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MANAGEMENT OF  HEAD & NECK RADIOTHERAPY PATIENTS Dr. Gillian Soskin General   Medicine D344/QP344
Head & Neck Cancer Diagnosis
Squamous Cell Carcinoma <ul><li>90% of all oral cancers </li></ul><ul><li>50% 5-year survival </li></ul><ul><li>can occur ...
Radiation Treatment Centres In Ontario Sudbury Ottawa Kingston Toronto London Windsor
Treatment plan is based on: <ul><li>anatomical considerations </li></ul>
Treatment plan is based on: <ul><li>Staging of disease using  TNM  classification </li></ul><ul><ul><li>Eg. T 3 N 2 M 0  l...
Treatment plan is based on: <ul><li>age of patient </li></ul>
Treatment plan is based on: <ul><li>co-morbid conditions </li></ul>
Treatment Options +/- +/- +/- +/- OR
Treatment Options <ul><li>no treatment </li></ul><ul><li>palliation </li></ul>
Dental Management <ul><li>Will involve : </li></ul>General Dentist Hygienist Dental Assistant Reception Staff
Dental Management <ul><li>And may involve: </li></ul>
Radiation Therapy <ul><li>External beam </li></ul><ul><li>most common </li></ul><ul><li>largest fields </li></ul>
Radiation Therapy <ul><li>Brachytherapy </li></ul><ul><ul><li>interstitial implantation of radioisotope-filled needles </l...
Radiation Therapy <ul><li>Brachytherapy </li></ul><ul><ul><li>interstitial implantation of  </li></ul></ul><ul><ul><li>rad...
Radiation Therapy Au grain or Iridium Implants
Radiation Dosimetry <ul><li>How much? </li></ul><ul><li>Where? </li></ul>
How much radiation? 1 “rad” = 1 centiGray (cGy) 200 cGy per day 5 days per week 1000 cGy per week
How much radiation? Total dose ranges from 6000 cGy – 7000 cGy 6 – 7 WEEKS of treatment
Where are the radiation fields? <ul><li>unilateral or bilateral? </li></ul><ul><li>neck only? </li></ul><ul><li>posterior ...
Dental Consultation  <ul><li>Clinical examination </li></ul><ul><ul><ul><li>charting (odontogram) </li></ul></ul></ul><ul>...
Dental Consultation  <ul><li>Radiographic examination </li></ul><ul><ul><ul><li>Panorex </li></ul></ul></ul><ul><ul><ul><l...
Dental Consultation  <ul><li>Diagnoses </li></ul><ul><ul><li>Dental </li></ul></ul><ul><ul><ul><li>Caries </li></ul></ul><...
Dental Consultation (cont.) <ul><li>Treatment Plan based on: </li></ul><ul><ul><li>prognosis of individual teeth </li></ul...
Dental Treatment <ul><li>Must be done immediately </li></ul><ul><ul><li>no delay in radiotherapy </li></ul></ul><ul><ul><l...
Dental Treatment <ul><li>Extractions </li></ul><ul><ul><li>abscesses, gross caries </li></ul></ul><ul><ul><li>advanced per...
Dental Treatment  <ul><li>Cleaning </li></ul><ul><li>Restorations </li></ul><ul><li>Complete these during healing phase po...
Dental Treatment  <ul><li>Dentate? </li></ul><ul><ul><li>fabricate custom fluoride trays </li></ul></ul>
Dental Treatment  <ul><li>Dentate? </li></ul><ul><ul><li>daily topical application </li></ul></ul><ul><ul><li>1.23% APF ge...
4 minutes once a day EVERY DAY for the rest of your life!!
Dental Treatment  <ul><li>Edentulous? </li></ul><ul><ul><li>Poorly-fitting dentures? </li></ul></ul><ul><ul><li>Candida?  ...
Acute Sequelae <ul><li>General </li></ul><ul><li>Weight loss (variable) </li></ul><ul><li>Nausea +/- vomiting </li></ul><u...
Acute Sequelae <ul><li>Extra-Oral </li></ul><ul><li>Cutaneous burns </li></ul><ul><li>Alopecia </li></ul><ul><li>Xeroderma...
Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Mucositis </li></ul><ul><ul><li>erythema </li></ul></ul><ul><ul><li>ul...
  TREATMENT:  1.  Nystatin 100,000 u/ml oral suspension   5 mL (1 tsp.) P.O. qid   Swish for 1 min. and  swallow ** If ano...
<ul><li>TREATMENT: </li></ul><ul><ul><li>2.  Diphenhydramine (Benadryl) elixir </li></ul></ul><ul><ul><li>Mixed with Kaope...
<ul><li>TREATMENT:  </li></ul><ul><li>0.1% Hydrocortisone rinse </li></ul><ul><li>15 mL P.O. tid </li></ul><ul><li>Swish f...
Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Xerostomia </li></ul>
Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Hypogeusia (diminished taste) </li></ul><ul><li>Odynophagia (painful s...
Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Dysphagia (difficulty swallowing) </li></ul><ul><ul><li>may necessitat...
Chronic Sequelae <ul><li>Xerostomia </li></ul><ul><ul><li>begins ~ 1 week into treatment </li></ul></ul><ul><ul><li>perman...
Chronic Sequelae <ul><li>Problems with xerostomia </li></ul><ul><ul><li>increased  caries  risk </li></ul></ul><ul><ul><ul...
Chronic Sequelae <ul><li>Problems with xerostomia   </li></ul><ul><ul><li>increased  trauma  risk </li></ul></ul><ul><ul><...
Chronic Sequelae <ul><li>Problems with xerostomia  </li></ul><ul><ul><li>thick secretions </li></ul></ul><ul><ul><ul><li>c...
Chronic Sequelae <ul><li>Problems with xerostomia  </li></ul><ul><ul><li>difficulty swallowing </li></ul></ul><ul><ul><ul>...
Chronic Sequelae <ul><li>Trismus </li></ul><ul><ul><li>2 o  to fibrosis of muscles </li></ul></ul><ul><ul><li>exacerbated ...
Chronic Sequelae <ul><li>Problems with trismus </li></ul><ul><ul><li>impaired nutrition if severe </li></ul></ul><ul><ul><...
Chronic Sequelae <ul><li>Physiotherapy for trismus </li></ul>
Chronic Sequelae <ul><li>Edema </li></ul><ul><ul><li>2 o  to decreased lymphatic drainage from fibrosis </li></ul></ul><ul...
Chronic Sequelae <ul><li>Impaired wound healing </li></ul><ul><ul><ul><li>increased fibrosis  </li></ul></ul></ul><ul><ul>...
Chronic Sequelae <ul><li>Impaired wound healing </li></ul><ul><ul><ul><li>NO extractions without consultation </li></ul></...
Complications <ul><li>Post- radiotherapy </li></ul><ul><ul><li>potential for healing worse </li></ul></ul><ul><ul><li>leng...
Complications <ul><li>Soft tissue necrosis </li></ul><ul><ul><li>2 o  to trauma  2 o  to ischemia </li></ul></ul>
Complications <ul><li>Areas most susceptible </li></ul><ul><ul><li>hard/soft palate </li></ul></ul><ul><ul><li>FOM, ventra...
Complications <ul><li>Definition:   Osteoradionecrosis </li></ul><ul><li>“ death of bone  </li></ul><ul><li>following radi...
Complications <ul><li>Osteoradionecrosis </li></ul><ul><ul><li>hypoxic injury </li></ul></ul><ul><ul><li>devitalized bone ...
Complications  <ul><li>Problems with Osteoradionecrosis </li></ul><ul><ul><li>superinfection with bacteria/fungus </li></u...
Hyperbaric Oxygen Therapy <ul><li>helps to promote vascularity </li></ul><ul><li>growth of new blood vessels </li></ul><ul...
Hyperbaric Oxygen Therapy Prior to HBO
Hyperbaric Oxygen Therapy During HBO
Hyperbaric Oxygen Therapy Following HBO
Hyperbaric Oxygen Therapy <ul><li>Only 2 facilities in Ontario: </li></ul><ul><li>Hamilton </li></ul><ul><li>Toronto </li>...
