1 / 64

Oral Complications

Oral Complications. chemotherapy (CT) radiation therapy (RT), hematopoietic stem cell transplantation (HSCT). Oral complications. CT- and RT-related stomatitis oropharyngeal pain xerostomia oral infection oral chronic graft-versus-host disease ( cGVHD ). . Stomatitis.

eileen
Download Presentation

Oral Complications

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Oral Complications

  2. chemotherapy (CT) • radiation therapy (RT), • hematopoietic stem cell transplantation (HSCT)

  3. Oral complications • CT- and RT-related stomatitis • oropharyngeal pain • xerostomia • oral infection • oral chronic graft-versus-host disease (cGVHD).

  4. Stomatitis • Stomatitis is an inflammation of the mucous membranes of the oral cavity and oropharynx characterized by tissue erythema, edema, and atrophy, often progressing to ulceration. • The clinical significance of CT- and RT-related stomatitis as a dose- and treatment-limiting side effect is well appreciated.

  5. Cancer Treatment- and Patient-Related Risk Factors for Stomatitis • PATIENT-RELATEDAge older than 65 y or younger than 20 yGenderInadequate oral health and hygiene practicesPeriodontal diseasesMicrobial floraChronic low-grade mouth infectionsSalivary gland secretory dysfunctionHerpes simplex virus infectionInborn inability to metabolize chemotherapeutic agents effectivelyInadequate nutritional statusExposure to oral stressors including alcohol and smokingIll-fitting dental prostheses

  6. TREATMENT-RELATEDRadiation therapy: dose, scheduleChemotherapy: agent; dose, scheduleMyelosuppressionNeutropeniaImmunosuppressionReduced secretory immunoglobulin AInadequate oral care during treatmentInfections of bacterial, viral, fungal originUse of antidepressants, opiates, antihypertensives, antihistamines, diuretics, and sedativesImpairment of renal and/or hepatic functionProtein or calorie malnutrition, and dehydrationXerostomia

  7. Risk factors for CT-related stomatitis are complex, and study results are conflicting.

  8. Known risk factors include • continuous CT infusion therapy for breast and colon cancer [5-FU and leucovorin ] • selected anthracyclines • alkylating agents • taxanes • vinca alkaloids • Antimetabolites • antitumor antibiotics • myeloablative conditioning regimens for HSCT; • RT to the head and neck.

  9. Children are 3 times more likely than adults to develop stomatitis because of a higher proliferating fraction of basal cells. • Individual drug metabolism affects stomatitis incidence and severity, as seen with patients who are unable to adequately metabolize certain CT

  10. Chemotherapy-Induced Stomatitis • 40% of CT patients develop stomatitis, • Half requiring parenteral analgesia that may lead to treatment modification. • 60% are seen in the HSCT setting, • Oral infection, herpes simplex virus (HSV) in particular, may increase stomatitis severity • a 4 times greater relative risk of septicemia

  11. Stomatitis presents • asymptomatic erythema and progresses from solitary, white, elevated desquamative patches that are slightly painful to large, contiguous, pseudomembranous, painful lesions.

  12. Radiation-Induced Stomatitis • Area • Type of ionizing radiation • volume of irradiated tissue • daily and cumulative dose • duration of RT

  13. Stomatitis is a dose- and rate-limiting toxicity of RT for head and neck cancer, and of hyperfractionated RT and CT that is designed to improve survival time. • COX-2 plays an amplifying role in RT-related stomatitis. • Atrophic changes in the oral epithelium usually occur at total doses of 1,600 to 2,200 cGy, administered at a rate of 200 cGy per day. Doses higher than 6,000 cGy place the patient at risk for permanent changes in the salivary glands.

  14. RT-induced dental effects • depend primarily on salivary changes rather than on direct irradiation of the teeth. • Direct irradiation of teeth may alter the organic or inorganic components making them more susceptible to decalcification or hypocalcification. • daily fluoride application is necessary

  15. Radiation Therapy-Related Complications • Long-term effects of head and neck RT • Soft tissue fibrosis • Obliterativeendoarteritis • Trismus • Nonhealing or slow-healing mucosal ulcerations • slow healing of dental extraction sites.

  16. RT-induced fibrotic changes • up to 1 year post-therapy, becoming more serious over time.

  17. Osteoradionecrosis (ORN) • Higher incidences are seen after total doses to the bone exceed 65 Gy. • The risk of ORN actually increases over time following RT. • pathologic fracture, infection of surrounding soft tissues, and severe pain. • time to allow adequate extraction site healing is 10 to 14 days before start of RT.

  18. Osteonecrosis of the jaw bone • Long use :bisphosphonate therapy • majority required surgical procedures to remove the involved bone.

  19. H &N RT • Oral candidiasis angular cheilitis, may appear as white and removable chronic hyperplastic (nonremovable) chronic erythematous (diffuse patchy erythema).

