1. Module 7: Treatment Options

2. Surgery and/or Radiation Treatment usually involves surgery or radiation or both Chemotherapy primarily used as an adjunctive procedure in advanced cases Advanced lesions < 30% 5-year survival rate 9 - 25% of patients develop additional mouth or throat cancer

3. Treatment Oropharyngeal lesions: radiation therapy Lip lesions: surgically excised Tongue lesions: hemiglossectomy; then radiation Alveolar ridge cancer: segmental resection Metastasis to local lymph nodes: radical or modified radical neck dissection

4. Considerations Regarding Treatment Options The oral cavity is a complex structure composed of muscles, nerves, jaws, tongue and lubricated by the salivary glands. Rehabilitation must be considered prior to surgical or radiographical intervention.

5. Quality of Life Issues Nutrition Speech Appearance All functions must be addressed in treatment planning

6. Surgery Type depends upon the extent and location of cancer Wide local excision: soft tissue Resection: invaded bone Marginal resection: inferior border of mandible intact

7. Surgery Segmental resection: full height of mandible removed Composite resection: hard and soft tissue (nodes, mandible, and soft tissues--tongue or floor of the mouth)

8. Wide Local Excision Silverman, 2003

9. Silverman, 2003:98,100 Squamous Cell Carcinoma / Reconstruction

10. SCC of anterior maxillary gingiva and bone One month post-surgical Silverman, 2003 Squamous Cell Carcinoma (SCC)

11. Neck Dissections Comprehensive neck dissections include radical neck dissection and modified neck dissection. Radical neck dissection removes lymph nodes of the neck, the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.

12. Neck Dissections Modified neck dissection preserves the sternocleidomastoid muscle or internal jugular vein, or the spinal accessory nerve. Selective neck dissections remove lymph nodes only, preserving the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.

13. Radiation Therapy Radiation therapy is indicated following surgery if: –soft tissue margin positive –one or more lymph nodes exhibit extracapsular invasion –bone invasion present –more than one lymph node positive in the absence of extracapsular invasion –comorbid immunosuppressive disease present, or –perineural invasion occurred

14. Radiation Therapy CT and/or MRI scan, PET scanning Dental panoramic

15. Radiation Therapy Dental consult Extractions prior to beginning Fluoride Meticulous oral hygiene Osteoradionecrosis

16. Types of Radiation Therapy (EBRT) primary external-beam radiotherapy (IMRT) intensity-modulated radiotherapy (ISRT) brachytherapy or interstitial radiotherapy

17. Radiation Therapy Squamous cell carcinomaOne month postradiotherapy Silverman, 2003

18. Radiation Therapy Silverman, 2003

19. Brachytherapy Silverman, 2003:105

20. Chemotherapy Chemotherapy was primarily used as a palliative measure until fairly recently. It was typically administered before, during or after radiotherapy or surgery –neoadjuvant (before irradiation) –concurrent (during irradiation) –adjuvant (after irradiation)

21. Chemotherapy Several drugs currently being used include: –Paclitaxel (Taxol, Bristol-Myers Squibb) –Methotrexate –Bleomycin –Cisplatin –5-Fluorouracil Other research includes the use of: –Intraarterial chemotherapy –Intralesional chemotherapy

22. Care Prior to Cancer Therapy Comprehensive oral examination Understand cancer diagnosis/location/stage/planned treatment (prognosis, chemotherapy??, radiation field) Stabilize/resolve oral disease and institute preventive program

23. Care Prior to Cancer Therapy Goal: Eliminate dental disease that cannot be maintained lifelong in radiated field or that may cause infection of become symptomatic during chemotherapy High dose radiation therapy causes PERMANENT change in vascularity, cellularity of soft tissue, salivary gland and bone Chemotherapy causes reversible changes, highest risk if caused neutropenia

24. Telangiectasia and Telangiectasia and Mucosal Fibrosis Mucosal Fibrosis Silverman, 2003: 115

25. Care Prior to Cancer Therapy Oral Disease Status –Mucosal and periodontal health –Caries risk –Unerupted/impacted teeth –Root tips –Endodontic lesions –Past dental disease: caries / restorations / endo –Dental prostheses: condition / fit / function –Salivary function –Temporomandibular function –Oral hygiene effectiveness / patient motivation