Hyperbaric Oxygen Therapy <ul><li>Marx Protocol (Prophylaxis): </li></ul><ul><li>20 treatments </li></ul><ul><li>Extractio...
Hyperbaric Oxygen Therapy <ul><li>Marx Protocol (Osteoradionecrosis): </li></ul><ul><li>30 treatments </li></ul><ul><li>Re...
Summary <ul><li>Squamous cell carcinoma (head & neck) represents 4% of new cases </li></ul><ul><li>Average age of populati...
References <ul><li>The Head & Neck Radiotherapy Patient </li></ul><ul><li>Part I:  Oral Manifestations of Radiation Therap...
References <ul><li>National Institute of Dental & Craniofacial Research ( www.nohic.nidcr.nih.gov ) </li></ul><ul><li>Cana...
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Managementof Head & Neck Radiotherapy Patients

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Managementof Head & Neck Radiotherapy Patients

  1. 1. MANAGEMENT OF HEAD & NECK RADIOTHERAPY PATIENTS Dr. Gillian Soskin General Medicine D344/QP344
  2. 2. Head & Neck Cancer Diagnosis
  3. 3. Squamous Cell Carcinoma <ul><li>90% of all oral cancers </li></ul><ul><li>50% 5-year survival </li></ul><ul><li>can occur in: </li></ul><ul><ul><li>tongue </li></ul></ul><ul><ul><li>skin </li></ul></ul><ul><ul><li>throat </li></ul></ul><ul><ul><li>soft palate </li></ul></ul>
  4. 4. Radiation Treatment Centres In Ontario Sudbury Ottawa Kingston Toronto London Windsor
  5. 5. Treatment plan is based on: <ul><li>anatomical considerations </li></ul>
  6. 6. Treatment plan is based on: <ul><li>Staging of disease using TNM classification </li></ul><ul><ul><li>Eg. T 3 N 2 M 0 laryngeal carcinoma </li></ul></ul>
  7. 7. Treatment plan is based on: <ul><li>age of patient </li></ul>
  8. 8. Treatment plan is based on: <ul><li>co-morbid conditions </li></ul>
  9. 9. Treatment Options +/- +/- +/- +/- OR
  10. 10. Treatment Options <ul><li>no treatment </li></ul><ul><li>palliation </li></ul>
  11. 11. Dental Management <ul><li>Will involve : </li></ul>General Dentist Hygienist Dental Assistant Reception Staff
  12. 12. Dental Management <ul><li>And may involve: </li></ul>
  13. 13. Radiation Therapy <ul><li>External beam </li></ul><ul><li>most common </li></ul><ul><li>largest fields </li></ul>
  14. 14. Radiation Therapy <ul><li>Brachytherapy </li></ul><ul><ul><li>interstitial implantation of radioisotope-filled needles </li></ul></ul>
  15. 15. Radiation Therapy <ul><li>Brachytherapy </li></ul><ul><ul><li>interstitial implantation of </li></ul></ul><ul><ul><li>radioisotope-filled needles </li></ul></ul>
  16. 16. Radiation Therapy Au grain or Iridium Implants
  17. 17. Radiation Dosimetry <ul><li>How much? </li></ul><ul><li>Where? </li></ul>
  18. 18. How much radiation? 1 “rad” = 1 centiGray (cGy) 200 cGy per day 5 days per week 1000 cGy per week
  19. 19. How much radiation? Total dose ranges from 6000 cGy – 7000 cGy 6 – 7 WEEKS of treatment
  20. 20. Where are the radiation fields? <ul><li>unilateral or bilateral? </li></ul><ul><li>neck only? </li></ul><ul><li>posterior mandible and neck? </li></ul><ul><li>oral cavity and neck? </li></ul><ul><li>base of skull to clavicles? </li></ul>Impact on oral health!!!
