With thw evolution of the medicine and increasing of the survival rate of cancer patients , its commonly to be seen in dental clinics. OMFS must know about their patients conditions , treatments and how to manage them in order to provide them good care and good life.

1. Management of Patients Undergoing
Cancer T herapy
Hanan Shanab

2. • Few information obtained from cancer pt. which is relevant to the
surgeon. .. Like:
– The type of treatment.
– The duration of treatment .
– Whether he is an outpatient or inpatient

3. There are three treatment modalities involved in
eradicating head and neck cancer:
(1) surgery;
(2) radiation therapy.
(3) Chemotherapy.

4. Combination Chemoradiotherapy
• Cetuximab is a chimeric monoclonal antibody that targets epidermal
growth factor receptor. The FDA approved cetuximab for treatment
of squamous cell carcinoma of the head and neck in March 2006.

5. Treatment modalities involved in eradicating head and
neck cancer:
(1) surgery;
(2) radiation therapy.
(3) Chemotherapy.
(1) Immunotherapy
(2) Gene therapy.
(3) Antiangiogenic therapy.

6. Pt . Evaluation before cancer therapy:
– Age of the pt.
– Condition of dentition.
– Level of oral hygiene and pt. attitude.
– Radiation field and dose.

7. Guidelines for extraction before
RTx
• All questionable ,carious teeth in the field of
radiation (>6000 cG) must be extracted.
• Optimal time for extraction is 21 days before the
beginning of RTx (not less than 2 w).

8. • Less optimally, extraction can be done
within 4 months after completion of RTx.
(after HBO)
• Perform radical alveolectomy with primary
soft tissue closure following extraction .

9. Radiotherapy
• More effective on well oxygenated and
mitotically active..
– Induce cell necrosis .
– Microvascular damage.
– Parenchyma and stromal damage.

10. Types of Radiation therapy
1-External beam radiation.
– (tumoricidal dose is 6000-7600 cGy)
– Hyperfractionated to 200 cGy for 5 days/week.
– 150-180 cGy twice daily-3-4 days/week
2- Interstitial Radiotherapy (brachytherapy).
Radium
Iridium- ½ life 74 days-no gaseous by product
3-Neutron Beam Radiotherapy.
Rarely used today

11. Chemotherapy
TYPES:
CCS CCNS
•Antimetabolites.
• Alkylating agents
•Hormons. • Antibiotics.
•Mitotic inhibitors

12. Complication of Cancer Therapy

13. Complication of Cancer Therapy
• 1-Mucositis.
• 2- Xerostomia.
• 3-secondary infection.
• 4- bleeding.
• 5-Muscle Trismus.
• 6-osteoradionecrosis.
• 7-alopecia.

14. 1-Mucositis.
– More in non keratinized tissues like palatal , buccal
mucosa , ventral tongue ..
– Started by the second week of radiation therapy.(if the
dose 200 cGy/week)
– 7th -14th day after chemotherapy.
Complications of Cancer Therapy

15. • More higher in young
pt…high division rate.
• Produce red,raw, tender
oral mucosa with
sloughing epi. ..Like burn..
• Pt. has dysphagia, pain,
loss of taste difficulty in
eating which increase
systemic infection. Its generally subsides 1-2
weeks after completion of
treatment.
Complication..Mucositis.

16. WHO Scale for Oral Mucositis
• Degree 0:
is when there are no signs or symptoms.
• Degree 1 :
is when the mucosa is erythematose and painful.
• Degree 2 :
is characterized by ulcers, and the patient can eat
normally.

17. • Degree 3 :
is when the patient has ulcers and can only
drink fluids.
• Degree 4 :
is when the patient cannot eat or drink.

18. Phases of Mucositis

19. Phase 1 (Initiation): radiation or chemotherapy causes DNA damage in
basal epithelial cells and generates reactive oxygen species (ROS), which
further damage cells and blood vessels in the submucosa.

