ontario
Sudbury
Ottawa
Kingston
London
Toronto
Windsor
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Treatment plan is based on

• anatomical considerations

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Treatment plan is based on

• Staging of disease using TNM classification
• Eg. T3N2M0 laryngeal carcinoma

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Treatment plan is based on

• age of patient

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Treatment plan is based on

• co-morbid conditions

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Treatment Options
OR
/-
/-
/-
/-
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Treatment Options

• no treatment
• palliation

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Dental Management

• Will involve

General Dentist Hygienist Dental
Assistant Reception Staff
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Dental Management

• And may involve

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Radiation Therapy

• External beam

• most common
• largest fields

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Radiation Therapy

• Brachytherapy
• interstitial implantation of radioisotope-filled
  needles

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Radiation Therapy

• Brachytherapy
• interstitial implantation of
• radioisotope-filled needles

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Radiation Therapy
Au grain or Iridium Implants
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Radiation Dosimetry

• How much?
• Where?

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How much radiation?
1 rad 1 centiGray (cGy) 200 cGy per
day 5 days per week 1000 cGy
per week
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How much radiation?
Total dose ranges from 6000 cGy 7000
cGy 6 7 WEEKS of treatment
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Where are the radiation fields?

• unilateral or bilateral?
• neck only?
• posterior mandible and neck?
• oral cavity and neck?
• base of skull to clavicles?

Impact on oral health!!!
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Dental Consultation

• Clinical examination
• charting (odontogram)
• visual (other lesions?)
• palpation

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Dental Consultation

• Radiographic examination
• Panorex
• intra-oral films as required

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Dental Consultation

• Diagnoses
• Dental
• Caries
• Periodontal disease
• Other Pathology
• Medical
• co-morbidities

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Dental Consultation (cont.)

• Treatment Plan based on
• prognosis of individual teeth
• past dental history (compliance)
• sequelae and potential complications from
  radiotherapy
• LONG TERM RISKS!

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Dental Treatment

• Must be done immediately
• no delay in radiotherapy
• cancer is progressing!!

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Dental Treatment

• Extractions
• abscesses, gross caries
• advanced periodontal disease
• heavily restored teeth w/ poor OH
• Must have 2 weeks healing prior to start of
  radiotherapy!!!

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Dental Treatment

• Cleaning
• Restorations
• Complete these during healing phase
  post-extraction

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Dental Treatment

• Dentate?
• fabricate custom fluoride trays

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Dental Treatment

• Dentate?
• daily topical application
• 1.23 APF gel
• 2 Neutral NaF gel

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4 minutes once a day EVERY DAY for the rest of
your life!!
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Dental Treatment

• Edentulous?
• Poorly-fitting dentures?
• Candida?
• Rx Nystatin before radiotherapy starts

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Acute Sequelae

• General
• Weight loss (variable)
• Nausea /- vomiting
• Fatigue
• Depression

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Acute Sequelae

• Extra-Oral
• Cutaneous burns
• Alopecia
• Xeroderma

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Acute Sequelae

• Intra-Oral
• Mucositis
• erythema
• ulceration

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CANDIDIASIS
TREATMENT 1. Nystatin 100,000 u/ml oral
suspension 5 mL (1 tsp.) P.O. qid
Swish for 1 min. and swallow If another
organism or systemic infection is suspected,
alert the medical oncologist immediately
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ORAL MUCOSITIS
TREATMENT 2. Diphenhydramine (Benadryl) elixir
Mixed with Kaopectate or Maalox 11 by
pharmacist 15 mL (1 Tbsp.) P.O. prn pain
Swish for 30 sec. then spit out
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ORAL MUCOSITIS

• TREATMENT
• 0.1 Hydrocortisone rinse
• 15 mL P.O. tid
• Swish for 30 sec. then spit out
• contra-indicated if active viral lesions
• are present intra-orally

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Acute Sequelae

• Intra-Oral
• Xerostomia

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Acute Sequelae

• Intra-Oral
• Hypogeusia (diminished taste)
• Odynophagia (painful swallowing)
• 2o to mucositis/ulceration

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Acute Sequelae

• Intra-Oral
• Dysphagia (difficulty swallowing)
• may necessitate J-tube
• may persist 2o to esophageal scarring

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Chronic Sequelae

• Xerostomia
• begins 1 week into treatment
• permanent!

