Pre R/T Dental Management

Presenter: R1 Instructor: VS Date: 2012/3/16

Oral Assessment before R/T

Acute effects of RT: mucositis, altered salivary gland function and risk of mucosal infection. Long-term effects of RT: hypovascularity, hypocellularity and hypoxia of the tissues, damage to the salivary glands and increased collagen synthesis resulting in fibrosis. The affected bone and soft tissue have a reduced capacity to remodel. A consultation with a dental teamshould be completed before

Oral Assessment before R/T

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A complete dental examination to identify preexisting problems. Prior to treatment, potentially complicating diseases should be corrected. Patient adherence to hygiene protocols are critical.

Strategies
Before R/T
Medical history Denitive diagnosis Dental knowledge Oral hygiene Complete dental examination Radiographic examination Prior cancer history, risk factors Tumour size and type Past and current dental care Current practices Mucosa, dentition, periodontium, TMJ Panoramic, selected periapical, bitewing Resting (> 0.1 mL/minute), Whole salivary ow rates stimulated (> 1.0 mL/minute) Adjunctive tests as Pulp tests, specic cultures (fungal, indicated viral, bacterial) Prognosis (cure or palliation)

Oral Assessment before R/T

All teeth, but especially those located within the radiation elds, should be closely evaluated. Only 11.2% of patients required no dental treatment before RT. The criteria for extractions before R/T are not universally accepted and are subject to clinical judgement.

Criteria for pre R/T extractions

Teeth in the high-dose radiation eld and

Caries (nonrestorable) Active periapical disease (symptomatic teeth) Moderate to severe periodontal disease Lack of opposing teeth, compromised hygiene Partial impactions or incomplete eruption Extensive periapical lesions (if not chronic or well localized A more aggressive dental management strategy should be considered for patients

Guidelines for extractions

At least 2 weeks, ideally 3 weeks, before R/T. Trim bone at wound margins to eliminate sharp edges. Primary closure should be done. Intra alveolar hemostatic packing agents should be avoided that can serve as a nidus of microbeal growth. If the platelets count is < 50000/mm3 than transfusion is mandatory. Delay the extraction if the WBC < 2000/mm3 or absolute neutrophil is < 1000/mm3. Prophylatic antibiotics .

During R/T

Monitoring of the oral cavity Systematically applied oral hygiene protocols may reduce the incidence, severity and duration of oral complications. Frequent brushing with a soft-bristled toothbrush and uoride toothpaste or gel to help prevent plaque accumulation and demineralization or caries of the teeth.

Strategies
During R/T
Maintenance of good oral hygiene Daily topical uoride Frequent saline rinses Lip moisturizer (non-petroleum based) Passive jaw-opening exercises to reduce trismus Brushing 2 to 4 times daily with soft-bristled brush; ossing daily Custom trays, brush-on prescription-strength uoride

Side Effects of R/T

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Directly affects the salivary glands, the mucosal membranes, the jaw muscles and bone. Dry mouth (xerostomia): loss of saliva periodontal disease, rampant caries, and oral fungal and bacterial infections. Oral Infection (Candida) Oral Mucositis: by the 3rd week of treatment Fibrosis around the mastication m. trismus Bone: blood flow, loss of osteocytes limited remodelling of bone and limited

Xerostomia

Sialagogues

If >40Gy , permanent dysfunction of the salivary glands should be expected.

residual function

Sjogrens disease

No optimal substitute for saliva: without rheologic and antimicrobial factors Sugarless gum or lozenges, ice cubes or ice water, eating foods high in ascorbic acid, malic acid or citric acid, but not recommended in dentate

Xerostomia

For the prevention of rampant caries

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Apply 1.1% neutral sodium fluoride gel daily (for at least 5 minutes) with a custom fitted vinyl tray. Started on the first day of R/T and continued daily as long as salivary flow rates are low. High-potency fluoride brush-on gels and dentifrices in those who are unable or unwilling to comply with the use of fluoride trays.

Oral Infection

A fungal, bacterial or viral culture Candida during R/T (pseudomembranous, ,

chronic hyperplastic, chronic cheilitis)
contraindications

unpleasant flavour, may cause nausea and vomiting, high sucrose content.

liver toxicity

antifungal, antibacterial and antiplaque

Oral Infection

If CHX is used, it is important to note that nystatin and CHX should not be used concurrently, because chlorhexidine binds to nystatin, rendering both ineffective. CHX should be used at least 30 minutes before or after the use of any other topical agents with which it may bind. Viral infections, such as Herpes simplex 1 acyclovir or penciclovir (newer, with increased tissue penetration)

Mucositis

Combinations of rinses: interfere dilution Isotonic saline/sodium bicarbonate Prophylactic rinses with CHX Candida counts but has no effect on mucositis. Cheapest and easiest: a teaspoon (10 mL) of salt + a teaspoon (10 mL) of baking soda (sodium bicarbonate) in 8 ounces (250 mL) of water. Oral rinses should be discontinued because of their drying and irritating effects.

Mucositisoccurs 12- 17 days after

the initiation of therapy

contraindications

Risk of aspiration Systemic absorption cardiac effects

Lack of saliva and damaged taste buds Alter the sensation of taste (transient phenomenon)

After R/T

After the completion of R/T, acute oral complications usually begin to resolve. Oral exercises should be continued to reduce/prevent trismus. Additional dietary adaptations Long-term management and close follow-up of patients after radiation therapy is mandatory. Excellent time to resolve any deferred dental care.

Strategies
After R/T
Complete dental work that was deferred during radiotherapy Maintain integrity of teeth Especially those in radiation elds Check for oral hygiene, xerostomia, decalcication, decay, ORN, metastatic disease, recurrent disease, new malignant disease

Frequent follow-up appointments

Osteoradionecrosis

Irreversible, progressive devitalization of irradiated bone Most in the mandible, where vascularization is poor and bone density is high. Symptoms: pain, orofacial fistulas, exposed necrotic bone, pathologic fracture and suppuration One-third of cases occur spontaneously. The majority result from extraction of teeth. Incidence: dentate = edentulous*2 Poor oral hygiene and continued use of alcohol and tobacco may also lead to rapid

Conclusion

The complications of radiotherapy must be considered thoroughly so that every effort is undertaken to minimize the oral morbidity of these patients before, during and after cancer treatment and throughout the patients lifetime.

Referrence
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Pamela J. Hancock, BSc, DMD, Joel B. Epstein, DMD, MSD, FRCD(C), Georgia Robins Sadler, BSN, MBA, PhD. Oral and Dental Management Related to Radiation Therapy for Head and Neck Cancer. J Can Dent Assoc 2003; 69(9):58590. Jay Lucas, DMD, MD, David Rombach, DMD, MD, Joel Goldwein, MD. Effects of Radiotherapy on the Oral Cavity. November 1, 2001. Virendra Singh M.D.S., Sunita Malik M.D.S. Oral Care Of Patients Undergoing Chemotherapy And Radiotherapy: A Review Of Clinical Approach. The Internet Journal of Radiology ISSN: 1528-8404.