20. Phase 2 (Signaling): chemotherapy, radiation,
induce apoptosis and upregulated inflammatory
cytokines in cells.

21. Phase 3 (Amplification): inflammatory cytokines produce
further tissue damage, amplifying signaling cascades and the
injury process.

22. Phase 4 (Ulceration): loss of mucosal integrity produces
extremely painful lesions, providing portals of entry for
bacteria, viruses, and fungi.

23. • Phase 5 (Healing): proliferation, differentiation, and
migration of epithelial cells to restore the integrity of the
mucosa.

24. Management of Mucositis
• 1-A bland mouth rinse (salt
and water).. To keep ulcerated areas
clean as possible.
• 2-Topical anesthesia and /or
antihistamine solution or with
coating agents (milk of
magnesia).

25. • 3-Anti microbial-
Chlorohixidine.12%
• 4-Anti-inflammatory or
topical steroids.
• 5-Diet consisting of soft food,
proteins, and vitamins
supplements at therapeutic
level.
Management of Mucositis

26. • 6-Oral lubricants and
lip palm ..containing
(beeswax).
• 7-Avoidance of alcohol,
tobacco and irritant
foods

27. 2-Xerostomia
• If major salivary gland have been irradiated.
• Occur following the onset of mucositis.
– Altered taste sensation.
– Increase susceptibility for caries and mucosal
inflammation.
– Difficult in swallowing, speech.

28. • Side effects of pain medicine: Opioids for
painful swallowing may cause dry mouth
and constipation.

29. Management of Xerstomia
• Recommended sugarless
lemon drops.
• Sorbitol-based chewing
gum.
• Buffered solution of
glycerine and water or
salivary substitutes.

30. 3-Secondary infection:
Causes:
• Decrease in quantity of salivary flow.
• Immunosuppressed (WBC<2000/mm3).
• In pt. receiving chemotherapy and antibiotics.

31. Fungal infection
• Candida albicans
• Candidal infection produce pain, burning taste and
intolerance to certain foods.
• The most common type is pseudomembranous
candidiasis.. Curdled milk
• Other forms (angular cheilosis and less common
hypertrophic form.

32. Bacterial infection
• Shift occurs in the oral flora to gram –ve that’s
Normally inhabit the GIT or respiratory tract like
Pseudomonas, Klebsielaa, Proteus, E coli,
Enterobacter.

33. Viral infection
• Recurrent herpes simplex (HSV).
• Occur often during chemotherapy and less
frequent with radiotherapy.
• Takes longer to heal.
• Mimic aphthous ulcer on nonkeratinized mucosa.

34. Management of Infection
• Cytology study.
• Culture any non
healed ulcerations
for Dx and for
accurate treatment.

35. For Candida infection :
– Oral nystatin suspention 100,000 IU/ml 4-5 times
daily.
– Cotrimazole (10mg 5 times daily).
– Systemic ketoconazol(Nizoral).
– Alternatively, putting pt. on granulocyte (monocyte)
colony-stimulating factor to elevate neutrophil count
to normal.
Management of Infection

36. For Viral infection:
• Enzyme-linked immunoassay for accurate Dx.
• For HSV antibody-positive pt:
– Acyclovir, famcyclovir, valcyclovir.
– Daily dose of at least 1 g.
Management of Infection

37. 4- Bleeding
• Pt. undergo total body irradiation
• High dose chemotherapy.
Thrombocytopenia

38. • Clinical signs:
– Plat. <50,000 cells/mm3
– Petechia, purpra on lateral margin of tongue.
– Gingival bleeding.
– Submucosal hemorrhage… from minor trauma

39. Management of Bleeding
• Avoid trauma to the oral cavity.
• Control bleeding by local measures by
– Pressure.
– Gelatine sponge.
– Thrombin or microfibrillar collagen.
– Antifibrinolytic rinse .. Amicar syrup 250mg/ml. on
soft vinyl mouth guard.
• Platelet transfusion in sever cases.

