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DENTAL MANAGEMENT OF PATIENTS UNDERGOING RADIOTHERAPY TO HEAD AND NECk

DENTAL MANAGEMENT OF PATIENTS UNDERGOING RADIOTHERAPY TO HEAD AND NECk

INTRODUCTION

The Head and neck cancer (CCC) anatomical regions comprising its location and have different developments lymphatic dissemination and histopathological diagnoses and hence different treatment alternatives. It is more common in men than in women and has its highest incidence in the 5th-6th decade of life. You can reach affects as important as speech and swallowing functions. It can be located at: nasal passages and sinuses, nasopharynx, oral cavity, oropharynx, larynx, hypopharynx and salivary glands. The most common histological type is squamous cell carcinoma or squamous 1,2,3. At present it is not yet know the cause of oral cancer, but we know that the risk factors that predispose to the development of the disease are smoking, excess alcohol (the snuff more alcohol combination seems to multiply the risks) actinic radiation, dietary factors (iron deficiency, vitamin C, zinc, copper, etc.), chronic friction, viral infections (mainly papillomavirus) and precancerous lesions (erythroplakia, leukoplakia) 1,2,4,5 . The tumor can spread to surrounding local infiltration or metastasize to regional lymph nodes tissues. The treatment of this cancer depends essentially on tumor stage (Table 1) according to the TNM system 4.

Oral Manifestations of Radiotherapy in Head and Neck

In the last decade the prevalence of oral cancer has increased significantly, if we add that 80% of patients receiving chemotherapy, 100% of those who have been treated with radiation in the cervicofacial area, and 80% of pediatric patients with malignant neoplastic processes survivors who received radiation therapy to the cervicofacial region will develop some type of oral complication, so we can realize that the mouth is a major recipient of adverse effects that present clinically as a result of cancer treatments, such a turn are the main complaint of the patient and are often the reason that treatment should suspenderse6.

Radiotherapy (RT) is an important in the treatment of many injuries that occur in this anatomical region, either q is used as a single resource or in combination with other therapeutic modalities alternative; however, the effects of radiation not only affect the malignant cells, but that this is also absorbed by the oral and perioral tissues, particularly those with greater capacity for cell renewal 7. Within these lesions is the following:

IMMEDIATE DEMONSTRATIONS:

Mucositis (Figure 1) produced by a metabolic interference with the growth, maturation and replication of the cells in the oral mucosa, which are expressed clinically by denudation and mucosal ulceration and may be exacerbated by poor oral health, gingivitis and periodontitis 8 . Usually this condition leads to the appearance of opportunistic infections such as candidiasis and herpes simplex. Furthermore, the presence of mucositis can lead to the interruption of the antineoplastic treatment, for the presence of dysphagia, pain and bleeding of the oral mucosa which may lead to a limitation in the dose or treatment failure, which results in an increase in treatment costs and hospital stay 9. There are various scales commonly used to assess and quantify the severity of mucositis, including established by WHO, which distinguishes five levels of severity (0-4), with the grades 3 and 4 the most disabling (Table 2). 11

XEROSTOMIA: RT damage to the salivary glands results in a significant decreased saliva production, which in turn produces xerostomia and various complications that exacerbate mucositis, making the buccal mucosa in an area more amenable to both traumatic factor infecciones7 as possible. It usually occurs within days of starting treatment with doses greater than 1500 cGy. It manifests with a feeling of a thick, viscous by condition of acinar cells saliva, which may be permanent in some patients (doses between 4000-6000 cGy) 9,10,13.

PERIODONTITIS: radiation generated hypovascular, hypoxic and hypocellular changes in the soft and hard tissues. For example, damage to the salivary glands and fibrosis by increasing collagen synthesis affects bone remodeling and increases the risk of infection and necrosis, periodontal damage affect the level of the periodontal ligament space, which widens putting jeopardize the stability of teeth, if you add to this periodontal destruction root crown improper relationship, poor oral hygiene a major risk factor as malocclusions, occlusal trauma and the inability of the bone to remodel and repair after persistent periodontal disease. 10

Hypogeusia, dysgeusia, and AGEUSIA: Irradiation of taste buds usually leads to a, total (ageusia) or abnormal taste (dysgeusia) partial disability (hypogeusia). This is a common complaint in patients with CCC after being subjected to RT, which may contribute to anorexia and weight loss that is often observed in these patients. A study by Maes et al in 2002 showed that 53 to 88% of patients experienced loss and dysfunction of the quality of taste, and it was observed that the gradual recovery thereof is slow and persists for 1 to 2 years after 14 treatment.

