Chapter 55 The Patient With Cancer DH210 Clinical Sciences Lisa Mayo, RDH, BSDH Successful people are always looking for ways to help others, unsuccessful people ask whats in it for me? ~Brian Tracy Objectives 1.Cancer Basics 2.Cancer Tx 3.Dental Hygiene Care Objective #1: Cancer Basics Cancer Tx modalities: radiation therapy, chemotherapy, surgery, hematopoietic cell transplantation AFFECT THE ORAL CAVITY TREMENDOUSLY! Definition: Group of neoplastic diseases in which there is transformation of normal cells into malignant ones Cancer cells will spread to distant sites (metastasis) Characteristics of benign and malignant neoplasms: Table 55-1 Classification of cancer based on origin of the tissue involved Review Sheet CH55 #2-3 Oral Cancer Survival Factors of survival Location and size of tumor Type Presence of metastasis Tumor sensitivity to tx Physical status/age of patient Risk Factors Tobacco use Alcohol use Sunlight exposure Environmental/occupational Low SES Viruses Epstein-Barr Hep C HPV Review Sheet CH55 #4 NBQ The MOST common location of oral cancer is the a.Floor of the mouth b.Lateral border of the tongue c.Lip d.Pharynx NBQ The MOST common location of oral cancer is the a.Floor of the mouth b.Lateral border of the tongue c.Lip d.Pharynx NBQ Clients over age 60 who smoke are the fastest growing segment of the oral cancer population. Human papilloma virus 16 (HPV 16) is responsible for the increased risk for oral cancer especially in the tonsillar area. a.The first statement is TRUE; the second is FALSE b.The first statement is FALSE; the second is TRUE c.Both statements are TRUE d.Both statements are FALSE NBQ Clients over age 60 who smoke are the fastest growing segment of the oral cancer population. Human papilloma virus 16 (HPV 16) is responsible for the increased risk for oral cancer especially in the tonsillar area. a.The first statement is TRUE; the second is FALSE b.The first statement is FALSE; the second is TRUE c.Both statements are TRUE d.Both statements are FALSE Objective #2: Cancer Treatments Surgery Chemotherapy Radiation therapy Hematopoietic cell transplantation Hormone therapy Vaccine therapy Biotherapy Combo Cancer Treatment Based on location/Size of tumor Treatment objectives Cure Control Palliative Surgery Most common form of treatment for solid tumors Debulk large tumors then chemo/radiation Provide pain relief or prolong life when no chance of cure is possible Chemotherapy Involves the use of drugs that affect the rapidly dividing cancer cell at different points in the cell cycle Wilkins p.839, Box 55-3 (NEED TO KNOW types of agents used!) Objectives Destroy cancer cells & keep it from metastasizing Prevent cancer from recurring Improve quality of life Chemotherapy Indications Eliminate a localized tumor too large for surgical removal Prior to surgery: makes tumor easier to remove Treat cancer that has metastasized to other parts of the body Prevent cancer recurrence Extend life when no chance of a cure is possible Systemic side effects (MANY!) SEE WILKINS p.840 Affects rapidly dividing parts of the body the most (hair, oral mucosa, GI, bone marrow) Alopecia (hair loss) Myelosuppression: bone marrow suppression Immunosuppression Review Sheet CH55 #13 Oral Complications of Chemotherapy Oral mucositis/stomatitis (next slide) Xerostomia Infections: bacterial, viral, fungal Bleeding Neurotoxicity: mimic toothache, usually bilateral Review Sheet CH55 #8, 14 WHO: Oral Mucositis Scale Wilkins Table 55-2 Review Sheet CH55 #8-9, 16 Review All of the following are systemic side effects of chemotherapy except: A) alopecia B) skin reaction C) nausea D) anemia Review All of the following are systemic side effects of chemotherapy except: A) alopecia B) skin reaction C) nausea D) anemia Radiation Therapy Ionizing radiation to tx cancer Impacts the cancer cell's ability to replicate and survive Not all tumors are radiosensitive Indications Tx small localized tumor that is radiosensitive Shrink a large tumor prior to surgery Assist chemotherapy effect when used concurrently Radiation Therapy Types 1.External beam: radiation that is applied outside the body. (next slide illustrates exposure areas for external radiation) 2.Internal: the source (such as implants or seeds) of the radiation is placed within the