40. 5-Neural and chemosensory changes
• Diminshed taste sensation… damage of
microvilli of taste cells.
• Pt on chemotherapy complaints of
– bitter taste,
– unpleasent odors
– conditioned aversion of foods

41. • Neurotoxicity effect from chemotherapy
(vincristine and vinblastin).
• Occur in peripheral nerves.
• Pt. experience pain in molar area bilateral.

42. Management
• 1-Restore taste sensation within 3-4 months after
completion of radiotherapy.
• 2-In chronic loss of taste, zinc supplementation.
Silverman recommends 220 mg of zinc 2x/day.
• 3-No effective treatment for completely restores damaged
taste.

43. 6-Muscle Trismus
• Caused by radiation
therapy.
• Damage to the vasculature
of ms.(obliterative endoartritis).

44. – Progressive later
dysphagia from fibrosis
in the pharyngeal
musculature
– reduces nutritional
intake
– promotes aspiration.
Muscle Trismus

45. • Pneumonia and respiratory failure: Patients who have trouble
swallowing may aspirate when trying to eat or drink.
• Poor nutrition: Being unable to swallow normally makes it hard to
eat well. Wounds heal more slowly and the body is less able to fight
off infections.
• Use of tubefeeding: A patient who is not able to take in enough food
by mouth may be fed through a tube.

46. management
• Mouth block should be placed during
radiotherapy.
• Perform daily stretching exercises to improve
trismus. By using tongue plates for 3 times aday for 10 min
• Apply warm, moist heat on
the area.
Muscle Trismus

47. 7-Osteoradionecrosis
• Exposed bone for 6 months after high dose
of radiation.
• Results from:
– Radiation.
– Three-H tissue.(hypocellularity,hypoxia, hypovascularity)
– Tissue breakdown..necrosis
– nonhealing wound.

48. When the radiation dose is >7500 cGy.
• The mandible more affected than maxilla

49. • Clinically..
– Exposed bone, loss of soft tissue and bone.
– Pain (dysesthesia/anasthesia).
– Pathological fracture and orocutaneous fistula.
– Trismus.
– Soft tissue necrosis.

50. • Radiographic..
– Diffuse radiolucency without sclerotic demarcation.
– Mottled osteoporosis and sclerotic areas after bone sequestra are
formed.

51. Management of ORN

52. Conservative management
• Daily local irrigation..salineor chlorohixidine.2%
• Systemic antibiotics.
• Avoidance of irritants..tobaco,alcohol,denture.
• Good oral hyigene instructions.
• General removal of sequestrum in sequestrating lesions.

53. HBO protocol
– It is esablished protocols of the Undersea and
Hyperbaric Medicine Society.
– Either monoplace or multiplace chamber.
– Each session 100% O2 @ 2.4 ATA for 90 min.
– Increase the vascularity by 75%

54. • Allow healing ….
– Angiogenesis.
– Inducing fibroplasia and neocellularity.
– Promoting survival of osteoprogenitor cells.
– Promoting the formation of functional periosteum.
HBO Protocol

55. Indication of HBO
1. Prophylaxis.. In surgical procedure in irradiated
field.
2. Treatment of ORN.
3. Before bony and soft tissue reconstruction and
before placement of dental implants in irradiated
bone.
4. Treatment of Necrotizing Fascitis, gas gangrene and
chronic refractory osteomyelitis.
HBO Protocol

56. Prophylactic HBO before oral surgical
procedure
Marx et al 1991
 300 pts
 Incidence of ORN in non –HBO 30% compared with 5.4% in –
HBO group.
 HBO is very cost effective

57. Against:
× overall risk of developing ORN with preradiation or postradiation
extractions is quite low.
× HBO therapy is expensive.
× it is time consuming.
× HBO has not definitely been shown to prevent the development of
ORN, and it does not reverse established ORN.