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Chronic Sequelae

• Problems with xerostomia
• increased caries risk
• daily topical fluoride application
• frequent recalls - every 3 months
• increased cost to patient

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Chronic Sequelae

• Problems with xerostomia
• increased trauma risk
• soft tissues very dry
• easily injured

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Chronic Sequelae

• Problems with xerostomia
• thick secretions
• change in mucousserous ratio
• increased gag
• difficulty wearing dentures

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Chronic Sequelae

• Problems with xerostomia
• difficulty swallowing
• H2O with/between meals
• chronic Candidiasis

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Chronic Sequelae

• Trismus
• 2o to fibrosis of muscles
• exacerbated by pre-XRT trauma (ie. Surgery)

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Chronic Sequelae

• Problems with trismus
• impaired nutrition if severe
• very limited access for dental treatment
• restorations
• cleaning
• inability to make/wear dentures

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Chronic Sequelae

• Physiotherapy for trismus

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Chronic Sequelae

• Edema
• 2o to decreased lymphatic drainage from fibrosis
• not usually a functional problem but cosmetic

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Chronic Sequelae

• Impaired wound healing
• increased fibrosis
• decreased circulation

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Chronic Sequelae

• Impaired wound healing
• NO extractions without consultation
• wait 6-9 months before dentures

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Complications

• Post- radiotherapy
• potential for healing worse
• length of time is NOT self-limiting

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Complications

• Soft tissue necrosis
• 2o to trauma 2o to ischemia

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Complications

• Areas most susceptible
• hard/soft palate
• FOM, ventral surface of tongue
• mucosa overlying internal oblique ridge
• Treatment REFER

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Complications

• Definition Osteoradionecrosis
• death of bone
• following radiation

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Complications

• Osteoradionecrosis
• hypoxic injury
• devitalized bone will often not be painful!
• patient may not be aware of it - LOOK!
• radiographic changes may/may not be present
• CLD often a problem, source of trauma

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Complications

• Problems with Osteoradionecrosis
• superinfection with bacteria/fungus
• sharp spicules will traumatize other soft tissues
  - more problems
• can be progressive, potential en bloc resection
• Treatment REFER

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Hyperbaric Oxygen Therapy

• helps to promote vascularity
• growth of new blood vessels
• increased oxygen tension
• within tissues
• Therefore helps healing process

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Hyperbaric Oxygen Therapy
Prior to HBO
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Hyperbaric Oxygen Therapy
During HBO
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Hyperbaric Oxygen Therapy
Following HBO
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Hyperbaric Oxygen Therapy

• Only 2 facilities in Ontario
• Hamilton
• Toronto

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Hyperbaric Oxygen Therapy

• Marx Protocol (Prophylaxis)
• 20 treatments
• Extractions
• 10 treatments

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Hyperbaric Oxygen Therapy

• Marx Protocol (Osteoradionecrosis)
• 30 treatments
• Resection
• 10 treatments

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Summary

• Squamous cell carcinoma (head neck) represents
  4 of new cases
• Average age of population increasing
• Average practice will see these patients
• Long-term follow-up necessary
• Medical/dental management of these patients is
  complicated and requires a team approach

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References

• The Head Neck Radiotherapy Patient
• Part I Oral Manifestations of Radiation
  Therapy
• Part II Management of Oral Complications
• Compendium (1994), vol. 15(2), pp.250-260
• 
  15(4), pp.442-454
• Head Neck Cancer Patients Receiving Radiation
  Therapy
• ADA Oral Health Care Series

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References

• National Institute of Dental Craniofacial
  Research (www.nohic.nidcr.nih.gov)
• Canadian Cancer Society (www.cancer.ca)
• Oral Cancer Foundation
• (www.oralcancerfoundation.org)