Complications during the treatment of malignant neoplasms
Original article is written in RU language (link to read it).
The need for emergency dental treatment of patients during the period of specialized therapy is due to the side effects and complications caused by chemotherapy and radiation therapy, as well as exacerbations of chronic odontogenic processes in the oral cavity.
The severity of these pathological manifestations is determined by the initial state of the patient’s mucous membrane, teeth, and dental system as a whole.
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Emergency care is provided by dentists, subject to coordination of all necessary procedures with oncologists.
Figure 1. Patient undergoing radiation therapy.
Complications of antitumor drug treatment
Complications and side effects that are caused by chemotherapy treatment depend on various factors, including: type of drug, dose, and concomitant pathology.
All adverse reactions caused by chemotherapy can be divided into the following groups:
complications caused by the toxic effects of chemotherapy;
associated with immune disorders;
intolerance to cytostatics;
cross-drug interactions between chemotherapy and other medications.
The most common side effect of chemotherapy treatment is damage to the mucous membrane of the digestive system - mucositis syndrome. The development of this complication is mainly associated with high doses of cytostatics, which provoke myelo- and immunosuppression and activate fungal and bacterial infections.
Mucositis syndrome includes stomatitis, esophagitis, and enteritis. Stomatitis develops within 5-16 days from the start of taking cytostatics, and continues for another two weeks after completion of chemotherapy.
The oral mucosa is a highly proliferating tissue; its complete recovery occurs after 7–14 days. This feature underlies the high risk of stomatitis. Extensive microbiological contamination of the oral mucosa is the reason for its activation against the background of febrile neutropenia, typical of chemotherapy.
Figure 2. Patient undergoing chemotherapy.
Prevention of stomatitis
To prevent the development of stomatitis during chemotherapy treatment and to minimize its severity, you must follow the following recommendations:
sanitation of the oral cavity before starting chemotherapy;
resorption of an ice cube when administering cytostatics;
antiseptic treatment of mucous membranes;
using a soft toothbrush;
quitting smoking and alcohol;
self-control on the part of the patient;
treatment of the mucous membrane with a low-intensity helium-neon laser.
Principles of treatment
There is no specific treatment for stomatitis caused by chemotherapy drugs. The help of a dentist is aimed at:
reduction of pain syndrome,
preventing the addition of a secondary infection,
acceleration of epithelization of damaged areas.
Complications of radiation therapy
The therapeutic effects of radiation are associated with its side effects on healthy tissues and organs located in close proximity to the tumor and exposed to ionizing effects to the same extent as the affected area.
Factors influencing the severity of side effects and complications:
the size of single and total doses;
initial state of tissues,
the volume of normal tissue exposed to radiation along with the neoplasm,
number of fractions of radiotherapy,
the period of time during which the course of radiation therapy was carried out,
the patient's general health condition,
Radiation reactions are pathological processes in tissues that go away on their own within a few weeks after the end of radiation therapy and do not require special treatment. Radiation reactions include skin erythema.
Radiation damage is a functional and organic disorder that occurs in organs and tissues, the elimination of which requires special treatment.
Figure 3. Radiation therapy machine.
Radiation reactions are divided into general ones:
pathology of the gastrointestinal tract (loss of appetite, diarrhea, vomiting),
cardiac dysfunction (tachycardia),
damage to the hematopoietic and nervous systems.
Radiation reactions are local in degree of manifestation; they are characterized by pathological changes that are observed exclusively at the site of irradiation.
A distinctive characteristic of the biological influence of radiation is the latent period, the duration of which is determined by the dose and intensity of radiation.
Complications that develop immediately after the start of radiation therapy or over the next three months are classified as early radiation reactions. Complications that appear no earlier than three months after the start of irradiation are called late. The latter can develop even years after the end of treatment.
The mechanism of late complications is based on damage to the vascular bed of the irradiated tissue area, which in the future leads to disruption of trophism, contributes to the launch of degenerative phenomena and destructive processes, which, as they progress, cause fibrosis or the formation of a radiation ulcer.
As a result of the side effects of radiation therapy, capillaries and small venules are destroyed and stop functioning normally, and up to half of the vascular bed is gradually cut off from the blood circulation.
The severity of pathological processes in epithelial cells during radiation therapy is determined by the following factors:
total radiation dose,
mitotic activity of epithelial cells.
The soft palate area is lined with non-keratinizing epithelium, which is more sensitive than the keratinizing epithelium covering the gums and hard palate. Irradiation primarily affects the processes of biosynthesis, as well as the differentiation of epithelial cells, mainly of the basal layer.
Figure 4. Administration of chemotherapy drug to a patient.
During radiation therapy, the regenerative capabilities of the cells of the oral mucosa are significantly reduced, the renewal period of which is 7-14 days. Radiation reactions clinically appear a week after the start of radiotherapy.
The oral mucosa and skin are the areas that are affected in all patients, without exception, undergoing radiation therapy.
Radiation reactions of mucosal erythema begin, which is not accompanied by complaints from the patient.
Gradually, the surface of the mucous membrane becomes cloudy and the shine disappears.
White plaques appear, covered with necrotic films.
As plaques progress, they form confluent pseudomembranous areas. Patients experience pain when eating and talking.
Atrophic disorders develop, necrosis develops, and ulcers appear.
The patient has difficulty chewing, speaking, swallowing, he refuses food, and loses a lot of weight.
The interdental papillae and periodontal tissues are gradually destroyed, and the dryness of the mucous membranes increases.
Preventing complications of radiation therapy
Mandatory sanitation of the oral cavity before the start of radiation therapy.
The use of anti-inflammatory, antimicrobial drugs, anesthetics, antioxidants, radioprotectors.
After radiotherapy, you can treat the oral mucosa with sea buckthorn oil.
Local cooling of oral tissues, gentle diet.
Application of low-intensity laser radiation.
Magnetotherapy improves the patient's general condition and increases the body's reactive capabilities.
Hyposalivation during antitumor treatment
Xerostomia is a late complication of radiation therapy. However, most patients notice the appearance of dry mouth after the first radiotherapy sessions. Within 14 days, salivation drops by 90%. As a dose of 40 Gray accumulates, irreversible damage is observed in the salivary glands included in the irradiation zone.
Figure 5. Manifestation of xerostomia.
In the case of chemotherapy, xerostomia appears only during the administration of cytostatics and is reversible.
Prevention of hyposalivation syndrome is associated with great difficulties and is a difficult task for the doctor. You can prevent the appearance of signs of xerostomia by trying to exclude the salivary glands from the area of radiation.
Symptoms can be reduced by using frequent rinses of the mouth with mineral water, saline, diluted lemon juice with sugar substitutes. The use of sugar-free chewing gum has a positive effect.
Artificial saliva has good results; you can make it yourself by mixing water with glycerin to obtain a 1% solution.