58. Prophylactic HBO before oral
surgical procedure
• 20 sessions before
• 100% O2 @2.4ATA-90 min.
• Once daily treatment 5 days/week.
• 10 sessions post op.
20/10

59. Prophylactic HBO before dental
implants
Animal and clinical studies treated with HBO showed:
• Improved soft tissue wound healing .
• Decreased dehiscence after implants with HBO.
This study also showed:
• Improved torque removal forces of implants.
• Greater quantity of bone-implant contact in irradiated rabbit tibias
treated with HBO compared with that not treated.

60. Against:
The potential benefit of HBO therapy balanced against its
cost and potential complications doesn’t justify its use.
In 1997, the Journal of Oral and Maxillofacial Surgery
highlighted a similar controversy. Keller and Larsen took
opposing views. Keller examined 14 studies of implants in
radiated tissue without HBO, which had remarkable success.

61. Evidence supports enhanced long-term
survival in all sites, but the clinician must
weigh the availability, complications, and
added cost in the decision-making process.

62. Protocol for HBO therapy before
implant placement
• Good oral hygiene before &after
implantation.
• The use of the longest &widesttype and
maximum no. of implants.
• Implant delay until 6 months after
radiation.

63. • Cessation of smoking.
• Preop. HBO ( increase integration time by 3
months).
• This protocol is the same for maxilla and the
mandible.
Protocol for HBO therapy before implant placement

64. • Previously integrated implants should be
buried before irradiation and subjected to
20 HBO ttt before uncovering.
Protocol for HBO therapy before implant placement

65. Gidlines of using HBO

66. Osteoradionecrosis Treatment
Exposed Bone Exposed Bone with:
Continued
exposure
A- not respond to stageII.
B-pt who presents with:
Stage I Stage I 1-pathologic Fx or
30 Session HBO Nonresponder 2-orocutaneous Fistula or
3-osteolysis to inferior border of
1-Bone softens. the mandible (radiographic).
2-Granulation tissue develops
Dehiscence,
cont. bone exposure
Stage I Responder Stage II Stage III
Local debridment Surgical debridement 30 Session HBO
10 Session HBO 10 Session HBO
1-continuity resection.
2-Jaw stabilization.
Bone and mucosa healed 3-Soft tissue flap if
needed.
10 Session HBO
Resolution of ORN Resolution of ORN Resolution of ORN

67. • However, several studies have shown some
benefit in using HBO in the management of
Stage I and II ORN.
• Most reconstructive surgeons currently use
vascularized free tissue transfers instead of HBO
therapy in the management of stage III ORN.

68. Early criticism of microvascular reconstruction of
the mandible included:
• inadequate bone stock for prosthetic
dental reconstruction,
• prolonged ICU stay and hospitalization,
• increased donor site morbidity.
Experience with microvascular reconstruction has
lessened these concerns.

69. Complication of HBO
1-Barotrauma:
Middle ear.
Nasal sinus.
Inner ear .
Lung.
Teeth.

70. 2-oxygen toxicity:
CNS..seizur .
Lung.. Pneumothorax &air embolism.
Complication of HBO

71. 3- confinement anxiety.
4- Ocular defect..myopia and catarct growth
Complication of HBO

73. Contraindication of HBO

74. Guidelines for tooth extraction in Radio.
or chemotherapy pt.
• Perform extraction with minimal trauma.
• Within first 4 months of radiotherapy
‘’Golden Window’’.

75. • Trim bone at wound margins to eliminate
sharp edges.
• Obtain primary closure.
• Avoid intraalveolar haemostatic packing
agents that can serve as nidus of microbial
growth.
Guidelines for tooth extraction in Radio. or chemotherapy pt.

76. • Transfuse if the platelet count is less than
50,000/mm3.
• Delay if WBC < 2000/mm3. or absolute
neutrophil is <1000/mm3. or expected to be this
level within 10 days.
• Prophylactic antibiotics (cephalosporin) may be
used with extractions are mandatory.
Guidelines for tooth extraction in Radio. or chemotherapy pt.

77. • Prophylaxis:
– Penicillin V 500mg q4h one day pre op.
– Continue for at least 3 days post op.

