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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.
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.
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
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
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.
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
Submukosa
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.
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
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