Restorative aspects management of head and neck oncology patients Flashcards
How many new patients per year NI?
300
Survival of head and neck oncology
78% 1 year
56% at 5 years
Side effects of HANC tx
Post surgical defects
salivary gland hypofunction
dental caries
periodontal disease
trismus
mucositis
osteoradionecrosis
damaging effects of radiation
salivary gland acinar degeneration and interstitial fibrosis
loss of enamel prism structure, gaps at EDJ, obliteration of dentinal tubules, degeneration of odontoblast processes
avascularity, acellularity, widening of PDL
Pre radiotherapy dental extractions
teeth with poor prognosis
2-3 weeks prior to xrt
ORN risk pre-XRT extractions - 4.16%
ORN risk post XRT extractions - 7%
during active cancer therapy
leave out dentures as much as possible
manage mucositis
treat acute dental pain
liaise with oncology team RE neutrophil levels
advice from OMFS
Post radiotherapy dental assessments
6 months post XRT
Prevention reinforced
Treatment planning
Xerostomia
Stimulation - pilocarpine
Substitution
Trismus
Mechanical devices
Therabite device
7-7- or 5-5-30 protocol
physiotherapist involved
continue for 6-10 weeks post XRT
Osteoradionecrosis
spontaneous cases
denture induced trauma and active periodontitis
triple therapy
QOL of patients
generally reduces from diagnosis and 3 months
slow improvement 1 year post tx
determinants of poor QOL
Smokers
Problem drinkers
Psychosocial difficulties
maladaptive coping issues
Disfigurement
tumour resection
effects of xrt
anxiety
relationship with partner
social isolation
depression
Eating and Swallowing
Dysphagia can impact nutritional intake and poorer QOL
PEG/RIG feeding tube
Mucositis
Xerostomia
Taste disturbances
infections
trismus
psychological issues
Shoulder dysfunction
Neck dissection
movement limited and painful
Pain
25% pts experience pain at 12 and 24 months post TX
Poorer QOL, increase in depression
Analgesics can mask dental pain and thus delay intervention
Fatigue
Insomnia
Mood disturbances
Managed with physical exercises, psychotherapy and relaxation
Employment issues
up to 50% do not return to work
many require financial support
psychological distress
rates of depression 13-52%
younger pts
limited social support
fatigue
suicide risk
requires careful management
Benefits of dental implants
improves support and retention of a removal prosthesis
help to raise self esteem
improve overall QOL
psychological crutch
bar-retained obturator
implants can dramatically improve the stability and retention of the complete denture with obturator
Zygomatic implants
used to retain obturators, an alternative to free flap reconstruction or conventional obturation
2/3 can be used in each quadrant
risk of orbital trauma
v difficult when trismus present.
Mandible
More commonly reconstructed with graft than maxilla
Range of donor sites available:
iliac crest
radius
fibula
scapula
implants in irradiated jaws
possible but careful case selection required
failure rates higher than in non-irradiated bone
failure rates higher than in maxilla compared to the mandible
Risk of causing ORN
Failures less likely with dose of less than 45Gy
Implants for post XRT pts?
where dose is less than 50 Gy, survival likely to be comparable to non-irradiated patients
conflicting evidence on timing of placement
non-smoker
failure of implants
implants can be placed into vascularised grafts at primary surgery or secondarily into irradiated or non-irradiated grafts.
There may be an increased risk of implant failure in free flap bone that has been irradiated
osteoradionecrosis
usually observed after several years of radiotherapy
related to local trauma with hypovascular, hypocellular, hypoxic tissue
a result of radiation induced endartheritis
