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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.

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Oral Complications

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  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

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