Oral complications: an overview DR ANDREW DAVIES FRCP CONSULTANT IN PALLIATIVE MEDICINE ROYAL SURREY COUNTY HOSPITAL, GUILDFORD, UK

Oral complications: an overview DR ANDREW DAVIES FRCP CONSULTANT IN PALLIATIVE MEDICINE ROYAL SURREY COUNTY HOSPITAL, GUILDFORD, UK

Introduction

Introduction Outline: Epidemiology Aetiology Clinical features Management Conclusion

Epidemiology

Epidemiology Oral complications: All types of cancer All stages of disease All types of treatment

Epidemiology Oral complications: 10% receiving adjuvant chemotherapy 40% receiving primary chemotherapy 80% receiving myeloablative chemotherapy 100% receiving head & neck radiotherapy National Cancer Institute, 2008

Epidemiology

Epidemiology Prevalence xerostomia recorded in clinical notes (patients referred to specialist palliative care services): 16% total Joint 10 th most common symptom Potter et al, 2003

Epidemiology Prevalence xerostomia elicited by Memorial Symptom Assessment Scale (patients referred to specialist palliative care services): 78-82% total 2 nd / 4 th most common symptom Davies, 2000 Tranmer et al, 2003

Epidemiology 10 Healthcare professionals may not enquire about a symptom if: a) they perceive the symptom to be uncommon b) they perceive the symptom to be unimportant c) they perceive there is no treatment d) time does not permit

Epidemiology Patients may not volunteer a symptom if: a) they perceive the symptom to be inevitable b) they perceive there is no treatment c) they sense that healthcare professional is uninterested (in the symptom) d) other symptoms predominate

Aetiology

Aetiology Direct effect of cancer Indirect effect of cancer Direct/indirect effect of cancer treatment Direct/indirect effect of supportive care interventions Related to co-existent oral condition Related to co-existent physical condition Related to co-existent psychological condition Direct/indirect effect of treatment for other conditions Combination of factors*

Direct effect cancer Oral tumours Disseminated tumours

Indirect effect cancer Paraneoplastic syndromes Physiological effects

Effect cancer treatment Direct effect Indirect effect

Local radiotherapy Oral complication Oral mucositis Oral infections - fungal, bacterial Taste disturbance Salivary gland dysfunction Osteonecrosis Soft tissue necrosis Soft tissue fibrosis - trismus Dental/skeletal developmental problems* Induction of second malignancies Comment Acute complication Acute/chronic complication Acute/chronic complication Acute/chronic complication Chronic complication Chronic complication Chronic complication Chronic complication Chronic complication

Local radiotherapy Conventional head & neck radiotherapy: 66.5% dysgeusia (during radiotherapy) 37.4% oral candidosis (during radiotherapy) 24.1% dental caries (post radiotherapy) 25.4% trismus 7.4% osteonecrosis [80% oral mucositis] Oral Care Study Group of MASCC / ISOO, 2010

Local radiotherapy Conventional head & neck radiotherapy: 81.4% xerostomia (during radiotherapy) 83.8% xerostomia (1-2 yr post radiotherapy) Intensity modulated radiation therapy (IMRT): 100% xerostomia (during radiotherapy) 66% xerostomia (1-2 yr post radiotherapy) Oral Care Study Group of MASCC / ISOO, 2010

Systemic chemotherapy 20 Oral complication Oral mucositis Oral infections - viral, fungal, bacterial Taste disturbance Salivary gland dysfunction Neuropathy - jaw pain (vinca alkaloids) Haemorrhage Dental/skeletal developmental problems* Induction of second malignancies Comment Acute complication Acute complication Acute complication Acute complication Acute complication Acute complication Chronic complication Chronic complication

Systemic chemotherapy Conventional chemotherapy: 56.3% dysgeusia (during chemotherapy) 38.0% oral candidosis (during chemotherapy) 37.3% dental caries (post chemotherapy) 49.9% xerostomia (during chemotherapy) [40% oral mucositis] Oral Care Study Group of MASCC / ISOO, 2010

