Información sobre riesgo, prevención, detección, síntomas, diagnosis, tratamiento y apoyo para el cáncer.
Información sobre el tratamiento del cáncer incluyendo quirúrgica, quimioterapia, radioterapia, estudios clínicos, terapia con protón, medicina complementaria avanzadas.
OncoLink se complace en ofrecer una amplia lista de lista completa de los agentes quimioterapéuticos más comúnmente usados??. Esta guía de referencia incluye información sobre la forma en que cada fármaco se administra, cómo funcionan, y los pacientes los efectos secundarios comunes pueden experimentar.
Maneras que los pacientes de cáncer y las personas que le cuidan puedan enfrentar el cáncer, los efectos secundarios, nutrición, cuestiones en general sobre el apoyo para el cáncer, duelo/decisiones sobre el termino de vida, y experiencias compartidas por sobrevivientes.
Jay Lucas, DMD, MD, David Rombach, DMD, MD, Joel Goldwein, MD
Ultima Vez Modificado: 1 de noviembre del 2001
Approximately one million people will develop invasive cancer each year. Of these, 40% will receive curative benefit from surgery, radiation, chemotherapy, or a combination modality.(5) In dealing with patients with cancer of the head and neck a team approach is required for effective management. When radiation therapy is indicated, it is imperativ that health of the oral cavity be assessed initially as well as throughout therapy.
All members of the cancer treatment team should be informed of the oncologic treatment plan. Oral care should be initiated at the onset of treatment, with the goal of reducing morbidity and improving compliance. Total body irradiation and irradiation to the head and neck cause both direct and indirect effects on oral and related structures, and may be acute or chronic in nature. These complications may include mucositis, xerostomia, dental caries, loss of taste, trismus, infection, osteoradionecrosis, and abnormalities of growth and development.
Prevention, on the part of the Radiation Oncologist is essential to minimizing excessive morbidity of the oral mucosa . This is accomplished by designing portals that limit the exposure to tissues not at risk for tumor reoccurrence. When interstitial implants are a part of a treatment protocol, soft tissues of the oropharynx are at greater risk for developing soft tissue ulcerations.(5) Mucosa thickness, another important predictor of exaggerated tissue response, should be considered. The anterior commisures of the mouth and the medial surface of the angle of the mandible are sites which contain very thin mucosa and would benefit from field blocks if possible. (5)
Lack of saliva and damaged taste buds may alter the sensation of taste during radiotherapy. Often, patients complain that many foods taste excessively salty which may reduce the motivation for adequate oral intake. In response to their altered taste sensation, patients tend to compensate by increasing their intake of sugar. Counseling should be provided to avoid this behavior due to the increased risk of dental caries. However, altered taste sensorium is a transient phenomenon since the taste buds recover in two to four months post therapy.(1)
Local and total body irradiation may irreversibly affect the production and quality
of saliva in the major and minor salivary glands. Doses as low as 20 Gy will result in
clinically noticeable changes such as sparse thick ropy saliva. In particular, if the parotid
glands are in a field which received 40Gy or over, permanent dysfunction of the salivary
glands should be expected and discussed with the patient prior to treatment.
Concomitant administration of medications which are known to induce xerostomia (i.e.
psychotropics, antiemitics, antihistamines, and thousands of other commonly prescribed
medications.) should be carefully considered.(1)
The diagnosis of xerostomia is based on subjective impressions by the patient and the clinician. Dry mouth may affect speech, taste, nutrition and the patients ability to wear a prosthesis. Saliva also contains antimicrobial compounds (i.e. sIgA, and mucins) which reduce pathogenic bacteria and decrease the risk of infection in the oropharynx . However, saliva's most important role lies in its ability to mechanically cleanse the teeth and soft tissues. Therefore, with radiation induced xerostomia it is common for this to lead to an increased incidence of caries, especially in the cervical portion of the clinical crown at the cementoenamel junction.(2) Similarly, the change in salivary content and quantity also leads to an increased incidence of candidiasis and periodontal disease.
However, the critical aspect in managing head and neck irradiated patients with xerostomia is controlling the risks for oral diseases. Therefore, initiation of meticulous oral hygiene regimens including topical fluoride trays , chlorhexidine rinses, and regular dental hygiene therapy sessions are required. In addition, dietary advice is recommended to reduce the intake of carogenic foods.(2)
The practitioner should be aware of the multiple presentation of candida including pseudomembranous (removable white plaques with an erythematous base), chronic hyperplastic (leukoplakia like plaques that do not wipe away), and chronic cheilitis. These infections should be eliminated to decrease mucositis and the chance of distant gastrointestinal infections.
