Module 7:Module 7:

Treatment OptionsTreatment Options

Surgery and/or RadiationSurgery and/or Radiation

• Treatment usually involves surgery or radiation or both

• Chemotherapy primarily used as an adjunctive procedure in advanced cases

• Advanced lesions < 30% 5-year survival rate

• 9 - 25% of patients develop additional mouth or throat cancer

TreatmentTreatment

• Oropharyngeal lesions: radiation therapy

• Lip lesions: surgically excised

• Tongue lesions: hemiglossectomy; then radiation

• Alveolar ridge cancer: segmental resection

• Metastasis to local lymph nodes: radical or modified radical neck dissection

Considerations Regarding Considerations Regarding Treatment OptionsTreatment Options

• The oral cavity is a complex structure composed of muscles, nerves, jaws, tongue and lubricated by the salivary glands.

• Rehabilitation must be considered prior to surgical or radiographical intervention.

Quality of Life IssuesQuality of Life Issues

• Nutrition

• Speech

• Appearance

• All functions must be addressed in

treatment planning

SurgerySurgery

• Type depends upon the extent and location of cancer

• Wide local excision: soft tissue• Resection: invaded bone• Marginal resection: inferior border of

mandible intact

SurgerySurgery

• Segmental resection: full height of mandible removed

• Composite resection: hard and soft tissue (nodes, mandible, and soft tissues--tongue or floor of the mouth)

Wide Local ExcisionWide Local Excision

Silverman, 2003

Silverman, 2003:98,100

Squamous Cell Carcinoma / ReconstructionSquamous Cell Carcinoma / Reconstruction

SCC of anterior maxillary gingiva and bone

One month post-surgical

Silverman, 2003

Squamous Cell Carcinoma (SCC)

Neck DissectionsNeck Dissections

• Comprehensive neck dissections include radical neck dissection and modified neck dissection.

• Radical neck dissection removes lymph nodes of the neck, the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.

Neck DissectionsNeck Dissections

• Modified neck dissection preserves the sternocleidomastoid muscle or internal jugular vein, or the spinal accessory nerve.

• Selective neck dissections remove lymph nodes only, preserving the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.

Radiation TherapyRadiation Therapy

• Radiation therapy is indicated following surgery if:

– soft tissue margin positive

– one or more lymph nodes exhibit extracapsular invasion

– bone invasion present

– more than one lymph node positive in the absence of extracapsular invasion

– comorbid immunosuppressive disease present, or

– perineural invasion occurred

Radiation TherapyRadiation Therapy

• CT and/or MRI scan, PET scanning

• Dental panoramic

Radiation TherapyRadiation Therapy

• Dental consult

• Extractions prior to beginning

• Fluoride

• Meticulous oral hygiene

• Osteoradionecrosis

Types of Radiation TherapyTypes of Radiation Therapy

• (EBRT) primary external-beam radiotherapy

• (IMRT) intensity-modulated radiotherapy

• (ISRT) brachytherapy or interstitial radiotherapy

Radiation TherapyRadiation Therapy

Squamous cell carcinoma One month postradiotherapy

Silverman, 2003

Radiation TherapyRadiation Therapy

Silverman, 2003

BrachytherapyBrachytherapy

Silverman, 2003:105

ChemotherapyChemotherapy

• Chemotherapy was primarily used as a palliative measure until fairly recently. It was typically administered before, during or after radiotherapy or surgery– neoadjuvant (before irradiation)– concurrent (during irradiation)– adjuvant (after irradiation)

ChemotherapyChemotherapy

• Several drugs currently being used include:– Paclitaxel (Taxol, Bristol-Myers Squibb)– Methotrexate– Bleomycin– Cisplatin– 5-Fluorouracil

• Other research includes the use of:– Intraarterial chemotherapy– Intralesional chemotherapy

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

• Comprehensive oral examination

• Understand cancer diagnosis/location/stage/planned treatment (prognosis, chemotherapy??, radiation field)

• Stabilize/resolve oral disease and institute preventive program

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

Goal:• Eliminate dental disease that cannot be

maintained lifelong in radiated field or that may cause infection of become symptomatic during chemotherapy

• High dose radiation therapy causes PERMANENT change in vascularity, cellularity of soft tissue, salivary gland and bone

• Chemotherapy causes reversible changes, highest risk if caused neutropenia

Telangiectasia and Telangiectasia and

Mucosal FibrosisMucosal Fibrosis

Silverman, 2003: 115

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

• Oral Disease Status– Mucosal and periodontal health– Caries risk– Unerupted/impacted teeth– Root tips– Endodontic lesions– Past dental disease: caries / restorations / endo– Dental prostheses: condition / fit / function– Salivary function– Temporomandibular function– Oral hygiene effectiveness / patient motivation