Mediate PROTESTS:

This complication is multifactorial, because it influences the presence of mucositis, which causes poor oral hygiene in these patients for the inconvenience caused it, increasing the risk of caries. As explained above the taste is affected being more appreciated taste salty and sweet so the patient tends to realiazar high carbohydrate diet to feel the sensation of taste. However, the main cause of caries is the radiation damage of the salivary glands, which reduces salivary flow affects the composition of saliva (alters the electrolyte concentration, which in turn lowers the pH from 7.0 to 5.0 which is definitely cariogenic. in addition to this there is a substantial deficiency of immunoproteins, which is accompanied by a decrease in self-cleaning ability of the oral cavity by the tongue and salivary flow, which results in an increase of the effect acidogenic and cariogenic microorganisms (Streptococcus mutans, Lactobacillus and Candida) 15.

Radiation caries

Lockjaw: The direct effect of radiation on the muscles of mastication triggers fibrosis and contraction thereof, in addition to degenerative damage to the temporomandibular joint; gradually begin at 9 months after having completed radiotherapy, consequently resulting in lockjaw, which manifests as a limitation of mouth opening with less than 18-20mm interincisal distance, has a prevalence of 5 to 38% of patients receiving RT CCC. I affecting the quality of life of patients, because it has difficulty speaking, commitment to oral hygiene and malnutrition caused by the difficulty chewing 8.16.

DENTAL MANAGEMENT OF PATIENTS ON SYSTEMIC CHEMOTHERAPY FOR MALIGNANT OISEASE

DENTAL MANAGEMENT OF PATIENTS ON SYSTEMIC CHEMOTHERAPY FOR MALIGNANT OISEASE

Malignant disease.

Acute or chronic complications of cancer treatment and matching causes unrelated to cancer.

Cancer pain results in increased morbidity, decreased performance status, increased anxiety and depression and decreased quality of life (QOL). The following are the dimensions of acute or chronic pain:

Sensory

Physiological

Affective

Cognitive

Behavioral

Sociocultural

The pain of the head and neck, and oral pain can be particularly challenging because eating, speaking, swallowing and other motor functions of the head, neck and oropharynx trigger pain constantly.

Orofacial pain due to cancer

Acute and chronic cancer pain can be due to several factors, including the following:

Pain malignant disease:

Local or regional cancer.

Oral involvement in systemic or hematopoietic cancer.

Metastatic disease.

Pain treatment:

Surgery.

Radiation.

Chemotherapy.

Pain unrelated to the disease.

Often the pain at the time of diagnosis is of low intensity, but usually render more frequent and severe as the disease progresses. The effects of local or distant tumors can cause cancer pain. Direct cancer invasion may cause pain resulting from neuropathic and inflammatory mechanisms. To achieve effective prevention and treatment of cancer pain, it is necessary to know the factors and mechanisms involved.

It is estimated that between 45 and 80% of all cancer patients have inadequate pain management. In 75-90% of patients with terminal or advanced cancer can feel pain, that may be present in up to 85% of patients with head and neck cancers (CCC) at the time of diagnosis.

The orofacial pain related to cancer treatment is a well-known side effect of treatment. The pain of oral mucositis is the most common complaint of patients during cancer treatment. Severe and painful mucositis is related to an additional hospitalization and for longer time, leading to a delay, interruption or disruption of cancer treatment protocols that may affect prognosis, CV and cost of treatment. The Graft-versus-host disease (GVHD) is a common complication of hematopoietic cell transplantation (TCH), which occurs in 25-70% of patients; usually, oral lesions are painful.