Chemo-radiotherapy Oral Complication Dysgeusia (during Rx) Oral candidosis (during Rx) Dental caries (post Rx) Chemotherapy Radiotherapy Chemoradiotherapy 56.3% 66.5% 76.0% 38.0% 37.4% 66.7% 37.3% 24.1% 21.4% Oral Care Study Group of MASCC / ISOO, 2010

Haematopoietic stem cell transplant Complications of chemotherapy Complications of radiotherapy Complications of stem cell transplant Complications of immunosuppression [Complications of supportive treatment]

Haematopoietic stem cell transplant Acute GVHD: 50-70% allogeneic transplants 35-60% oral involvement (Systemic disease) Tongue, buccal mucosa, labial mucosa Hyperkeratotic, erythematous, ulcerative, desquamative

Haematopoietic stem cell transplant Chronic GVHD: 30-50% allogeneic transplants Up to 80% oral involvement (Systemic disease) Similar agvhd; mucocoeles; stiffness oral tissues; SGD; malignancy

Haematopoietic stem cell transplant Ciclosporin: Infections Malignancies Gingival hyperplasia (1-10%)

Haematopoietic stem cell transplant Palifermin: Dysgeusia (> 10%) Oral paraesthesia (1-10%) Oral mucosal / tongue hypertrophy (> 10%) Oral mucosal / tongue discolouration Lip swelling (1-10%) Oral / tongue oedema

Novel agents Drug Bortezomib (Velcade ) proteasome inhibitor Sunitinib (Sutent ) protein kinase inhibitor Very common side effects ( 1/10 patients) Common side effects ( 1/100 1/10 patients) - Mucositis Oral ulceration Taste disturbance Xerostomia Mucositis Taste disturbance Glossodynia Xerostomia Oral pain Uncommon side effects ( 1/1000 1/100 patients) Oral pain Jaw pain Gingival bleeding Coated tongue Discoloured tongue Hypersalivation -

Novel biological agents Drug Bevacizumab (Avastin ) monoclonal Ab against VEGF Trastuzumab (Herceptin ) Monoclonal Ab against HER2 Very common side effects ( 1/10 patients) Mucositis Taste disturbance Mucositis Taste disturbance Common side effects ( 1/100 1/10 patients) (Gingival bleeding) Xerostomia - Uncommon side effects ( 1/1000 1/100 patients) -

Supportive care agents 30

Medication (general) Oral side effects of frequently prescribed drugs : 79% - oral side effects 63% - xerostomia 37% - dysgeusia 27% - stomatitis 20% - glossitis 9% - coated tongue Smith & Burtner, 1994

Medication (oral care)

Medication (oral care) Chlorhexidene: Discolouration teeth Discolouration tongue Calculus formation Dysgeusia Parotid gland swelling Mucosal dryness Mucosal irritation [Inactivation nystatin]

Paediatrics

Paediatrics

Clinical features

Clinical features Variable - frequency, intensity, bothersomeness - clinical presentation Cause direct morbidity Cause indirect morbidity

Clinical features

Clinical features

Clinical features 40

Clinical features Xerostomia dysphagia poor oral intake malnutrition fatigue depression ETC!

Clinical features Directly result in mortality oral infection/colonisation leading to systemic infection Indirectly result in mortality alteration chemotherapy leading to reduction in chemotherapy response

Management

Management Multi-disciplinary teams Evidence based practice [Common sense]

Management

Management Screening Prevention* Treatment

Management Assessment Treatment - definitive - symptomatic Re-assessment

Conclusion

Oral complications Oral problems are common in cancer patients, and are a significant cause of morbidity and impaired quality of life in this group of patients. Moreover, in some patients they can prevent administration of potentially life-saving treatment, whilst in other patients they can themselves cause potentially lifethreatening complications. Oral complications of cancer and its management, 2010

Oral complications Oral problems are usually predictable, and may be prevented or ameliorated by appropriate interventions. However, even when it is not possible to prevent the oral problem, it is usually possible to treat / palliate the oral problem (and so to prevent or ameliorate the associated complications). Oral complications of cancer and its management, 2010