PBL ORAL CANCER AND REHABILITATION TRIGGER 2

Ulcer – >1 month – Increasing in size – No pain – No history of trauma Habit – Smoking since 30 years, 20 sticks perday – No alcohol and betel nut intake O/E – Lesion: 3.5cm diameter with induration – Tongue mobility is good – Palpable fixed left submandibular lymph node of 2.5cm Incisional biopsy is taken Dx: squamous cell carcinoma

TNM Staging Txno available information on primary tumour T0no evidence of primary tumour TISonly carcinoma in-situ on primary sites T1<2 cm T22 to 4 cm T3>4 cm T4>4 cm, involvement of natrum, pterygoid muscles, base of tongue or skin NxCannot be assessed N0No clinical positive nodes N1Single, ipsilateral, <3 cm N2aSingle, ipsilateral, 3-6 cm N2bMultiple, ipsilateral, <6 cm N3aSingle/multiple, iIpsilateral node(s), one more than 6 cm N3bbilateral N3ccontralateral MxNot assessed M0No evidence M1Distant metastasis present

Cancer staging T2 N3c Stage IV

Histology Loss of well-architecture epithelium Cellular poleomorphism Hyperchromatism Formation of keratin pearl seen in those island or cord. Enlarge nuclei Increase nuclear cytoplasmic ratio Increase number of mitotic figure

Dental Management before radiotherapy A comprehensive oral assessment – Identify existing oral disease and potential risk of oral disease. – All sharp teeth and restorations are suitably adjusted and polished. – Remove infectious dental disease before the start of cancer therapy. Extraction – Wherever possible, teeth with a dubious prognosis are removed no less than ten days prior to cancer therapy. – Detailed oral hygiene instruction with reinforcement and elaboration of diet advice is provided in cooperation with the dietician. Periodontal disease Oral hygiene practices are supplemented with the use of an alcohol free chlorhexidine mouthwash or dental gel, if there is gingival disease diagnosed. Prosthesis The patient is counselled about denture wear during therapy. If aremovable prosthesis is worn, it is important to ensure that it is clean and well adapted to the tissue. The patient should be instructed not to wear the prosthesis during cancer therapy treatment, if possible; or at least, not to wear it at night. Ortho appliance Orthodontic treatment is discontinued.

Effect of radiotherapy During treatment: – severe xerostomia – mucositis and ulceration – acute candidosis – skin erythema Long term: – xerostomia – mucosal and skin atrophy – risk of osteomyelitis (osteoradionecrosis) – scarring and fibrosis of tissues – cataract if eye irradiated (eg: antral carcinoma) – risk of late radiation-induced malignancy

Management before surgery Monitor vital sign BP, pulse, respiratory rate,temperature, oxygen saturation Monitor blood glucose level Premedication before surgery – analgesic or antibiotic Patient education on the importance of deep breathing and coughing, regular gentle leg exercises and early mobilisation to reduce the risk of complications such as chest infection, deep-vein thrombosis and pulmonary embolism VTE prophylaxis - measure patient for anti-embolism stockings, foot impulse device or intermittent pneumatic compression device (NICE, 2010); Urinary catheter- if long surgical time is expected.

Management of oral cancer Lip cancer: treated mainly surgically Intraoral cancers < 4 cm in diameter: treated equally effectively by surgery or radiotherapy

T1 tumours: – generally managed surgically T2 tumours: – generally managed surgically. – However, tumours of the lateral margin of tongue may be treated by radiotherapy using external beam (40 Gy) plus radioactive iridium implants (25–30 Gy). – For many patients, the treatment must include treatment of the lymph nodes in the neck and thus often the treatment of choice is surgery (tumour excision with radical neck dissection), together with radiotherapy T3 tumours: – generally treated by surgery followed by radiotherapy if there is extracapsular spread or multiple lymph node involvement. – For many patients, the treatment must include treatment of the lymph nodes in the neck and thus often the treatment of choice is surgery (tumour excision with radical neck dissection),together with radiotherapy T4 tumours: – may be treated with chemo-radiotherapy. – Drugs used include cisplatin, fluorouracil (5-Fu) taxanes and methotrexate. – TPF is a common regimen (taxane platinum, 5-Fu)

Neck treatment N1: Supraomohyoid head and neck dissection N2a-b or N3: modified radial neck dissection N2c: radial neck dissection/ modified radial neck dissection

Oral cancer rehabilitation tongue and mandibular defect causes impaired speech articulation severe dysphagia in 1/3 posterior resection deviation of mandible during functional movement poor control of saliva secretion cosmetic disfigurement pt seldom return to presurgical level

functional defect remains because compromised motor and sensory control inadequate tissue control inadequate bulk of key tissue articulation of speech depend upon tongue mobility and the present of adequate tongue bulk

pt that underwent hemiglossectomy could benefit from swallowing therapy the intervention that can be apply: – postural changes – sensory procedure – manouver – diet changes – physiologic exercise – orofacial prosthetic

Role of dentist ​perform a competent oral cancer examination; ​describe oral lesions of local and systemic etiology;​ ​identify oral lesions that should raise the suspicion of malignancy​; ​appropriately select and consider using diagnostic adjuncts to assist in oral cancer early detectio​n;

​describe an approach to managing questionable and suspicious oral lesio​ns; ​develop and implement an office protocol for oral cancer screen​ing;​ ​discuss the role of the dentist in the comprehensive management of oral/head & neck cancer pati​ents​; ​articulate the ethical and medical/legal responsibility of dentists to screen for oral cancer, especially in high risk populations