26. Care Prior to Cancer Therapy At risk teeth in radiation field –Periodontal status (pockets > 5 mm, advanced attachment loss –Caries / restoration status –Partially erupted third molars –Endodontic lesions Goal: 1 – 2 weeks healing prior to radiation Atraumatic extraction with primary closure, no dressing in socket

27. Care Prior to Cancer Therapy Dental extractions of symptomatic teeth due to infection, if sufficient time for healing of extraction site prior to neutropenia; if insufficient healing time, cover with antibiotics Dental extractions considered if required between courses of multi-course chemotherapy, at time of count recovery

28. Care Prior to Cancer Therapy Preventive Program: 1.Gingival health: oral hygiene, chlorhexidine 2.Caries risk: oral hygiene, diet, fluoride carriers, chlorhexidine, saliva function 3.Mucosal health: mucositis preventive program 4.Mucosal infection: antifungal, oral hygiene 5.Saliva: sialogogue, mucolytic, mouth wetting 6.Lip lubrication 7.Reinforce tobacco / alcohol cessation

29. Oral Care During Cancer Therapy Mucositis: preventive program, pain management, diet instruction Oral hygiene Caries prevention Saliva management Lip lubrication Manage dental emergencies Manage oral mucosal infections Range of motion exercises for radiation patients Reinforce tobacco / alcohol cessation

30. Complications from Radiation Pain; neuropathy Xerostomia: low flow rate, thick consistency Loss of taste Cervical caries Epithelial atrophy Fibrosis of soft tissue and muscles Focal alopecia Focal hyperpigmentation Osteroradionecrosis Telangiectasias Dental prostheses fit / function Esthetic, speech concerns

31. Complications Acute mucositis 5 th week after radiation for base of the tongue squamous cell carcinoma Oral candidiasis in a patient with marked xerostomia Silverman, 2003: 114, 119

32. Mucositis Management Treatment of mucositis: –Symptomatic management: topical analgesics; systemic analgesics –Nutritional support –Developing therapies: cytokines/growth factors

33. Management of Hyposalivation Fluid intake, sugar free gum / candy Sialogogues: –Salagen –Evoxac –Bethanechol –Sialor Caries prevention Symptomatic (mouth wetting agents)

34. Oropharyngeal / Head / Neck Pain Treat cause when possible Topical analgesics / anesthetics Systemic analgesics Adjunctive medications (e.g. tricyclics) Muscle relaxants (myogenic pain) Physiotherapy (TMD, neck pain) Oral prostheses (TMD)

35. Follow-up of Cancer Patients Thorough head and neck and oral exam Salivary function, caries, demineralization risk, denture fit / function, oral hygiene, diet, mucosal condition, cancer risk Tobacco / alcohol cessation Risk of osteonecrosis with H&N RT; myelosuppression/immunosuppression Know medical therapy, prognosis, change in risk factors prior to treatment planning

36. Osteonecrosis Silverman, 2003:121 Two years after radiotherapyThree years after radiotherapy

37. Care Following Radiation Therapy Osteonecrosis: –Prevention: Pretreatment oral care Cancer therapy Amputation of crown, endodontics Atraumatic extraction if needed –Therapy: Hyperbaric oxygen, trental, Vitamin E Surgery – vascularized flaps

38. Complications National Institutes for Dental and Craniofacial Research (NIDCR) offers excellent free materials for patients Ordering information included in Resources section

39. Reconstruction Various methods of reconstruction follow surgery Deltopectoral flaps and pectoralis major muocutaneous flaps Bone and soft tissue grafts provide good cosmetic appearance and function Osseointegrated implants and dentures The fibula can be used to reconstruct the mandible

40. Silverman, 2003: 147 Reconstruction

41. Silverman 2003:146 Reconstruction Reconstruction

42. Summary Early detection of lesions is critical to allow conservative treatment and protect the patient’s quality of life. Many avenues are available to treat oral cancers, with improved methods constantly under investigation. A multidisciplinary team can help oral cancer patients deal with the aftermath of treatment.