12/3/2010

MANIFESTASI KEMOTERAPI DI RONGGA MULUT

Wilda Hafny Lubis drg MSi

Kanker sering dijumpai saat ini

Ahli- ahli scince+kemoterapi Melakukan Identifikasi & eksploitasi Perbedaan biologi sel kanker Mengembangkan obat dan kombinasinya

Menghancurkan tumor>dari pada sel normal Beberapa respons pnk kanker Terhadap kemoterapi: 1. Untuk penyembuhan kanker 2. Mungkin dapat menyembuhkan kanker 3. Memperpanjang hidup 4. Tidak respon terhadap kanker

Manifestasi kemoterapi dapat dijumpai di rongga mulut

12/3/2010

Kemoterapi
Perawatan kanker dengan menggunakan obat- obatan yang dapat menghancurkan sel kanker, menghentikan berlipat ganda Disebut obat anti kanker Sel normal tumbuh dan mati secara terkontrol Sel kanker sel tidak normal >tidak terkontrol membentuk Kerusakan sel= efek samping, merusakkan sel normal juga
membelah

Efek samping berpengaruh pada:

Pembentukan sel darah dalam sumsum tulang Sel dalam saluran cerna (mouth, stomach, intestines) Sistem reproduksi Folikel rambut Organ vital juga dapat terpengaruh eq. heart, lung, kidneys, nervous system

12/3/2010

Kemoterapi dapat mempengaruhi pada :Cont.

Efek samping tergantung pada tipe dan dosis kemoterapi. Recovery time tergantung pada kesehatan secara umum dan tipe kemoterapi yang diberikan

Beberapa efek samping kemoterapi

Anemia
mengurangi kemampuan sel darah merah Sedikit sel darah merah yang membawa Oksigen Nafas pendek Lemah capek

Nausea Vomiting
Obat baru

Pain
Obat KH dapat merusak syaraf

Kehilangan rambut
Dapat mengenai semua jenis rambut

Rasa terbakar

Reduce this

Mati rasa

Sakit mencucuk Pada kaki dan tangan

Akan tumbuh kembali setelah perawatan

12/3/2010

Manifestations in Oral Cavity :

Mukositis and ulceration : mucosa gastrointestinal rentan terhadap efek toksik Infeksi oral: Leucopenia meningkatnya risiko infeksi , pengobatan setelah dilakukan kultur, mencegah infeksi sistemik atau septicaemia. Neurotosik, sakit yang dalam, terus menerus, bilateral dan seperti sakit gigi Xerostomia Perubahan pengecapan

Manifestation.. Cont..
Perdarahan, pengurangan platelet ( thrombocytopenia )

Perkembangan gigi yang abnormal

12/3/2010

Tindakan pre kemoterapi:

Pemeriksaan jaringan lunak, keras dan jaringan periodontal Pasien dengan kelainan haematologi ,mungkin menderita immunosuppression atau thrombocytopenia harus di konsul ke onkologi Hilangkan daerah infeksi dan iritasi seperti akar gigi , gigi tajam dll. Jadwal kemoterapi selanjutnya sebaiknya 7-10 hari setelah penyembuhan

12/3/2010

Informasi penting :
Faktor pembekuan darah Komplikasi haemaragik terjadi Kateter vena central Tempat kolonisasi bakteri

Perlu antibiotic prophylactic

Platelet < 50 ribu/mm

Neutrophil < High risk of infection and septicaemia

Perawatan Dental / Oral yang harus diperhatikan

Teknik menyikat gigi Makanan yang tajam Berkumur dengan alkohol Penggunaan propilaksis Pencegahan demineralisasi Pasien sering muntah Tidak boleh pakai gigi palsu Pertahankan oral hygiene

12/3/2010

Sebelum memulai kemoterapi kanker , pada penderita dilakukan evaluasi untuk mengenali dan menyingkirkan sumbersumber infeksi oral yang dapat memperburuk rangkaian perawatan kemoterapi