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

• At risk teeth in radiation field– Periodontal status (pockets > 5 mm,

advanced attachment loss– Caries / restoration status– Partially erupted third molars– Endodontic lesions

Goal: 1 – 2 weeks healing prior to radiationAtraumatic extraction with primary closure,

no dressing in socket

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

• Dental extractions of symptomatic teeth due to infection, if sufficient time for healing of extraction site prior to neutropenia; if insufficient healing time, cover with antibiotics

• Dental extractions considered if required between courses of multi-course chemotherapy, at time of count recovery

Care Prior to Cancer TherapyCare Prior to Cancer Therapy

• Preventive Program:1. Gingival health: oral hygiene, chlorhexidine2. Caries risk: oral hygiene, diet, fluoride carriers,

chlorhexidine, saliva function3. Mucosal health: mucositis preventive program4. Mucosal infection: antifungal, oral hygiene5. Saliva: sialogogue, mucolytic, mouth wetting6. Lip lubrication7. Reinforce tobacco / alcohol cessation

Oral Care During Cancer TherapyOral Care During Cancer Therapy

• Mucositis: preventive program, pain management, diet instruction

• Oral hygiene• Caries prevention• Saliva management• Lip lubrication• Manage dental emergencies• Manage oral mucosal infections• Range of motion exercises for radiation patients• Reinforce tobacco / alcohol cessation

Complications from RadiationComplications from Radiation

• Pain; neuropathy• Xerostomia: low flow rate, thick consistency• Loss of taste • Cervical caries • Epithelial atrophy• Fibrosis of soft tissue and muscles• Focal alopecia• Focal hyperpigmentation• Osteroradionecrosis • Telangiectasias• Dental prostheses fit / function• Esthetic, speech concerns

ComplicationsComplications

Acute mucositis 5th week after radiation for base of the tongue squamous cell carcinoma

Oral candidiasis in a patient with marked xerostomia

Silverman, 2003: 114, 119

Mucositis ManagementMucositis Management

• Treatment of mucositis:– Symptomatic management: topical

analgesics; systemic analgesics– Nutritional support– Developing therapies: cytokines/growth

factors

Management of HyposalivationManagement of Hyposalivation

• Fluid intake, sugar free gum / candy

• Sialogogues: – Salagen– Evoxac– Bethanechol– Sialor

• Caries prevention

• Symptomatic (mouth wetting agents)

Oropharyngeal / Head / Neck PainOropharyngeal / Head / Neck Pain

• Treat cause when possible

• Topical analgesics / anesthetics

• Systemic analgesics

• Adjunctive medications (e.g. tricyclics)

• Muscle relaxants (myogenic pain)

• Physiotherapy (TMD, neck pain)

• Oral prostheses (TMD)

Follow-up of Cancer PatientsFollow-up of Cancer Patients

• Thorough head and neck and oral exam

• Salivary function, caries, demineralization risk, denture fit / function, oral hygiene, diet, mucosal condition, cancer risk

• Tobacco / alcohol cessation

• Risk of osteonecrosis with H&N RT; myelosuppression/immunosuppression

• Know medical therapy, prognosis, change in risk factors prior to treatment planning

OsteonecrosisOsteonecrosis

Silverman, 2003:121

Two years after radiotherapy Three years after radiotherapy

Care Following Radiation TherapyCare Following Radiation Therapy

• Osteonecrosis:– Prevention:

• Pretreatment oral care• Cancer therapy• Amputation of crown, endodontics• Atraumatic extraction if needed

– Therapy: • Hyperbaric oxygen, trental, Vitamin E• Surgery – vascularized flaps

ComplicationsComplications

• National Institutes for Dental and

Craniofacial Research (NIDCR) offers

excellent free materials for patients

• Ordering information included in

Resources section

ReconstructionReconstruction

• Various methods of reconstruction follow surgery• Deltopectoral flaps and pectoralis major

muocutaneous flaps• Bone and soft tissue grafts

provide good cosmetic

appearance and function• Osseointegrated implants

and dentures• The fibula can be used to

reconstruct the mandible

Silverman, 2003: 147

ReconstructionReconstruction

Silverman 2003:146

ReconstructionReconstruction

SummarySummary

• Early detection of lesions is critical to allow conservative treatment and protect the patient’s quality of life.

• Many avenues are available to treat oral cancers, with improved methods constantly under investigation.

• A multidisciplinary team can help oral cancer patients deal with the aftermath of treatment.