  20. Chronic Graft-Versus-Host Disease Oral Manifestations • Acute GVHD occurs within the first 100 days after allogeneic HSCT. • Chronic GVHD begins as early as 70 days or as late as 15 months after allogeneic transplant. • 80% of patients with extensive cGVHD have some type of oral involvement • Oral infection in cGVHD patients is a risk factor for systemic infections that are the primary cause of death in this population

  21. Oropharyngeal Pain • stomatitis-related pain • Immunocompromised cancer patients with HSV infections have larger, more painful lesions as compared with noncancer patients • cGVHD

  22. The effect on the patient's psychological well-being: • medication usage, • decreased oral intake • use of analgesics and opioids.

  23. Cognitive dimension of pain • individual's thought process, • self-perception, • reported pain relief, • the personal meaning of the pain.

  24. Multidimensional oral pain • The sociocultural dimension includes demographic characteristics, cultural background, and family and work roles. • age and pain perception, • intraethnic differences in pain perception • Gender

  25. Pain control is critical to accomplish to avoid suffering and psychological distress. • Effective oral pain management is promoted through open, consistent communication between and among patient, physician, nurse, and caregiver. • A comprehensive pain assessment tool?

  26. Xerostomia • Xerostomia • Severity dependent on the radiation dosage and location, and volume of exposed salivary glands. • Significant xerostomia has not been reported in patients treated with CT alone. • Xerostomia can affect oral comfort, fit of prostheses, speech, and swallowing. • Xerostomia-associated enzymes contribute to the growth of caries (decay)-producing organisms, and the decrease in quantity and quality of saliva can be very harmful to dentition

  27. Strategies for Prevention and Treatment of Oral Complications • Pretherapy Dental Evaluation and Intervention • Assessment of the Oral Mucosa

  28. Pretherapy Dental Evaluation and Intervention • an experienced dental team • Many health care institution-specific policies and preventive approaches exist for oral care for CT and RT patients.

  29. Patients scheduled for CT and/or head and neck RT: • dental screening at least 2 weeks before therapy • Oral hygiene

  30. The decision to extract asymptomatic teeth related to several important factors, including radiation exposure , type, portal field, fractionization, total dosage tumor prognosis, expediency of control of the cancer.

  31. Careful examination of extraction sites must be performed before RT commences. • Dental extractions following RT require collaborations between dental and radiation oncology team members to minimize the risk of ORN. • A low incidence of ORN is seen when pre-RT dental consultation and appropriate treatment (e.g., extractions) are rendered. • Follow-up

  32. Assessment of the Oral Mucosa

  33. Treatment Strategies • The optimal treatment ? • mainly empirical • The only standard forms of care are pretreatment oral/dental stabilization, saline mouthwashes, and oropharyngeal pain management. • oral hygiene

  34. stomatitis treatment. • unreliable evidence for the effectiveness of • allopurinol mouthwash, • vitamin E, • immunoglobulin, • human placental extract • no single agent completely prevented stomatitis, suggesting that combined strategies may be necessary

  35. A standardized approach for the prevention and treatment of CT- and RT-induced stomatitis is essential.

  36. prophylactic measures • Chlorhexidinegluconate (Peridex), • Saline rinses, • Sodium bicarbonate rinses, • Acyclovir • Amphotericin B • Ice

  37. Treatment of stomatitis and related pain • a local anesthetic such as lidocaine or dyclonine hydrochloride, magnesium-based antacids (Maalox, Mylanta), diphenhydramine hydrochloride (Benadryl), nystatin, or sucralfate • These agents are used either alone or in various combinations as a mouthwash formulation. • opioids

  38. Other agents • used less commonly include kaolin-pectin (Kaopectate), allopurinol, vitamin E, beta-carotene, chamomile (Kamillosan) liquid, aspirin, antiprostaglandins, prostaglandins, MGI 209 (marketed as Oratect Gel), silver nitrate, and antibiotics

  39. Direct CytoprotectantsSucralfate • has shown efficacy in the treatment of gastrointestinal (GI) ulceration • has been tested as a mouthwash for the prevention and treatment of stomatitis? • CT? • Sucralfate has also been tested in the head and neck RT population?

  40. Gelclair • Gelclair is a concentrated, bioadherent gel that has received for the management of stomatitis-related oral pain.

  41. Prostaglandins, Antiprostaglandins, and Nonsteroidal Agents? • Benzydamine is a nonsteroidal anti-inflammatory drug with reported analgesic, anesthetic, anti-inflammatory, and antimicrobial properties.

  42. Corticosteroids • بتامتازون +اب • هیدروکورتیزون +نیستاتین +تتراسایکلین +دیفن هیدرامین

  43. Vitamins and Other Antioxidants • Vitamin E + • vitamins C and E and glutathione? • Azelastine may be useful to prevent CT-induced stomatitis

  44. Silver Nitrate + • Laser? • Miscellaneous Agents? diphenhydraminehydrochlor-ide (Benadryl), saline, sodium bicarbonate, and gentian violet

  45. Cryotherapy • Cryotherapy used to induce vasoconstriction should be considered for patients receiving 5-FU or melphalan when these agents are administered during short infusion times.

  46. Indirect Cytoprotectants • Hematopoietic Growth Factors? • Keratinocyte Growth Factors • Antimicrobials • Pharmacologic Modulation

  47. Keratinocyte Growth Factors • Recently, palifermin, which is a recombinant human keratinocyte growth factor, has shown efficacy in the reduction of oral mucosal injury related to cytotoxic therapy

More Related