  21. 21. Dental Consultation <ul><li>Clinical examination </li></ul><ul><ul><ul><li>charting (odontogram) </li></ul></ul></ul><ul><ul><ul><li>visual (other lesions?) </li></ul></ul></ul><ul><ul><ul><li>palpation </li></ul></ul></ul>
  22. 22. Dental Consultation <ul><li>Radiographic examination </li></ul><ul><ul><ul><li>Panorex </li></ul></ul></ul><ul><ul><ul><li>intra-oral films as required </li></ul></ul></ul>
  23. 23. Dental Consultation <ul><li>Diagnoses </li></ul><ul><ul><li>Dental </li></ul></ul><ul><ul><ul><li>Caries </li></ul></ul></ul><ul><ul><ul><li>Periodontal disease </li></ul></ul></ul><ul><ul><ul><li>Other Pathology </li></ul></ul></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><ul><li>co-morbidities </li></ul></ul></ul>
  24. 24. Dental Consultation (cont.) <ul><li>Treatment Plan based on: </li></ul><ul><ul><li>prognosis of individual teeth </li></ul></ul><ul><ul><li>past dental history (compliance) </li></ul></ul><ul><ul><li>sequelae and potential complications from radiotherapy </li></ul></ul><ul><ul><li>LONG TERM RISKS! </li></ul></ul>
  25. 25. Dental Treatment <ul><li>Must be done immediately </li></ul><ul><ul><li>no delay in radiotherapy </li></ul></ul><ul><ul><li>cancer is progressing!! </li></ul></ul>
  26. 26. Dental Treatment <ul><li>Extractions </li></ul><ul><ul><li>abscesses, gross caries </li></ul></ul><ul><ul><li>advanced periodontal disease </li></ul></ul><ul><ul><li>heavily restored teeth w/ poor OH </li></ul></ul><ul><ul><li>Must have 2 weeks healing prior to start of radiotherapy!!! </li></ul></ul>
  27. 27. Dental Treatment <ul><li>Cleaning </li></ul><ul><li>Restorations </li></ul><ul><li>Complete these during healing phase post-extraction </li></ul>
  28. 28. Dental Treatment <ul><li>Dentate? </li></ul><ul><ul><li>fabricate custom fluoride trays </li></ul></ul>
  29. 29. Dental Treatment <ul><li>Dentate? </li></ul><ul><ul><li>daily topical application </li></ul></ul><ul><ul><li>1.23% APF gel </li></ul></ul><ul><ul><li>2% Neutral NaF gel </li></ul></ul>
  30. 30. 4 minutes once a day EVERY DAY for the rest of your life!!
  31. 31. Dental Treatment <ul><li>Edentulous? </li></ul><ul><ul><li>Poorly-fitting dentures? </li></ul></ul><ul><ul><li>Candida? </li></ul></ul><ul><ul><ul><li>Rx Nystatin before radiotherapy starts </li></ul></ul></ul>
  32. 32. Acute Sequelae <ul><li>General </li></ul><ul><li>Weight loss (variable) </li></ul><ul><li>Nausea +/- vomiting </li></ul><ul><li>Fatigue </li></ul><ul><li>Depression </li></ul>
  33. 33. Acute Sequelae <ul><li>Extra-Oral </li></ul><ul><li>Cutaneous burns </li></ul><ul><li>Alopecia </li></ul><ul><li>Xeroderma </li></ul>
  34. 34. Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Mucositis </li></ul><ul><ul><li>erythema </li></ul></ul><ul><ul><li>ulceration </li></ul></ul>
  35. 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. 36. <ul><li>TREATMENT: </li></ul><ul><ul><li>2. Diphenhydramine (Benadryl) elixir </li></ul></ul><ul><ul><li>Mixed with Kaopectate or Maalox 1:1 </li></ul></ul><ul><ul><li>by pharmacist </li></ul></ul><ul><ul><li>15 mL (1 Tbsp.) P.O. prn pain </li></ul></ul><ul><ul><li>Swish for 30 sec. then spit out </li></ul></ul>ORAL MUCOSITIS