Gingival bleeding may be the first sign of thrombocytopenia. The patients' ability to accomplish adequate oral hygiene may be limited. In these instances flossing may have to be discontinued . Again chlorhexadine rinses may be required to reduce pathogens found in plaque.(2)
Great importance should be placed on pretreatment evaluation of all remaining dentition. Any questionable teeth that cannot be adequately maintained for years should be extracted. A period of two weeks prior to radiation therapy is advised for adequate healing of extraction sites. All preprosthetic surgery required, should be performed prior to the initiation of radiation therapy.(8)
The role of hyperbaric oxygen has greatly enhanced the ability to reconstruct patients with osteoradionecrosis with large boney and soft tissue defects. However, the cost is tremendous and access to treatment is limited. Additionally it is felt that patients with active malignancies should not be exposed to HBO for fear that it can accelerate the repopulation process. The mechanism of action appears to be supporting neovascularization within tissues ,increasing the oxygen tension . The protocol is 20 pre- surgical hyperbaric oxygen (HBO) sessions, each consisting of 90 minutes of 2.4 atm of absolute pressure/day x five days /week. After the reconstructive surgery, an additional ten treatments is prescribed to ensure adequate vascularization of the grafted bone and soft tissue. There are contraindications to this treatment, covered on OncoLink and elsewhere (7)
Candida is often a problem and antifungals should be used. These drugs may be added into tissue conditioners or placed where needed. Dentures should be removed and cleaned every night. At first sign of discomfort, the denture should be removed, adjusted or relined. It is extremely important not to have soft tissue ulcerations, because the risk of osteoradionecrosis is a life-long threat.(8)
Oral complications of radiotherapy are usually the result of the direct effects of radiation on the oral tissues. The tissues most frequently affected are the mucosa, salivary glands and mineralized tissues.
Management of xerostomia in the child is similar to the adult and typically involves the use of synthetic salivary substitutes and baking soda rinses to break up the thickened viscous saliva.
Also, of utmost importance, a comprehensive oral hygiene regimen should be established for all radiation patient's. Patients four years of age and older, along with the parents, should be instructed in proper brushing and flossing technique. It has been said that these procedures should be carried out as long as the granulocyte count remains above 5/mm3 and the platelet count above 40,0/mm3. Below these levels, these practices should be avoided to prevent hemorrhage and/or bacteremia.(9) In addition, the use of fluoride gels applied in custom made trays, daily, at home, is an important adjunct to brushing and flossing in preventing the ravages of rampant radiation induced tooth decay.
Once treatment is begun, daily evaluation of the oral cavity should be performed prior to each treatment dose. Any unusual findings or side effects of radiation should be identified and addressed either by the radiation oncologist or the patients dentist. Frequent dental follow up visits should be scheduled throughout the treatment period for the purpose of addressing complications, new dental problems, patient questions and concerns, as well as reinforcing the importance of continued home oral hygiene.
Following radiation therapy, and healing of any acute reactions, the long term effects of radiation on the oral tissues require continued frequent assessment by the dentist. Continued surveillance of the oral cavity for xerostomia, increased caries development, malformed permanent teeth, malocclusion and facial maldevelopment are all important components of the long term care of the irradiated child. The early recognition and management of these conditions may allow better corrective measures to be implemented. Also, the psychological and emotional consequences of potential facial deformity and dysfunction deserve to be addressed in these patients and proper steps taken to deal with these problems.
Mucositis: This is a reaction of the skin inside the mouth to radiation. It typically occurs within the first two weeks of treatment. Your child's mouth will become reddened and quite sore. There may even develop ulcerations throughout the mouth with severe discomfort. This reaction usually resolves completely 2-3 weeks after the cessation of therapy. The soreness of the mouth may make it difficult for your child to speak, swallow or eat. However, it is very important that your child continue to take fluid and food to maintain hydration and nutrition for proper healing. Your doctor or dentist may be able to prescribe anesthetic mouth rinses to soothe the soreness and make eating and drinking easier.
