Patient with Throat Cancer: How To Approach This Case?
Dr. M asks:
I’d a like a second opinion please on this case. I have a patient, late fourties pretty healthy. He’s one of those patients where endo just doesn’t seem to do well. A few years ago I took a CBCT. We found some good looking endo tx, but large abscesses on several teeth. #14 and 15 were two of these teeth, one had been retreated. With class 2 mobility, and one with a draining fistula the prognosis was guarded. The endos looked great, that’s saying something when it looks great in a ct scan, and I could not find any missed canals. Gave patient option of trying apicos and retro fills or ext. If I could see poor endo I would traditionally retreat, but didn’t. Patient chose exts and, as he doesn’t have much money I thought it was a reasonable decision. So we removed the teeth and made a temporary partial denture.
A year after this he was diagnosed with throat cancer, 20% five year survival on average. Chemo and radiation were done and now he’s done with that. He is really unhappy not having his posterior teeth on the left. Two of the other teeth that had abscesses were #’s 2 & 3.
So here’s the question, do I insist he remove them? What if after the chemo and radiation his immune system was lowered and they are getting worse? PA’s really can’t show things and he is wary to have more radiation with another scan. I want to warn him in no uncertain terms of the risks, including life threatening infection/bacteremia and let him keep them, but legally I am concerned. Take a look.
21 Comments on Patient with Throat Cancer: How To Approach This Case?
New comments are currently closed for this post.
TOBooth
2/20/2012
Minimal intervention in thi scase, patient very likely to develop osteo-radionecrosis -so only treat infcetions and when you do under ab cover and never leave any exposed bone , maybe refer to an oral surgeon if your not sure.
NO IMPLANTS OR PERIAPICAL SURGERY.
OMS resident
2/20/2012
A couple of questions that could be relevant: What kind of cancer was it (more specific anatomical reference than "throat")? Where did he get the radiation (in which anatomical region)? What was the total radiation dose? What are his cell counts?
PS: A regular panoramic x-ray (new) could also be helpful.
John Kong, DDS
2/20/2012
If the radiation was focused just to the throat and did not hit the oral cavity, you should be okay. I'd get a medical consult first explaining your surgical tx for this patient. And if everything is okay, go and remove the tooth b/c you can't leave a tooth with a huge abscess with draining fistula alone forever. Otherwise send to an endodontist to have it re-treated b/c whether the fill looks good or not, you dont know if it was done without a rubberdam or the canals cleaned thoroughly.
Bob Schneider
2/21/2012
Please do yourself and the patient a huge favor and refer him to a center that treats these types of things on a daily basis and are famillar with his chemo/RT treatment, dosages, type of cancer, etc. It would be a good thing for both of you.
ttmillerjr
2/21/2012
I agree that referral is best, but that's not the question I posed. The patient has refused thus far to take any action on these teeth, and by the way it was one of the extracted teeth that had the fistula. Do I refuse to see him any more if he doesn't follow up on my referral?
ahmed
2/21/2012
I am totally agree with Bob schneider. It's so important to refer such cases to people who are familiar with this especially if it is your first time to deal with those cases, you can follow up the case and learn exactly what happened with him in those specialized centre to get more science and experience.
Brandt Foster
2/21/2012
Hey Dr M,
Im sure you will get multiple opinions on this but personally I would continue to see him. People have all kinds of personal reasons for acting the way they do. I try hard to get all these questionable teeth out prior to radiation and most good centers will require a dental clearance with head and neck radiation. But at the end of the day we are doctors and not dental police. If you dont like the guy and you dont feel you can help him then I guess its as good as an excuse as any to pass him off on someone else. I give my patients the best advise I can and then we deal with their decisions the best we can. I agree with you, the teeth should come out. But they are his teeth and he bc he is the one who ultimately has to live (or not) with the consequenses, he gets to make the final call. Document thuroughly when patients disagree with your recommendations and try not to say "I told you so". Good Luck
Dwight
2/22/2012
I agree with you Dr. Foster. Inform (including consequences of non-treatment), Refer (he needs a team approach from a center) and Document (have him sign a statement) then after that be sympathetic to the patient's autonomy.
Richard Hughes, DDS, FAAI
2/21/2012
Dr Kong, your advice is to simplistic. You have to confer with the patients oncologist (chemotherapy and radiation). They will call the shots as per the extent of treatment and when to treat. The patient should of been staged prior to radiation and chemotherapy. OMS resident mentioned very important points (what agent was used, how much radiation and where targeted. All this is v,ery important if the patient is being considered for hyperbearic tx. Some chemotherapy agents R/O hyperbearic O2. Some oncologist believe it will kick up recently treated cancer.
John Kong, DDS
2/22/2012
Dr.Hughes, there's an old adage I follow which goes something like this: Keep it Simple, Stupid.
