Professional Documents
Culture Documents
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Surgery
Cytotoxic chemotherapy
Radiotherapy
Effects of radiotherapy on oral structures and
management of those effects
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Cure – eradication of all cancer
Benefit – long term survival
Some long term side effects are acceptable
Palliation – alleviate effects of cancer
eg relieve pain, shrink cancer with chemotherapy
Benefit - modest
Side effects of treatment should be slight
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Oral Cavity 1970-2005 : Overall stage
100
90
85% (461-234) S1
80
75% (575-249) S2
70
67% (2142-777) All
% SURVIVAL
60 65% (346-122) S3
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45% (701-157) S4
40
30
20
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0
12 24 36 48 60
MONTHS
95% CI Median
S1 461 419 363 316 267 234 [ 82, 88 ]
S2 575 502 427 361 308 249 [ 72, 79 ]
All 2142 1673 1326 1108 935 777 [ 64, 68 ]
S3l 346 266 211 175 147 122 [ 59, 70 ]
S4l 701 440 289 227 191 157 [ 40, 49 ] 36 Mths
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Anticancer drugs given by iv injection as a course,
either weekly or every 3 weeks over about 4 months
Acute effects
Nausea, vomiting
Mucositis, mouth and lip ulcers
Bone marrow suppression – thrombocytopenia, neutropenia
(may be severe), hence increased risk of infection
Late effects uncommon except after leukemia chemo
Used to treat cancers of breast, bowel, lung, lymphoma,
head and neck
If an invasive dental procedure is needed during
chemotherapy check FBC and discuss with the
oncology team
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X-rays are part of the electromagnetic spectrum
beyond UV
Low dose used for diagnostic x-rays
Very high dose radiation produces tissue
effects
Radiotherapy uses very high energy x-rays to
very high dose (shielding treatment room 1m
thick concrete)
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Treatment machine – linear accelerator
May use multiple beams of various shapes
RT course – daily, 5 days per week for 6-7
weeks
Sometimes cytotoxic chemotherapy is added,
concurrent with radiotherapy, does increase
cure rates but increased toxicity
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Can cover a wider volume than surgery
For head and neck cancer, RT is used as an
alternative to surgery or as supplementary
treatment with surgery
where surgery would produce functional defect, eg
early larynx tumours, nasopharynx, posterior tongue
where surgery unlikely to be curative
where surgery likely to leave microscopic disease
Oral cancer – surgery preferred to RT
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Design radiation target volume to cover
primary plus regional nodes
Design dose radiation according to bulk of
tumour at various sites.
eg macroscopic disease - high dose,
microscopic disease - lower dose
If a well lateral tumour then design
radiotherapy volume to treat unilateral
structures avoiding high dose to contralateral
structures
Fractionation of radiotherapy – multiple
smaller fractions gives less late side effects than
shorter courses
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PTV 60Gy PTV 70Gy
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Loss of taste
Xerostomia
Mucositis
Oral thrush
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Hyposalivation – xerostomia.
Lack of taste
Atrophy mucosa
Atrophy of alveolus – delay fitting dentures
until 6-12 months after RT
Dental caries, may be severe
Osteoradionecrosis of the mandible
Trismus
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Hyposalivation - decreased saliva. Sometimes
symptoms of xerostomia improve a little over
time.
Increased viscosity
Acid saliva, from the normal pH 7 down to pH
5
Altered oral flora with increase acidogenic and
cariogenic organisms (Streptococcus mutans,
Lactobaccillus, Candida)
Altered electrolytes, effect remineralisation of
dentine
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Fluids frequent sips of water
Artificial saliva – based on
carboxymethylcellulose or mucin
Bicarbonate mouth washes
Neutral chewing gum
Treat oral thrush
Antiseptic mouth washes to treat infective
organisms
Pilocarpine – limited benefit
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Hypersensitivity of teeth initially
Decreased remineralisation
Increased caries, which may be severe, rapid
onset, painless
Caries may have a different pattern to usual, on
labial surfaces at dentin-enamel junction, and
may include mandibular anterior teeth
Black brown discoloration of entire tooth
crown
Dentin microhardness effected, enamel chips
break off
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Maxillofacial surgeon assessment prior to radiotherapy
Poor teeth extracted prior to RT
Good teeth preserved in moderate dose region
Molars in the high radiation dose region may be
extracted with alveoplasty and healing prior to RT
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Osteoradionecrosis of mandible
Factors
high radiation dose
trauma
infection
Avoid trauma to area of mandible that has
received very high radiation dose
Get information on radiation dose prior to dental
extraction
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High activity bisphosphonates
Zoldronate
Pamidronate
Above drugs mainly used for myeloma and breast
cancer
Sclerosis of bone
Trauma may precipitate osteonecrosis
Minor – small area of ulceration of mucosa over
alveolus with exposure of superficial mandible.
Sometimes small spicules of bone can be extruded.
Avoid trauma eg from dentures rubbing mandible
Treat any sharp areas causing abrasion
Tetracycline
Hyperbaric oxygen
Major – deep area of necrosis, infection
This is a major problem, difficult to treat
Management by a Maxillofacial surgeon
Drain abscess
Debride necrotic tissue (caution: trauma can exacerbate
osteoradionecrosis)
High dose broad spectrum antibiotics (infectious disease
specialist)
Hyperbaric oxygen
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Results of treatment of head and neck cancer
usually good
Chemotherapy effects are acute
Radiotherapy important treatment method
Radiotherapy to mouth has significant long
term side effects on saliva, teeth and mandible
As the results of treatment improve, it is
possible more dentists will come in contact
with patients who are having chemotherapy or
who have previously had radiotherapy
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Kielbassa AJ et al. Radiation-related damage to
dentition.
Lancet Oncology 2006;7:326-35.
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