1. MANAGEMENT OF HEAD & NECK RADIOTHERAPY PATIENTS Dr. Gillian Soskin General Medicine D344/QP344 March 11, 2005

2. Head & Neck Cancer Diagnosis

3. Squamous Cell Carcinoma 90% of all oral cancers 50% 5-year survival can occur in: tongue skin throat soft palate

4. Radiation Treatment Centres In Ontario Sudbury Ottawa Kingston Toronto London Windsor

5. Treatment plan is based on: anatomical considerations

6. Treatment plan is based on: Staging of disease using TNM classification Eg. T 3 N 2 M 0 laryngeal carcinoma Eg. T 3 N 2 M 0 laryngeal carcinoma

7. Treatment plan is based on: age of patient

8. Treatment plan is based on: co-morbid conditions

9. Treatment Options +/- OR

10. Treatment Options no treatment palliation

11. Dental Management Will involve : General Dentist Hygienist Dental Assistant Reception Staff

12. Dental Management And may involve:

13. Radiation Therapy External beam –most common –largest fields

14. Radiation Therapy Brachytherapy –interstitial implantation of radioisotope-filled needles

15. Radiation Therapy Brachytherapy –interstitial implantation of radioisotope-filled needles

16. Radiation Therapy Au grain or Iridium Implants

17. Radiation Dosimetry How much? Where?

18. How much radiation? 1 “rad” = 1 centiGray (cGy) 200 cGy per day 5 days per week 1000 cGy per week

19. How much radiation? Total dose ranges from 6000 cGy – 7000 cGy 6 – 7 WEEKS of treatment

20. 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!!!

21. Dental Consultation Clinical examination Clinical examination charting (odontogram) charting (odontogram) visual (other lesions?) visual (other lesions?) palpation palpation

22. Dental Consultation Radiographic examination Radiographic examination Panorex Panorex intra-oral films as required intra-oral films as required

23. Dental Consultation Diagnoses Diagnoses Dental Dental Caries Caries Periodontal disease Periodontal disease Other Pathology Other Pathology Medical Medical co-morbidities co-morbidities

24. Dental Consultation (cont.) Treatment Plan based on: Treatment Plan based on: prognosis of individual teeth prognosis of individual teeth past dental history (compliance) past dental history (compliance) sequelae and potential complications from radiotherapy sequelae and potential complications from radiotherapy LONG TERM RISKS! LONG TERM RISKS!

25. Dental Treatment Must be done immediately Must be done immediately no delay in radiotherapy no delay in radiotherapy cancer is progressing!! cancer is progressing!!

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

27. Dental Treatment Cleaning Cleaning Restorations Restorations Complete these during healing phase post-extraction

28. Dental Treatment Dentate? Dentate? fabricate custom fluoride trays fabricate custom fluoride trays

29. Dental Treatment Dentate? Dentate? daily topical application daily topical application 1.23% APF gel 1.23% APF gel 2% Neutral NaF gel 2% Neutral NaF gel

30. 4 minutes once a day EVERY DAY for the rest of your life!!

31. Dental Treatment Edentulous? Edentulous? Poorly-fitting dentures? Poorly-fitting dentures? Candida? Candida? Rx Nystatin before radiotherapy starts Rx Nystatin before radiotherapy starts

32. Acute Sequelae General Weight loss (variable) Weight loss (variable) Nausea +/- vomiting Nausea +/- vomiting Fatigue Fatigue Depression Depression

33. Acute Sequelae Extra-Oral Cutaneous burns Cutaneous burns Alopecia Alopecia Xeroderma Xeroderma

34. Acute Sequelae Intra-Oral Mucositis Mucositis erythema erythema ulceration ulceration

35. 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** CANDIDIASIS

36. TREATMENT: 2. Diphenhydramine (Benadryl) elixir Mixed with Kaopectate or Maalox 1:1 by pharmacist 15 mL (1 Tbsp.) P.O. prn pain Swish for 30 sec. then spit out ORAL MUCOSITIS