EFFECT OF RADIOTHERAPY Oral complications of head and neck radiation

1. Mucositis - Generalized mucosal erythema ( after initiation of treatment) -Desquamation and ulceration - Extreamly pain, eating nearly impossible - Sites : buccal, labial and lingual mucosae - Healing rapidly follows the cessation of radiation - Mucosal atrophy permanent - Candidiasis

12/3/2010

2.Xerostomia
- Bacterial colonization of the teeth - Difficulty of swallowing and managing food - Plaque formation and debris accumulation

3. Caries radiation - Rampant caries Caused by : xerostomia, accelerated decalcification of irrradiated teeth, reduced oral hygiene

12/3/2010

The three major risk factors in the development of osteoradionecrosis * Anatomic site of the trauma -----mandible develop necrosis 5 times more frequently * Dose of radiation * Dental status of patient ----- patients with teeth are more likely than edentulous patients

Osteoradionecrosis and extraction

Risk of development of osteoradionecrosis to timing of extraction : - High risk : extractions during radiation therapy - Elevated risk : extractions just prior to radiation therapy - Lowest risk : !2 mo or more after radiation therapy Extraction strategy Pre radiation extraction of actively infected teeth Extraction done 12 mo or more after radiation therapy are lesser risk

12/3/2010

Oral complications of cancer cemotheraphy

Factors affecting frequency of development of oral problems 1. Patient related variables - The younger patient ------ more likely affect - The type of malignancy----- lymphoma, leukemia : higest frequency - Patient with poor oral hygiene and pre existing odontogenic and periodontal infection -------high risk Dentist should be work with oncologist to optimize the

2. Therapy related variables * Type of drug - Antimetabolite ( methotrexate ) ------ mucositis - Alkylating agent ( 5 fluorouracil------ mucositis - Adriamycin ----- minor salivary gland * Dose of drug administration * The timing of drug administration

10

12/3/2010

Oral Complications Direct Stomatotoxicity 1. Mucositis

- Diffuse ulcerative condition - Generally on nonkeratinized oral mucosa - Extrem pain - Erythema and ulceration of some or all mucosal surfaces : typically ginggiva, dorsal surface of the tongue - Ulcerative area may appears grayish white with central areas of necrosis - Self limiting and tends to heal spontaneously in about 14 days

2. Xerostomia Adriamycin ---- xerostomia 3. Neurotoxicity Alkaloid ----- neurotoxicity ----- odontogenic pain Symptoms usually disappear with discontinueance drugs

Indirect Stomatotoxicity
Infection 1. Bacterial infection - Tooth pain, deep caries, sensitivity to percussion

11

12/3/2010

2. Soft tissue infection * Ginggiva

- Marginal, papillary and attached ginggiva in patients pre existing periodontal diseases - Infectious lesions : localized necrotic area of ginggiva ( similar to ANUG) - Tends to spread laterally, apically, large area of ginggiva and mucosa - Pain, bad taste - Underlying bone may be exposed - Bleeding

Mucosa - Ulceration secondary infection - The center is deeply punched out and contain grayish white necrotic center - The border of the ulcer may be raised - In leucopenic patients shoul be admitted to the hospital and treated with intravenous Antibiotic

12

12/3/2010

Salivary gland infection

- Parotid gland --- most frequently affected - Complain of pain of sudden onset - Unilateral - The parotid gland may be enlarged and erythemtous - Pus may be milked from the parotid duct - Fever - Dry mouth Myelosuppressed patients with salivary gland infection require hospitalization Management : cooperation of the dentist, oncologist and infectious disease specialist

2. Fungal infection
In the myelosuppressed host Oral Candidiasis - Raised, white, curdy looking areas - White necrotic areas may be scraped off, revealing a raw, bleeding base - Oral candida infectious may spread to the oesophagus or lungs ------ dysphagia, febrile

3. Viral infection
- Herpes simplex virus infections---- commissura of the lips - Herpes zoster infection - Recurrent herpes infection

Oral bleeding cause by thrombocytopenia

13