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ILL EFFECTS OF RADIOTHERAPY IN THE MANAGEMENT OF ORAL CANCER by Dr kashif ali Assistant professor ORAL CANCER Approximately 90% of oral cancer is SCC Particularly common in developing world Multifactorial etiology life style Habits and diet Others Head & Neck Cancer Diagnosis Salivary gland tumours 7% Lymphomas 9% Squamous cell carcinomas 78% Leukemias 5% Other 1% Squamous Cell Carcinoma • 90% of all oral cancers • 50% 5-year survival • can occur in: • tongue • skin • throat • soft palate Treatment plan is based on: • anatomical considerations Treatment plan is based on: Staging of disease using TNM classification T = Tumour size N = Nodal status M = Metastases Eg. T3N2M0 laryngeal carcinoma Treatment Options Primary surgery +/Adjuvant Radiotherapy +/Concurrent Chemotherapy OR Primary Radiotherapy +/Concurrent Chemotherapy +/Surgery for Salvage Aims of radiotherapy Radical radiotherapy -- curative intent Palliative radiotherapy --To control symptoms Radiation Therapy External beam –most common –largest fields Radiation Therapy Brachytherapy –interstitial implantation of radioisotope-filled needles Radiation Therapy Au grain or Iridium Implants Radiation • How much? • Where? How much radiation? 1 “rad” = 1 centiGray (cGy) 200 cGy per day 5 days per week 1000 cGy per week How much radiation? Total dose ranges from 6000 cGy – 7000 cGy 6 – 7 WEEKS of treatment ORAL CANCER TREATMENT MODALTIES Ablative Surgery Surgery and / or radiotherapy Radiotherapy and Chemotherapy ORAL CANCER RADIOTHERAPY Advantages Normal Anatomy and function Is maintained GA not needed Can be used to debulk inaccessible lesions ORAL CANCER RADIOTHERAPY Conventionally upto 60 Gys dose is given Post radiotherapy complaints increase tremendously when the radiation dose is increased ORAL CANCER RADIOTHERAPY ill effects Oral mucositis Xerostomia Loss of taste Osteoradionecrosis Oral mucosa Seen in 1-2 weeks Erythema with sever mucositis With or without ulceration Pain and disphagia Loss of test- test bud atrophy Delayed healing Pale and less vascular mucosa Radiotherapy induced Submucous fibrosis ORAL CANCER RADIOTHERAPY Salivary glands 1st week of radiotherapy Xerostomia Difficulty in swallowing Nasua Rampant caries Periodontitis Recovery 3 to 4 months Management Sipped of water Salivary substitute Mucous based sprays -saliva orthane spray Cellulose --- glandosane, glycerin Pilocarpine hydrocloride 5mg QID Cevimelive hydroloride 30mg TDS Stimulation of exocrine gland Skin Erythema 3rd week Dose greater than 50 gy Healing 7 to 10 days Bone Osteoradionecrosis Is devitilization of bone after cancericidal dose of radiation Endarteritis Bone turn over become slow, remolding dose not occur leads to exposed bone ORAL CANCER RADIOTHERAPY ORAL CANCER RADIOTHERAPY ORAL CANCER RADIOTHERAPY ORAL CANCER RADIOTHERAPY Other effects Alteration of flora Inc anaerobic species Inc fungi , Candida Nystatin 0.1% chlorexidine Late effects of radiation Eyes Cataract 10 gy Blindness 50 gy Spinal cord Paraplegia dose Inc 45gy Carotid artery stenosis ORAL CANCER RADIOTHERAPY Conclusion Surgery is the first choice Surgery may be followed by Radiotherapy or Chemotherapy if required Where bone is involved, Radiotherapy / Chemotherapy do not work Radiotherapy / Chemotherapy alone only work as palliative therapy Radiotherapy must be done under the supervision of experienced oncologist ORAL CANCER RADIOTHERAPY THANK YOU Evaluation of dentition before radiotherapy 1. 2. Most feared side effect is ORN Factor determine the fate of teeth Condition of residual dentition-- ? Pt awareness – past care pt with good oral hygiene , the clinician must retain as many of teeth as possible Neglected oral health --ext Factor determine the fate of teeth 3 Immediacy of radiotherapy 4 Radiation location Pre radiation ext considered 1- 2 week delay radiation 5 Radiation dose Inc 50 GY--- ext indicated Less than 50 – conservative Preparation of dentition for radiotherapy Pre radiation Restorations Topical fluoride application Oral hygiene measures and instructions Prevention of mechanical trauma Encourage to stop habitts Preparation of dentition for radiotherapy cont Per radiation Rinse mouth with saline at least 10 times daily Chlorhaxidine mouth wash 2 times Dental evaluation twice a week during radiotherapy If overgrowth of candida than nystatin / clotimazole Exercise – maintain mouth opening Weight loss should be checked NG tubes Post radiation Regular follow up every 3- 4 week Topical fluoride Method of preparing preirradiation extraction atraumatic extraction Interval B/w preirradiation ext and beginning of radiotherapy 7-14 days 3 weeks if possible Impacted 3rd molar removal before radiotherapy Partially erupted Complete embedded Carious teeth after radiotherapy Treatment accordingly Composite , amalgam Necrotic pulp __ RCT If RCT is difficult – amputation above the gingiva left at place Tooth ext after radiotherapy 4 month gap HBO before and after ext 20- 30 dives Denture after radiation Yes Soft liners