I have mouth cancer – To Whom Should I Be Referred
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Transcript of I have mouth cancer – To Whom Should I Be Referred
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“I have oral cancer – To Whom Should I Be Referred?”
Peter B. Lockhart, DDS, FDS RCPSChair, Department of Oral Medicine
Carolinas Medical Center
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Dental Management of Medically Complex Patients
• Cancer• Radiotherapy• Chemotherapy
• Coagulopathy• Cardiovascular• Renal• Immunosuppression• Diabetes• Bacteremia issues
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Who To See?Who To See?
Team approach! Team approach! The The whowho and the and the sequencesequence of care depends on: of care depends on:
anatomical location and TNM Stageanatomical location and TNM Stage medical and dental resourcesmedical and dental resources overall medical conditionoverall medical condition survival and quality of lifesurvival and quality of life organ preservation (larynx, tongue)organ preservation (larynx, tongue) training, experience, and time commitmenttraining, experience, and time commitment driven by the literature - RCTsdriven by the literature - RCTs
Evolving over timeEvolving over time
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Tumor StagingTumor Staging
Stage 1Stage 1Stage 2Stage 2Stage 3Stage 3
Stage 4Stage 4
T1T1 NONO MOMOT2T2 NONO MOMOT3T3 NO NO MOMOT1, T1, T2 or T3T2 or T3 N1 MON1 MOT4T4 NO or N1NO or N1 MOMOAny T Any T N2 or N3 MON2 or N3 MOAny TAny T Any NAny N M1M1
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Changes in H&N Cancer TherapyChanges in H&N Cancer Therapy
Surgical skills and medical oncology protocolsSurgical skills and medical oncology protocols Radiotherapy technology and methodologyRadiotherapy technology and methodology
IMRT and IGRTIMRT and IGRT altered fractionationaltered fractionation
Concomitant chemo/RTConcomitant chemo/RT Return to neo-adjuvant chemo (TPF)Return to neo-adjuvant chemo (TPF) Emphasis on feeding tubes, swallowing functionEmphasis on feeding tubes, swallowing function
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Estimated New Cases*
Jemal A, et al. CA Cancer J Clin 2008; 58:71-96
Oral cavity & pharynx 25,310 3%
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Jemal A, et al. CA Cancer J Clin 2008; 58:71-96
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A Tale of Two CitiesA Tale of Two Cities BostonBoston (Brigham and Women’s Hospital 1977-1987) (Brigham and Women’s Hospital 1977-1987)
Large medical school-based academic medical centers Large medical school-based academic medical centers including Dana Farber Cancer Instituteincluding Dana Farber Cancer Institute
Full time staff physicians and dentistsFull time staff physicians and dentists Twice weekly multi-disciplinary H&N clinicsTwice weekly multi-disciplinary H&N clinics
CharlotteCharlotte (Carolinas Medical Center 1987-2008) (Carolinas Medical Center 1987-2008) Non-medical school, community-based teaching Non-medical school, community-based teaching
hospitalhospital Community-based physicians and dentistsCommunity-based physicians and dentists No H&N clinicsNo H&N clinics
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Dana Farber Cancer Institute (DFCI) Dana Farber Cancer Institute (DFCI) Head and Neck ServiceHead and Neck Service
Director (Medical Oncologist)Director (Medical Oncologist) Large referral baseLarge referral base NIH funded protocolsNIH funded protocols 2 half day/week clinics (10+ hrs)2 half day/week clinics (10+ hrs) 2 exam. rooms and a conference room2 exam. rooms and a conference room
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DFCI Head and Neck Cancer TeamDFCI Head and Neck Cancer Team
3 rotating head and neck surgeons (ENT)3 rotating head and neck surgeons (ENT) Radiation oncologistRadiation oncologist 2 medical oncologists2 medical oncologists DentistDentist 2 oncology nurses2 oncology nurses NutritionistNutritionist Social workerSocial worker Speech pathologistSpeech pathologist Various house officersVarious house officers
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Data CollectionData Collection
Baseline oral statusBaseline oral status Chemo. & RT comps.Chemo. & RT comps. Surgery issuesSurgery issues Long term F/ULong term F/U Clinical trialsClinical trials
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Carolinas Medical CenterCarolinas Medical Center
No structure to H&N cancer care initiallyNo structure to H&N cancer care initially Dental service oncology research nurseDental service oncology research nurse Failed attempt at multidisciplinary clinicsFailed attempt at multidisciplinary clinics Evolved over time to suit the systemEvolved over time to suit the system Bi-monthly, multidisciplinary tele-conferencesBi-monthly, multidisciplinary tele-conferences Improved communication – Letters and emailImproved communication – Letters and email
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Critical Differences by Medical CenterCritical Differences by Medical Center
LeadershipLeadership Financial considerationsFinancial considerations Territorial instinctsTerritorial instincts Formal multidisciplinary clinics - facilitiesFormal multidisciplinary clinics - facilities Institutional commitment (e.g., dental service)Institutional commitment (e.g., dental service) Support staffSupport staff Communication and coordinationCommunication and coordination Emphasis on science and researchEmphasis on science and research TraineesTrainees
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Communication and Coordination