79. Bisphosphonate
• It is a synthetic analog of inorganic pyrophosphate.
• Which has high affinity to calcium.
• Accumulate over extended periods in mineralized bone
matrix.

80. • Used in :
– Paget’s disease.
– Osteoporosis.
– hypercalcemia of malignancy.
– Multiple myeloma in bone.
– metastatic solid cancer like breast.

81. • Action :
– Arrest bone loss.
– Increase bone density.
– Decrease bone fracture.

82. Rout of Administration
•Etidronate (Didronell)
•Pamidronate (Aredia)
•Zoledronic acid (Zometal)

83. What does it do?
• Bisphosphonate alter bone remodeling.
• The drug is taken up by osteoclasts (cytoplasm).
• Inhibit its function.
• Induce apoptotic cell death.
• Inhibits osteoblast mediated osteoclast resorbtion.
• Antiangeogenic properties.

85. • In oral cavity, the maxilla and mandible are subjected to
constant stress from masticatory forces.
• The bone becomes brittle and unable to repair
physiological micro-fractures occur in human skeleton.

86. • So BRONJ..as a result from:
– Low bone metabolism.
– Local trauma
– Increase demand for bone repair.
– Infection
– Hypovascularity.

87. Table 3. Dental risk factors for osteonecrosis of the jaw (ONJ).
° Clinically and radiographically evident periodontitis17,38: severe periodontitis with chronic infection and
inflammation of the supporting alveolar bone is a major risk factor for ONJ. This condition may be present in
3%–5% of seventh-decade and older adults who still have teeth17
° Tooth extraction: up to 60% of cases of ONJ have been reported in patients having had a recent tooth
extraction1,2,17,35,38,50,66
° Concomitant or past oral infection35,48,66,77,78
° Failing root canal treatment with retained periapical infection35
° Trauma caused by removable dentures2,35,38,77
° Implant placement, past or current1,2,17,78: newly placed implants have a poor healing rate in patients receiving
IV bisphosphonates and hence are contraindicated1. Previously placed implants may have a higher rate of
failure. This warrants further study
Table 4. Systemic and other risk factors for osteonecrosis of the jaw (ONJ).
° Concomitant malignant disease and chemotherapy1,17,38,66,79
° Glucocorticoid therapy1,17,35,66,80
° Diabetes1,38,81
° Advanced age: in review of cases of ONJ in patients with multiple myeloma, there was a 9% increase in the
risk of developing ONJ with each decade of life82
° Smoking and alcohol need to be evaluated further

88. Clinical picture of BRONJ
In early stage:
• No radiographic manifestation.
• Bone exposure
• Soft tissue dehiscence. Sever pain
• Secondary infection.
• Parasthesia from peripheral nerve compression

89. BRONJ Staging and Treatment
• At Risk
No apparent exposed/necrotic bone in pt.
treated with oral or I.V bisphosphonate.
• Treatment:
– No treatmen.t
– Pt. education.

90. Stage 1:
•Exposed /necrotic bone.
•Asymptomatic.
•No evidence of infection.
Treatment:
•Antibacterial mouth rinse.
•F/U every 3 months.
•Review indication for continued bisphosphonate
therapy.
•Pt. education.

91. Stage2:
•Exposed/necrotic bone.
•Pain and erythema. In the area of exposed bone.
•With/without purulent drainage.
•Treatment:
•Symptomatic treatment.
•Broad spectrum A/B.
•Pain control.
•Superficial debridement to relieve soft tissue
irritation.

92. Stage3:
•Exposed/necrotic bone.
•Pain and infection
•One or more of the following:
•Extraoral fistula.
•Osteolysis extending to the mandibular border.
•Treatment:
•Broad spectrum A/B.
•Pain control.
•Superficial debridement/resection for palliation
and pain.

93. Full understanding of the
behavior of the cancer
as well as the
treatment modality
available will help you
in optimal
management of those
patient

94. THANK YOU