13 - Head and neck cancer Flashcards
Describe the patient journey for head and neck cancers.
- screening and referral (GDP)
- investigation and diagnosis
- treatment planning by MDT
- dental pre-assessment (GDP)
- caner treatment
- dental support during treatment
- end of treatment
- restorative (GDP)
- maintenance post treatment
What is required of the GDP at the screening and referral stage?
- early detection through soft tissue exams
- photographs
- referral and pre-treatment assessment
When should GDPs refer for a H&N cancer assessment?
- stridor
- persistent lumps for more than 3 weeks
- ulceration or swelling of mucosa for more than 3 weeks
- red/red and white patches on the mucosa for more than 3 weeks
- persistent hoarseness for more than 3 weeks
- persistent pain in throat for more than 3 weeks
What can be done to investigate H&N cancer referrals?
- OMFS new patient assessment
- biopsy
- CT scan (extent of tumour or metastasis)
- lymph node biopsy
- baseline medical testing
- staging and grading
Who is part of the MDT for treatment planning?
- oncologist
- radiologist
- surgeons
- clinical nurse specialist
- speech and language therapist
- dietician
- dentist (restorative specialist)
- physio
- OT
- psychologist
How long should a patient wait maximum for their first appointment after referral?
14 days
What is the deadline for the start of H&N cancer treatment from referral?
62 days
What is involved in the dental pre-assessment?
- detailed exam
- radiographs (OPT and PAs)
- OHI
- fluoride treatment (varnish, tooth mousse)
- PMPR
- definitive restoration of carious teeth or XLA
- impressions for fluoride trays or soft splints
What treatments are used to treat H&N cancers?
- surgical resection +/- reconstruction
- radiotherapy
- chemo
What are the side effects of resection?
- alterations to normal anatomy
- adverse effects on function and appearance
What are the side effects of radiotherapy?
- damage to surrounding tissues
- increased risk of ORN
- xerostomia
What are the side effects of chemotherapy?
- acute mucosal and haematological toxicity
- xerostomia
- mucositis
What is the dentist’s role during cancer treatment?
- oral and denture hygiene
- antibacterial mouthwash for when brushing is too sore
- diet advice
- fluoride application
- management of mucositis and xerostomia
- monitor viral/fungal diseases
What is mucositis?
- 1-2 weeks post treatment (usually chemo)
- lasts up to 6 weeks
- severe pain caused by ulceration of mucosa
- inhibits OH
- can prevent eating
How do you manage mucositis?
- neutral supersaturated calcium phosphate mouth rinse (caphosol)
- sodium hyaluronate gel (gelclair)
- mucoadhesive oral rinse (mugard)
- soluble aspirin
- benzydamine hydrochloride (difflam spray)
- aloe vera or Manuka honey
- good OH helps to resolve quicker
- remove sharp edges (teeth or dentures)
- soft splint
What are the grades for mucositis?
1-3
Describe grade 1 mucositis.
- voice normal
- normal swallowing
- lips are smooth and moist
- tongue is pink, moist and papilla are present
- watery saliva
- mucosa is pink and moist
Describe grade 2 mucositis.
- voice deeper or raspy
- pain on swallowing
- lips are cracked/dry
- tongue is shiny, loss of papilla and +/- redness
- thick saliva
- mucosa is reddened or coated without ulceration
Describe grade 3 mucositis.
- difficulty or painful speaking
- unable to swallow
- lips are ulcerated and bleeding
- tongue is blistered or cracked
- absent saliva
- mucosa is ulcerated +/- bleeding
What oral issues can arise during cancer treatment?
- Candida infection
- HSV reactivation
- traumatic ulceration
- xerostomia
- trismus
- erosion
- caries
- perio
- ORN
How do you manage candidal infections during cancer treatment?
- offer antifungals as prevention
- chlorohexadine mouthwash
- topical miconazole
- systemic fluconazole
How do you manage traumatic ulceration during cancer treatment?
- teeth rubbing delicate mucosa
- soft splint constructed
How do you manage reactivated HSV during cancer treatment?
- pain prior to ulceration kwon as prodromal period
- urgent systemic antivirals
- clinical presentation is more extreme in those undergoing cancer treatment
How do you manage xerostomia during cancer treatment?
- oral gels or lubricants (Biotene, BioXtra, saliva orthana)
- pilocarpine HCl can stimulate glands that have some function
- sugar free chewing gum
- frequent sips of water
Describe xerostomia in cancer patients.
- reduced flow up to 60% in first week
- consistency is affected, more viscous and acidic which is damaging to dentition
- recovery may or may not happen over a few years
- affects chewing, swallowing, speech and taste
- higher risk of caries, perio, candida, sialadenitis
How do you manage trismus during cancer treatment?
- early intervention and compliance essesntial
- passive and active stretching exercises
- therabite
- stacked tongue depressors
Describe radiation induced caries.
- chemo and radiotherapy induced
- reduced salivary flow
- widespread and circumferential around teeth or incisal edges
How do you manage ORN during cancer treatment?
- XLA of poor prognosis teeth
- prevention and OH advice
- XLA must be 10 days prior to radiotherapy
- encourage healing with primary closure and sutures
Who is at increased risk of ORN?
- dose >60Gy
- local trauma eg XLA, perio
- immunodeficient
- malnourished
What are the stages of ORN?
0-3
Describe stage 0 of ORN.
Mucosal defects only, bone is exposed
Describe stage 1 of ORN.
Radiological evidence of exposed bone, dento-alveolar only
Describe stage 2 of ORN.
Radiographic findings including the IAN canal
Describe stage 3 of ORN.
Clinically exposed radionecrotic bone, with skin fistulas and infection +/- pathological fracture
When are implants appropriate for reconstruction?
- dose <45Gy
- patient must possess manual dexterity for OH
What is an obturator?
- used as part of a denture or a splint to fill a deficiency due to resection or hold open an area to allow fluid to drain
- should be worn 24/7 for first 6 months to allow area to heal around
- improve speech