Head & Neck Surgery
Dentistry
Radiation Oncology
Medical Oncology
Head & Neck Patients
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Interdisciplinary Team ApproachInterdisciplinary Team Approach
Critical to successful patient managementCritical to successful patient management Portals to head and neck cancer carePortals to head and neck cancer care CoordinationCoordination
sequence of caresequence of care timing of dental involvementtiming of dental involvement
Time commitmentTime commitment Importance of understanding our role and that of Importance of understanding our role and that of
other disciplines – formal trainingother disciplines – formal training General dentist – medical center-basedGeneral dentist – medical center-based
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Dentist’s Role in OncologyDentist’s Role in Oncology
Identification of malignancyIdentification of malignancy Prevention and management of problemsPrevention and management of problems
pre-cancer treatmentpre-cancer treatment during treatmentduring treatment post-treatment – especially RTpost-treatment – especially RT
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Presenting SignsPresenting Signs
Systemic:Systemic: InfectionInfection MalaiseMalaise Slow healingSlow healing FeverFever
Local:Local: UlcerationUlceration BleedingBleeding Loose teethLoose teeth ParaesthesiaParaesthesia
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BoneBone
AcellularityAcellularity
Poor repairPoor repair
VascularityVascularity
EndarteritisEndarteritis
IschemiaIschemia
GlandsGlands
XerostomiaXerostomia
Bacterial flora/pHBacterial flora/pH
MucosaMucosa
ThinningThinning
MucositisMucositis
InfectionInfection
Teeth/BoneTeeth/Bone MucosaMucosa
Radiotherapy SequelaeRadiotherapy Sequelae
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Additional Radiotherapy Additional Radiotherapy SequelaeSequelae
TasteTaste NutritionNutrition FunctionFunction
Trismus Musculature (TMD) Growth & development
Interim vs. Early vs. LateInterim vs. Early vs. Late
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Patient-related:Patient-related: MalignancyMalignancy AgeAge Medical statusMedical status Previous RTPrevious RT
Factors Influencing Frequency and Severity of Oral Complications
Pre-treatment oral status Level of oral care during
chemo. and RT Genetics?
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Factors Influencing Frequency and Factors Influencing Frequency and Severity of ComplicationsSeverity of Complications
Therapy-related:Therapy-related: Chemo agents and Chemo agents and
# rounds# rounds Total dose (RT)Total dose (RT)
Concomitant therapyConcomitant therapy Degree and duration of Degree and duration of
neutropenianeutropenia
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Pre-chemo./RT Oral StatusPre-chemo./RT Oral Status
AnatomyAnatomy Poor oral hygienePoor oral hygiene Perio. / pupal diseasePerio. / pupal disease Ill-fitting prosthesisIll-fitting prosthesis Defective restorationsDefective restorations
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Restorations – Crowns, etc.
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Trauma
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Level of Oral Care
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Frequency of Care
0
10
20
30
40
50
1
Perc
en
t Every 6
Every 12
Infrequent orEmergency
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Hygiene
0
20
40
60
Per
cen
t
Excellent
Good
Fair
Gross Debris
Periodontal Status
0
20
40
60
Per
ce
nt
Excellent
Gingivitis
Sig. Bone Loss
AdvancedDisease
Dentition: State of Repair
0
20
40
60
Pe
rce
nt
Excellent
OldRestorations
RecurrentCaries
Clinical Caries
0
10
20
30
40
Pe
rce
nt None
Incipient
Obvious
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Pre-Treatment Needs
0
20
40
60
80
100
Pe
rce
nt
Prophy/Scaling
Restorations
Extractions
PeriodontalSurgery
Endodontics
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0
50
100
Percent
Pre-Tx vs Resolved Needs
Yes
No
Yes
No
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Pre-Radiotherapy Dental Treatment Planning
Patient Factors – Medical
Cancer prognosis Planned treatment regimens Compliance with medical therapy Risk / Benefit issues Psychological factors Tobacco use
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Patient Factors - Patient Factors - Preventive ConsiderationsPreventive Considerations
Thorough examThorough exam Full series filmsFull series films CleaningCleaning Education:Education:
HygieneHygiene FluorideFluoride DietDiet RestorationsRestorations
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Patient Factors – Dental StatusPatient Factors – Dental Status
Gingival recession, exposed dentinGingival recession, exposed dentin Caries and periodontal diseaseCaries and periodontal disease Periapical diseasePeriapical disease MobilityMobility Removable appliancesRemovable appliances Orthodontic appliancesOrthodontic appliances
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Dental Treatment PlanningDental Treatment Planning
Tooth by tooth - need/prognosis for eachTooth by tooth - need/prognosis for each Single vs. multi-rooted toothSingle vs. multi-rooted tooth Mandible vs. maxillaMandible vs. maxilla Anterior vs. posterior toothAnterior vs. posterior tooth Prosthetic needsProsthetic needs Eliminate existing and potential sources of Eliminate existing and potential sources of
trauma and infectiontrauma and infection
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On the one hand…
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On the other hand…….
