Transcript PBL ORAL CANCER AND REHABILITATION

PBL
ORAL CANCER AND REHABILITATION
TRIGGER 2
• Ulcer
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>1 month
Increasing in size
No pain
No history of trauma
• Habit
– Smoking since 30 years, 20 sticks perday
– No alcohol and betel nut intake
• O/E
– Lesion: 3.5cm diameter with induration
– Tongue mobility is good
– Palpable fixed left submandibular lymph node of 2.5cm
• Incisional biopsy is taken
• Dx: squamous cell carcinoma
TNM Staging
Tx
no available information on
primary tumour
T0
no evidence of primary tumour
TIS
only carcinoma in-situ on
primary sites
T1
<2 cm
T2
2 to 4 cm
T3
>4 cm
T4
>4 cm, involvement of natrum,
pterygoid muscles, base of
tongue or skin
Mx
Not assessed
M0
No evidence
M1
Distant metastasis present
Nx
Cannot be assessed
N0
No clinical positive nodes
N1
Single, ipsilateral, <3 cm
N2a
Single, ipsilateral, 3-6 cm
N2b
Multiple, ipsilateral, <6 cm
N3a
Single/multiple, iIpsilateral
node(s), one more than 6 cm
N3b
bilateral
N3c
contralateral
Cancer staging
• T2 N3c
• Stage IV
Histology
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Loss of well-architecture epithelium
Cellular poleomorphism
Hyperchromatism
Formation of keratin pearl seen in those island
or cord .
• Enlarge nuclei
• Increase nuclear cytoplasmic ratio
• Increase number of mitotic figure
Dental Management before
radiotherapy
A comprehensive oral assessment
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Identify existing oral disease and potential
risk of oral disease.
All sharp teeth and restorations are suitably
adjusted and polished.
Remove infectious dental disease before the
start of cancer therapy.
Extraction
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Wherever possible, teeth with a dubious
prognosis are removed no less than ten days
prior to cancer therapy.
Detailed oral hygiene instruction with
reinforcement and elaboration of diet advice
is provided in cooperation with the dietician.
Periodontal disease
Oral hygiene practices are supplemented with the use
of an alcohol free chlorhexidine mouthwash or dental
gel, if there is gingival disease diagnosed.
Prosthesis
The patient is counselled about denture wear
during therapy. If aremovable prosthesis is worn,
it is important to ensure that it is clean and well
adapted to the tissue. The patient should be
instructed not to wear the prosthesis
during cancer therapy treatment, if possible; or
at least, not to wear it at night.
Ortho appliance
Orthodontic treatment is discontinued.
Effect of radiotherapy
During treatment:
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severe xerostomia
mucositis and ulceration
acute candidosis
skin erythema
Long term:
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xerostomia
mucosal and skin atrophy
risk of osteomyelitis (osteoradionecrosis)
scarring and fibrosis of tissues
cataract if eye irradiated (eg: antral carcinoma)
risk of late radiation-induced malignancy
Management before surgery
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Monitor vital sign
BP, pulse, respiratory rate,temperature, oxygen saturation
Monitor blood glucose level
Premedication before surgery – analgesic or antibiotic
Patient education on the importance of deep breathing and coughing,
regular gentle leg exercises and early mobilisation to reduce the risk of
complications such as chest infection, deep-vein thrombosis and
pulmonary embolism
• VTE prophylaxis - measure patient for anti-embolism stockings, foot
impulse device or intermittent pneumatic compression device (NICE,
2010);
• Urinary catheter- if long surgical time is expected.
Management of oral cancer
• Lip cancer: treated mainly surgically
• Intraoral cancers < 4 cm in diameter: treated
equally effectively by surgery or radiotherapy
• T1 tumours:
– generally managed surgically
• T2 tumours:
– generally managed surgically.
– However, tumours of the lateral margin of tongue may be treated by radiotherapy
using external beam (40 Gy) plus radioactive iridium implants (25–30 Gy).
– For many patients, the treatment must include treatment of the lymph nodes in the
neck and thus often the treatment of choice is surgery (tumour excision with radical
neck dissection), together with radiotherapy
• T3 tumours:
– generally treated by surgery followed by radiotherapy if there is extracapsular
spread or multiple lymph node involvement.
– For many patients, the treatment must include treatment of the lymph nodes in the
neck and thus often the treatment of choice is surgery (tumour excision with radical
neck dissection),together with radiotherapy
• T4 tumours:
– may be treated with chemo-radiotherapy.
– Drugs used include cisplatin, fluorouracil (5-Fu) taxanes and methotrexate.
– TPF is a common regimen (taxane platinum, 5-Fu)
Neck treatment
• N1: Supraomohyoid head and neck dissection
• N2a-b or N3: modified radial neck dissection
• N2c: radial neck dissection/ modified radial
neck dissection
Oral cancer rehabilitation
tongue and mandibular defect causes
• impaired speech articulation
• severe dysphagia in 1/3 posterior resection
• deviation of mandible during functional
movement
• poor control of saliva secretion
• cosmetic disfigurement
• pt seldom return to presurgical level
• functional defect remains because
• compromised motor and sensory control
• inadequate tissue control
• inadequate bulk of key tissue
• articulation of speech depend upon tongue
mobility and the present of adequate tongue
bulk
• pt that underwent hemiglossectomy could
benefit from swallowing therapy
• the intervention that can be apply:
– postural changes
– sensory procedure
– manouver
– diet changes
– physiologic exercise
– orofacial prosthetic
Role of dentist
• p
​ erform a competent oral cancer examination;
• d
​ escribe oral lesions of local and systemic
etiology;​
• ​identify oral lesions that should raise the
suspicion of malignancy​;
• ​appropriately select and consider using
diagnostic adjuncts to assist in oral cancer
early detectio​n;
• ​describe an approach to managing
questionable and suspicious oral lesio​ns;
• ​develop and implement an office protocol for
oral cancer screen​ing;​
• ​discuss the role of the dentist in the
comprehensive management of oral/head &
neck cancer pati​ents​;
• ​articulate the ethical and medical/legal
responsibility of dentists to screen for oral
cancer, especially in high risk populations