  37. 37. <ul><li>TREATMENT: </li></ul><ul><li>0.1% Hydrocortisone rinse </li></ul><ul><li>15 mL P.O. tid </li></ul><ul><li>Swish for 30 sec. then spit out </li></ul><ul><li>**contra-indicated if active viral lesions </li></ul><ul><li>are present intra-orally** </li></ul>ORAL MUCOSITIS
  38. 38. Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Xerostomia </li></ul>
  39. 39. Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Hypogeusia (diminished taste) </li></ul><ul><li>Odynophagia (painful swallowing) </li></ul><ul><ul><li>2 o to mucositis/ulceration </li></ul></ul>
  40. 40. Acute Sequelae <ul><li>Intra-Oral </li></ul><ul><li>Dysphagia (difficulty swallowing) </li></ul><ul><ul><li>may necessitate J-tube </li></ul></ul><ul><ul><li>may persist 2 o to esophageal scarring </li></ul></ul>
  41. 41. Chronic Sequelae <ul><li>Xerostomia </li></ul><ul><ul><li>begins ~ 1 week into treatment </li></ul></ul><ul><ul><li>permanent! </li></ul></ul>
  42. 42. Chronic Sequelae <ul><li>Problems with xerostomia </li></ul><ul><ul><li>increased caries risk </li></ul></ul><ul><ul><ul><li>daily topical fluoride application </li></ul></ul></ul><ul><ul><ul><li>frequent recalls - every 3 months </li></ul></ul></ul><ul><ul><ul><li>increased cost to patient </li></ul></ul></ul>
  43. 43. Chronic Sequelae <ul><li>Problems with xerostomia </li></ul><ul><ul><li>increased trauma risk </li></ul></ul><ul><ul><ul><li>soft tissues very dry </li></ul></ul></ul><ul><ul><ul><li>easily injured </li></ul></ul></ul>
  44. 44. Chronic Sequelae <ul><li>Problems with xerostomia </li></ul><ul><ul><li>thick secretions </li></ul></ul><ul><ul><ul><li>change in mucous:serous ratio </li></ul></ul></ul><ul><ul><ul><li>increased “gag” </li></ul></ul></ul><ul><ul><ul><li>difficulty wearing dentures </li></ul></ul></ul>
  45. 45. Chronic Sequelae <ul><li>Problems with xerostomia </li></ul><ul><ul><li>difficulty swallowing </li></ul></ul><ul><ul><ul><li>H2O with/between meals </li></ul></ul></ul><ul><ul><li>chronic Candidiasis </li></ul></ul>
  46. 46. Chronic Sequelae <ul><li>Trismus </li></ul><ul><ul><li>2 o to fibrosis of muscles </li></ul></ul><ul><ul><li>exacerbated by pre-XRT trauma (ie. Surgery) </li></ul></ul>
  47. 47. Chronic Sequelae <ul><li>Problems with trismus </li></ul><ul><ul><li>impaired nutrition if severe </li></ul></ul><ul><ul><li>very limited access for dental treatment </li></ul></ul><ul><ul><ul><li>restorations </li></ul></ul></ul><ul><ul><ul><li>cleaning </li></ul></ul></ul><ul><ul><ul><li>inability to make/wear dentures </li></ul></ul></ul>
  48. 48. Chronic Sequelae <ul><li>Physiotherapy for trismus </li></ul>
  49. 49. Chronic Sequelae <ul><li>Edema </li></ul><ul><ul><li>2 o to decreased lymphatic drainage from fibrosis </li></ul></ul><ul><ul><li>not usually a functional problem but cosmetic </li></ul></ul>
  50. 50. Chronic Sequelae <ul><li>Impaired wound healing </li></ul><ul><ul><ul><li>increased fibrosis </li></ul></ul></ul><ul><ul><ul><li>decreased circulation </li></ul></ul></ul>
  51. 51. Chronic Sequelae <ul><li>Impaired wound healing </li></ul><ul><ul><ul><li>NO extractions without consultation </li></ul></ul></ul><ul><ul><ul><li>wait 6-9 months before dentures </li></ul></ul></ul>
  52. 52. Complications <ul><li>Post- radiotherapy </li></ul><ul><ul><li>potential for healing worse </li></ul></ul><ul><ul><li>length of time is NOT self-limiting </li></ul></ul>