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Periodontal Disease
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Pericoronitis
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Dental ManagementDental Management
Ranges from no treatment to full mouth Ranges from no treatment to full mouth extractionsextractions
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Problems Problems DuringDuring Radiotherapy Radiotherapy
MucositisMucositis Direct and indirectDirect and indirect
Taste alteration/lossTaste alteration/loss XerostomiaXerostomia InfectionInfection
FungalFungal PeriodontalPeriodontal
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Mucositis Complications Mucositis Complications and Sequelaeand Sequelae
PainPain Oral infectionOral infection Systemic infectionSystemic infection SepsisSepsis Oral bleedingOral bleeding
Taste Hydration/Nutrition Fatigue Interrupted cancer
treatment
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Concomitant Therapy
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Irritation and Trauma
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Poor Appetite and NutritionPoor Appetite and Nutrition
MucositisMucositis XerostomiaXerostomia HypogeusiaHypogeusia Taste lossTaste loss
Causes: Outcomes:
Weight loss Dehydration Stomatitis (nutritional) 2° oral infection
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Xerostomia – Saliva FunctionsXerostomia – Saliva Functions
DysphagiaDysphagia SpeechSpeech ProsthesesProstheses Taste alterationTaste alteration AntimicrobialAntimicrobial RemineralizationRemineralization BufferBuffer
Lubrication Cleansing Digestive
Enzymes Chewing and swallowing
Mucosal integrity
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Infection
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““Late” RT ProblemsLate” RT Problems
Persistent xerostomiaPersistent xerostomia Oral prostheticsOral prosthetics Infection – bacterial and fungalInfection – bacterial and fungal Trismus – 45%*Trismus – 45%* Necrosis – Bone and soft tissueNecrosis – Bone and soft tissue Growth and developmentGrowth and development
* Kent ML Support Care Cancer 16:305-309, 2008
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Caries
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Pulp Necrosis
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Soft Tissue Necrosis
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Osteonecrosis
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TrismusTrismus
Unpredictable frequency and severityUnpredictable frequency and severity Muscle/ligament fibrosisMuscle/ligament fibrosis TMJ capsuleTMJ capsule Primary tumor sitePrimary tumor site 3-6 months after RT3-6 months after RT Effects on nutrition/hygieneEffects on nutrition/hygiene ExercisesExercises PreventionPrevention
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Patient ManagementPatient ManagementControversiesControversies
Fluoride traysFluoride trays DenturesDentures Pre vs. post RT extractionsPre vs. post RT extractions Endodontics vs. extractionsEndodontics vs. extractions 7-21 days for healing7-21 days for healing Hyperbaric oxygen pre and post RTHyperbaric oxygen pre and post RT
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Dentures
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Long Term Follow-Up Care – RTLong Term Follow-Up Care – RT
Daily Daily fluoridefluoride DietDiet – low refined carbohydrate – low refined carbohydrate Oral Oral hygienehygiene - meticulous - meticulous Frequent dental Frequent dental recall visitsrecall visits
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Institute for Oral MedicineInstitute for Oral MedicineCarolinas Medical Center, Charlotte, NCCarolinas Medical Center, Charlotte, NC
Jen-Luc Mougeot, PhDJen-Luc Mougeot, PhD Farah Mougeot, PhDFarah Mougeot, PhD Peter Lockhart, DDSPeter Lockhart, DDS Michael Brennan, DDSMichael Brennan, DDS Philip Fox, DDS Philip Fox, DDS Louise Kent, RNLouise Kent, RN Jenene Noll, RNJenene Noll, RN