body Less radiation is delivered to surrounding tissues than external Common Fields of Radiation for Head & Neck Tumors Oropharynx Field Antrum Field Parotid Field Floor of Mouth Radiation Systemic Side Effects Skin reactions: looks like a bad sunburn Fatigue Gastric upset Nausea, vomiting Constipation, diarrhea Radiation Oral Complications Oral mucositis or stomatitis Xerostomia Radiation caries Ageusia (Loss taste) Infection Bacterial Viral Fungal Trismus (pain/weakness of mastication muscles) Osteoradionecrosis Review Sheet CH55 #7-8, 14, 16 NBQ Radiation therapy such as brachytherapy or linear accelerator therapy can have serious side effects, the MOST serious of which is: a. Xerostomia b. Carious lesions c. Trismus d. Dysgeusia e. Osteoradionecrosis NBQ Radiation therapy such as brachytherapy or linear accelerator therapy can have serious side effects, the MOST serious of which is: a. Xerostomia b. Carious lesions c. Trismus d. Dysgeusia e. Osteoradionecrosis Hematopoietic Cell Transplantation Types of transplants Autologousself Allogenicmatched donor Syngeneicidentical twin Review Sheet CH55 #17 Stages of Transplantation 1.Patient selection: non-responsive to chemo/rad 2.Histocompatibility matching 3.Pancytopenic period All cellular elements of blood depressed Protective isolation for patient required (susceptible to infection) New marrow begins day Recovery Immune recovery: 3-12 months Long-term recovery: 1-3 years Review Sheet CH55 #17 Oral Complications Oral complications Xerostomia Severe oral mucositis (10-14 days post-op) Viral & fungal infections (Candidiasis) Review Sheet CH55 #7, 16 Systemic Complications 1.Infection: bacterial, viral, fungal 2.Organ complications 3.Acute graft-versus-host disease Donor's T-lymphocytes see host cell antigens as foreign & react against the host tissue Symptoms (1 st 100 days post-op) Painful red skin rash starting on the palms of hands and soles of feet and progressing to the upper trunk 4.Chronic graft-versus-host disease Affects all body organs Appears up to 2 years post-transplant Review Sheet CH55 #18 Objective #3: Dental Care Dental Hygiene/Dental Care Plan Optimal oral health PRIOR to STARTING any type of cancer therapy Personal factors: cancer brings fear and anxiety to the patient, and many times is viewed by the patient as cancer = death Encourage pt to bring a friend/family member to appt Positive reinforcement Written instructions Show patient you care about them and the success of their cancer tx Review Sheet CH55 #5, 19 Pretx Therapy Prior to therapy: Box 55-4 Reduced risks for development of oral complications Review Sheet CH55 #6 During Cancer Tx Box 55-5 Excellent home care Fl gel trays Xerostomia control Caries control (next slide) Perio control Mouthrinse: every 2-3hrs baking soda/water, no alcohol Monitor for trismus: pain/weakness of mastication muscles Review Sheet CH55 #9-12 Radiation Caries Chemotherapy During chemotherapy treatment Consult oncologist before any dental procedures Premed: patients with catheters Postpone clinical services: 1)Platelet count is less than 50,000/mm 3 2)Neutrophil count less than 1,000/mm 3 Special Care for Children At risk for same complications as adults Extract loose primary teeth Teeth expected to exfoliate during therapy Remove orthodontic bands/brackets Monitor craniofacial/dental structures Perform routine daily personal oral care Avoid cariogenic foods/beverages NBQ A patient undergoing chemotherapy presents with signs and symptoms of mucositis. Which of the following interventions would best relieve symptoms? a.Glycerin and water spray b.Sodium fluoride rinses c.Lidocaine topical spray d.Sodium bicarbonate rinses NBQ A patient undergoing chemotherapy presents with signs and symptoms of mucositis. Which of the following interventions would best relieve symptoms? a.Glycerin and water spray b.Sodium fluoride rinses c.Lidocaine topical spray d.Sodium bicarbonate rinses NBQ Which of the following is a common oral side effect of radiation to the head and neck area? a.Occlusal caries b.Fissuring of the tongue c.Cervical caries d.Periodontal abscesses NBQ Which of the following is a common oral side effect of radiation to the head and neck area? a.Occlusal caries b.Fissuring of the tongue c.Cervical caries d.Periodontal abscesses