  53. 53. Complications <ul><li>Soft tissue necrosis </li></ul><ul><ul><li>2 o to trauma 2 o to ischemia </li></ul></ul>
  54. 54. Complications <ul><li>Areas most susceptible </li></ul><ul><ul><li>hard/soft palate </li></ul></ul><ul><ul><li>FOM, ventral surface of tongue </li></ul></ul><ul><ul><li>mucosa overlying internal oblique ridge </li></ul></ul><ul><li>Treatment ***REFER*** </li></ul>
  55. 55. Complications <ul><li>Definition: Osteoradionecrosis </li></ul><ul><li>“ death of bone </li></ul><ul><li>following radiation” </li></ul>
  56. 56. Complications <ul><li>Osteoradionecrosis </li></ul><ul><ul><li>hypoxic injury </li></ul></ul><ul><ul><li>devitalized bone will often not be painful! </li></ul></ul><ul><ul><li>patient may not be aware of it - LOOK! </li></ul></ul><ul><ul><li>radiographic changes may/may not be present </li></ul></ul><ul><ul><li>CLD often a problem, source of trauma </li></ul></ul>
  57. 57. Complications <ul><li>Problems with Osteoradionecrosis </li></ul><ul><ul><li>superinfection with bacteria/fungus </li></ul></ul><ul><ul><li>sharp spicules will traumatize other soft tissues - more problems </li></ul></ul><ul><ul><li>can be progressive, potential “en bloc” resection </li></ul></ul><ul><li>Treatment ***REFER*** </li></ul>
  58. 58. Hyperbaric Oxygen Therapy <ul><li>helps to promote vascularity </li></ul><ul><li>growth of new blood vessels </li></ul><ul><li>increased oxygen tension </li></ul><ul><li>within tissues </li></ul><ul><li>Therefore helps healing process </li></ul>
  59. 59. Hyperbaric Oxygen Therapy Prior to HBO
  60. 60. Hyperbaric Oxygen Therapy During HBO
  61. 61. Hyperbaric Oxygen Therapy Following HBO
  62. 62. Hyperbaric Oxygen Therapy <ul><li>Only 2 facilities in Ontario: </li></ul><ul><li>Hamilton </li></ul><ul><li>Toronto </li></ul>
  63. 63. Hyperbaric Oxygen Therapy <ul><li>Marx Protocol (Prophylaxis): </li></ul><ul><li>20 treatments </li></ul><ul><li>Extractions </li></ul><ul><li>10 treatments </li></ul>
  64. 64. Hyperbaric Oxygen Therapy <ul><li>Marx Protocol (Osteoradionecrosis): </li></ul><ul><li>30 treatments </li></ul><ul><li>Resection </li></ul><ul><li>10 treatments </li></ul>
  65. 65. Summary <ul><li>Squamous cell carcinoma (head & neck) represents 4% of new cases </li></ul><ul><li>Average age of population increasing </li></ul><ul><li>Average practice will see these patients </li></ul><ul><li>Long-term follow-up necessary </li></ul><ul><li>Medical/dental management of these patients is complicated and requires a team approach </li></ul>
  66. 66. References <ul><li>The Head & Neck Radiotherapy Patient </li></ul><ul><li>Part I: Oral Manifestations of Radiation Therapy </li></ul><ul><li>Part II: Management of Oral Complications </li></ul><ul><li>Compendium (1994), vol. 15(2), pp.250-260 </li></ul><ul><li>15(4), pp.442-454 </li></ul><ul><li>Head & Neck Cancer Patients Receiving Radiation Therapy </li></ul><ul><li>ADA Oral Health Care Series </li></ul>
  67. 67. References <ul><li>National Institute of Dental & Craniofacial Research ( www.nohic.nidcr.nih.gov ) </li></ul><ul><li>Canadian Cancer Society ( www.cancer.ca ) </li></ul><ul><li>Oral Cancer Foundation </li></ul><ul><li>( www.oralcancerfoundation.org ) </li></ul>

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