37. TREATMENT: 3.0.1% Hydrocortisone rinse 15 mL P.O. tid Swish for 30 sec. then spit out **contra-indicated if active viral lesions are present intra-orally** ORAL MUCOSITIS

38. Acute Sequelae Intra-Oral Xerostomia Xerostomia

39. Acute Sequelae Intra-Oral Hypogeusia (diminished taste) Hypogeusia (diminished taste) Odynophagia (painful swallowing) Odynophagia (painful swallowing) 2 o to mucositis/ulceration 2 o to mucositis/ulceration

40. Acute Sequelae Intra-Oral Dysphagia (difficulty swallowing) Dysphagia (difficulty swallowing) may necessitate J- tube may necessitate J- tube may persist 2 o to esophageal scarring may persist 2 o to esophageal scarring

41. Chronic Sequelae Xerostomia Xerostomia begins ~ 1 week into treatment begins ~ 1 week into treatment permanent! permanent!

42. Chronic Sequelae Problems with xerostomia Problems with xerostomia increased caries risk increased caries risk daily topical fluoride application daily topical fluoride application frequent recalls - every 3 months frequent recalls - every 3 months increased cost to patient increased cost to patient

43. Chronic Sequelae Problems with xerostomia Problems with xerostomia increased trauma risk increased trauma risk soft tissues very dry soft tissues very dry easily injured easily injured

44. Chronic Sequelae Problems with xerostomia Problems with xerostomia thick secretions thick secretions change in mucous:serous ratio change in mucous:serous ratio increased “gag” increased “gag” difficulty wearing dentures difficulty wearing dentures

45. Chronic Sequelae Problems with xerostomia Problems with xerostomia difficulty swallowing difficulty swallowing H2O with/between meals H2O with/between meals chronic Candidiasis chronic Candidiasis

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

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

48. Chronic Sequelae Physiotherapy for trismus Physiotherapy for trismus

49. Chronic Sequelae Edema Edema 2 o to decreased lymphatic drainage from fibrosis 2 o to decreased lymphatic drainage from fibrosis not usually a functional problem but cosmetic not usually a functional problem but cosmetic

50. Chronic Sequelae Impaired wound healing Impaired wound healing increased fibrosis increased fibrosis decreased circulation decreased circulation

51. Chronic Sequelae Impaired wound healing Impaired wound healing NO extractions without consultation NO extractions without consultation wait 6-9 months before dentures wait 6-9 months before dentures

52. Complications Post- radiotherapy Post- radiotherapy potential for healing worse potential for healing worse length of time is NOT self-limiting length of time is NOT self-limiting

53. Complications Soft tissue necrosis Soft tissue necrosis 2 o to trauma 2 o to ischemia 2 o to trauma 2 o to ischemia

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

55. Complications Definition: Osteoradionecrosis “death of bone following radiation”

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

57. Complications Problems with Osteoradionecrosis superinfection with bacteria/fungus superinfection with bacteria/fungus sharp spicules will traumatize other soft tissues - more problems sharp spicules will traumatize other soft tissues - more problems can be progressive, potential “en bloc” resection can be progressive, potential “en bloc” resection Treatment ***REFER*** Treatment ***REFER***

58. Hyperbaric Oxygen Therapy helps to promote vascularity growth of new blood vessels increased oxygen tension within tissues Therefore helps healing process

59. Hyperbaric Oxygen Therapy Prior to HBO

60. Hyperbaric Oxygen Therapy During HBO

61. Hyperbaric Oxygen Therapy Following HBO

62. Hyperbaric Oxygen Therapy Only 2 facilities in Ontario: Hamilton Toronto

63. Hyperbaric Oxygen Therapy Marx Protocol (Prophylaxis): 20 treatments Extractions 10 treatments

64. Hyperbaric Oxygen Therapy Marx Protocol (Osteoradionecrosis): 30 treatments Resection 10 treatments

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

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

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