I recommended a Medical Consult...obviously, it would be with someone familiar with his medical history and not his podiatrist.
Also, is the dosage of the radiation used even relevant in coming to a decision on the patient's dental treatment? (You probably don't even know how to use that information) The physician will tell you if he's stable enough to undergo oral surgery and give you guidelines.
The poster states, that the patient is in his late forties and pretty healthy. The CT was done a few years ago, then 1 year later underwent radiation and chemo tx. So, he is at least 2-3 years removed from his cancer tx.
IF the radiation was localized just to the throat (99% likely) and the physician finds the patient stable and within guidelines for oral surgery, I see no reason not to extract it. If this is not in your comfort zone, refer to a specialist.
As for your suggestion for hyperbearic O2, are you always so dramatic?
Baker vinci
2/22/2012
Easy kong, certainly you are aware that we, does these types of procedures and the management of them , is subsequently second nature. I reserve my cancer surgery to stage one and two cancers, but some of "your" colleques, do all head and neck cancer. This is not the forum by which to learn how to manage this scenario, so any boarded omfs, will do. Bv
Baker vinci
2/22/2012
Dr. Miller, from a medical/legal perspective, I am going to encourage a certified letter , stating that you will provide palliative care only, until he finds a suitable omfs, to treat him appropriately . Bv
ttmillerjr
2/22/2012
Thank you all. Most of the questions on OsseoNews are asking what treatment is best, I see many of you couldn't help but go down that road, but thank you for your input just the same.
Baker vinci
2/23/2012
Dr. Miller, I'm gonna try to offer my opinion, however most of my stuff gets edited. So this is a third try . Explain to your freind that the dose of radiation with a scan is negligible, relative to what he has had and a new one is probably standard of care, in this situation. The radiation oncology doctor, can advise you, with a single phone call as to what pre surgical tx, he may need. Radiation necrosis occurs more in the mandie than the maxilla, almost 6:1, by most reports, but those teeth will most likely need to go. Follow the Marx protocol, until proven otherwise. There is no science to suggest hyperbaric oxegyn, exacerbates the tumor. If your patient survives the tumor, implants can be placed in irradiated bone. I accidently signed up for update emails, please disconnect, I can't watch kong and Richards piss fight anymore . Bv
Richard Hughes, DDS, FAAI
2/23/2012
Baker, I agree about the piss fight, I do not like them either. However, I am not going to take any BS. That said. I am asking you for the source as per hyperbearic 02. I had a case last fall, where the chemotherapy agent contraindicated the chemotherapy. I cannot remember the agent. I will have to refer to the pts chart. The oncologist also said no go for hyperbearic tx. This may be one of those grey areas.
Richard Hughes, DDS, FAAI
2/23/2012
Baker, the med was Cis-platinum.
Baker vinci
2/23/2012
Yuup, if your freind was or is being treated with cisplatin, there is a lot of literature that suggest that HBO tx may increase cytotoxic effects or prevent wound healing. This is why I'm on the site. Bv
osurg
2/23/2012
Dr. Kong if the mandible or maxilla were in the field of radiation and the dose is reported to be significant by the radiation oncologist then HBO is not dramatic it is the standard of care. The protocol is well established by Dr. Marx . This case has been mistreated from the start if the jaws were going to be in the field of treatment then any questionable teeth should have been removed before treatment. At this stage mdical consult is obligatory.If you have to ask about what to do you owe it to you patient to refer to a more experienced doctor. These are not good situations for on the job training. One case of osteoradionecrosis is one more then you want to see.
Baker vinci
2/24/2012
I'm posting at 2:45 am, because my gi system is not accepting the floral alteration afforded by three days of clindamycin. I'm too healthy to have c. diff., I pray? But after perusing your Prex. scan, it is apparent, even if the information is dated, that those posterior teeth must go. Maybe the patients endodonist, could give a hand, because he must been half asleep, when he was counting canals. If your buddy wasn't on a cisplatin regemine, then proceed with the appropriate protocol . Ten - twenty years ago, we would have to tell the HBO doctors, what to do, but today most are very current, with this stuff. Fortunately, there is nothing really life-threatening, about his dental condition, but it needs to be addressed. This guy, has to be your patient, not your freind, now! Bv
Richard Hughes, DDS, FAAI
2/24/2012
Dr M: you probably have had enough time for this pts tissues to recover from the chemotherapy/radiation tx. However, confer with his oncologist. When in doubt refer to an academic setting and then you can sleep well at night.
Ian
3/22/2012
I wouldn't be surprised if the throat cancer was caused by the obviously failed root canals. The proximity is uncanny .. Give the guy a chance, remove the infected teeth, and clean out all the infected bone.