In addition to the CCC, oral manifestations of leukemia and lymphoma can cause pain and loss of function. Lymphomas and leukemia may induce infiltration by pain responsive to the secondary structures and by oral infections. Multiple myeloma frequently presents with pain and when associated with teeth, represents a challenge for diagnosis. Intracranial malignancies may give rise to orofacial pain and headaches. Even in patients with cancer diagnosis, prognosis is difficult intracranial metastases of new or changed headache.

Pain can present similarly to classical trigeminal neuralgia. Pain in the jaw can be due to metastatic cancer and tumors arising in the breast, prostate, thyroid, lung and kidney, are likely to spread to the bones of the head and neck; this is observed more frequently in the rear jaw. Over 60% of patients, the first indication of malignancy far undiscovered, may be a metastasis in the oral region. Patients with nasopharyngeal cancer realize pain that may be reflected in the region of the temporomandibular joint and pass as a temporomandibular disorder. There are reports that the orofacial pain has been reported in patients with no distant metastatic cancer, usually in the lungs.

It is thought that the pain mechanism follows the commitment of the vagus or phrenic nerve. Paraneoplastic processes may present with peripheral neuropathy, especially in patients with lung cancer and lymphoma. Usually, it is reported neuropathies in patients with malignancies (1.7 to 5.5%) due to the direct effects of the tumor, paraneoplastic syndromes and toxic effects related to treatment.

Orofacial pain due to cancer treatment

The most common acute radiation therapy or oral cancer chemotherapy side effects is oral mucositis. Oral mucositis and related pains are symptoms that cause the most distress in patients receiving radiation therapy to the head and neck and intensive chemotherapy regimens that induce neutropenia. The combination of radiation and chemotherapy causes increased frequency, severity and duration of mucositis. (For more information, see the section of this summary for oral mucositis).

The pain of mucositis may interfere with daily activities in at least one third of patients, and social activities and humor in over half of these. Mucosal pain may persist long after the cessation of mucositis. Are common reports indicating sensitivity mucosal year follow-up, indicating that chronic symptoms may be related to the change in tissues such as epithelial atrophy or neuropathy.

The orofacial pain after treatment of CCC may be due to musculoskeletal syndromes, including temporomandibular disorders associated with muscular fibrosis, scarring and misalignment of the jaw. Ablative surgery can lead to tissue defects that can cause significant loss of orofacial function. Resection of the upper and lower jaw carries a sensory dysfunction and more than half of patients have regional hyperalgesia or allodynia. Pain scores after surgery CCC are higher for cancers of the oral cavity, followed by cancers of the larynx or oropharynx.

More than six months after surgery, you can see a dysfunction due to moderate to severe pain in approximately one third of patients. As usual, and physical therapy for the treatment of pain in these patients are used. The long-term survivors of CCC (> 3 years) continue to have more pain and functional problems. The pain associated with surgery involves mechanisms of inflammatory and neuropathic pain.

Postradiation osteonecrosis and bisphosphonate-related osteonecrosis oral complications are recognized for their ability to cause pain; their clinical presentations include pain, edema and bone exposure. Oral GVHD represents a local manifestation of systemic disease after HCT can cause arthritic pain and mucosítico. Viral reactivation of herpes viruses can cause pain. Postherpetic neuralgia can cause chronic pain that causes painful paresthesia in the affected area, which can persist for years.

Pain management in cancer patients

Pain management should be directed to the diagnosis of the etiologic factors, pain mechanisms involved and pain intensity. (For more information, refer to the PDQ summary on Pain). The following are the mechanisms of cancer pain:

Inflammation.

Malignant disease.

Complications of treatment.

Infection.

Tumor invasion, structures pressure ulceration or mucosal surface.

Nociceptive pain.

Neuropathic pain.

Treatment of oral mucositis pain

The oral mucositis pain is related to a release of proinflammatory cytokines and neurotransmitters that activate nociceptors at the site of the lesion and can be increased by a secondary infection of the mucosa. The pain is influenced by the degree of anxiety, depression, sociocultural variation, and quality and quantity of sleep.