Dry Mouth: If the glands that produce saliva have been included in the area to be treated, your child may develop a dry mouth. Depending on the degree of involvement of the glands, the dry mouth may be mild to severe, and may partially return or be permanent. This too may be uncomfortable for your child and make eating difficult. It may be necessary to take frequent sips of fluids (such as water or milk) with each bite of food, as well as take smaller bites, in order to properly moisten and allow easier swallowing. There are man made saliva substitutes available that may ease the discomfort of a dry mouth and make eating and speech easier.
Tooth Decay: Saliva is an important part of the body's mechanism for preventing tooth decay. As mentioned above, radiation therapy can cause a permanent decrease in the amount of saliva produced. This, in turn, can lead to an increased rate of tooth decay in your child's mouth. It is therefore very important to follow your dentist's recommendations on oral hygiene during radiation therapy. Brushing and flossing of the teeth to remove plaque and tartar is crucial to minimizing the risk of severe tooth decay and early tooth loss. Fluoride tooth paste should be used with a soft tooth brush. In addition, fluoride gels in custom trays supplied by your dentist should be used daily according to your dentist's recommendations. Any cavities or tooth aches should be brought to the attention of your dentist right away to avoid unnecessary loss of teeth due to decay. Finally, it is very important to keep your regularly scheduled check up appointments with your dentist so that any problems or concerns may be addressed.
Abnormal Eruption of Adult Teeth: Radiation therapy that involves the head and neck has affects on the developing adult teeth that lie within the jawbone. These affects include delayed eruption (the teeth will come into the mouth later than normal), eruption of teeth in an abnormal alignment (teeth may be crooked), or fusion of the baby teeth in the jaw bone preventing the adult teeth from erupting. These abnormalities can also be corrected, most times, with orthodontics and/or oral surgery.
Abnormal Facial Development: Radiation can also effect the areas of active growth, called growth centers, in the jaws and facial region. If these areas are in the area being treated by radiation, it is possible that future growth of the jaws and/or face may be delayed or disturbed. This altered growth may result in a small jaw with a poor bite, or an altered facial appearance later in life. However, many of the resultant deformities can be adequately corrected through a combination of orthodontic and/or oral surgical procedures.
Difficulty Opening the Mouth: The muscles that open and close the mouth may lie within the area to be treated with radiation. If so, they may be affected and undergo changes which make it difficult to open the mouth, called trismus. This may require a substantial amount of time to occur, even after treatment has stopped, and may develop gradually, making it difficult to notice. This is another reason to make sure you keep your follow up visits with your radiation oncologist and dentist even though treatment may be completed.
2. Fleming, P. Dental Management of the Pediatric Oncology Patient., Pediatric Dentistry, 1991
3. Joyston-Bechal, S. Prevention of Dental Disease Following Radiation Therapy and Chemotherapy. Int Dent Journ , 1992,42, pp. 47-53.
4. Sonis, A., Tarbell, N., Valachovic, R., Gelber,R., Schwenn,M., and Sallan,S., Dentofacial Development in Long-Term Survivors of ALL: A Comparison of Three Treatment Modalities. Cancer, 1990, 66:2645-52.
5. Wang, C.C. Radiation Therapy for Head and Neck Neoplasms: Indications, Techniques, and Results, pub 1983, Chapter 4, pp.19-21.
6. Coia,L.,Moylan,D., Introduction to Clinical Radiation Oncology, Medical Physics Publishing Company, copyright 1991,Chapter 4.
7. Marx,R., Comprehensive Review for Oral and Maxillofacial Surgeons and Residents., vol 1.,pp 17-19., University of Pennsylvania School of Dental Medicine, Aug 12-18, 1991.
8. Peterson, L., Ellis, E., Hupp,J., Tucker,M., Contemporary Oral and Maxillofacial Surgery, C.V. Mosby Company, St. Louis, 1988, chapters 14, and 18.
9. Pediatric Annals, 17 (11), November 1988, pp. 115-25.
10. Larson, D.L., Kroll, S., Jaffe, N., Serure, A., Goepfert, H., Long-Term Effects of Radiotherapy in Childhood and Adolescence, The American Journal of Surgery, 160, october 1990, pp.348-51.
11.Ruccione, Weinberg, Biologic Late Effects of Radiation Therapy, Seminars in Oncology Nursing, 5(1), February 1989, pp. 1-73.
Endocrine System Cancers
Head and Neck Cancers
Urinary Tract Cancers
Bone Marrow Transplants
General Treatment Concerns
Newly Diagnosed Patients
Causes and Prevention
Legal and Financial Information for Patients
Cancer Resource List
Resources for Young Adults