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Special Patients > Chapter 5: Dental Management Of The Oncological Patient > Flashcards

Chapter 5: Dental Management Of The Oncological Patient Flashcards

1
Q

Why is the oral cavity very susceptible to the toxic effect of oncotherapy?

A
  • high rate of cell renewal
  • complex and diverse micro flora
  • trauma to tissues in the normal oral function
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2
Q

4 groups of cancer treatment? And what do we do if we can’t irradiate cancer?

A
  • surgery
  • radio therapy
  • chemotherapy
  • biological therapy
  • if we can’t eradicate, palliation
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3
Q

Are there any effective drugs that prevent the side effects of cancer treatment?

A

No

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4
Q

Complications are divided into 3 categories?

A

Acute/ late coming, or during therapy, or months/years later

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5
Q

Frequency of complications:
1. Chemotherapy
2. Bone marrow transplant
3. Head and neck radiation therapy

A
  1. 40% related to chemotherapy
  2. 80% related to BMT
  3. 100% related to head and neck radiation therapy
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6
Q

Radiation therapy:

A

Preserves normal tissues and maintains their functionality but lasts a long time

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7
Q

Immediate oral complications of radiation therapy:

A
  • mucositis, dysgeusia, BMS, hyposialia, xerostomia
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8
Q

Medium oral complications of radiation therapy:

A
  • caries, mucosal necrosis, trismus, dysphagia
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9
Q

Long term complications of radiation therapy:

A

osteonecrosis, alterations of the development of the dental germ: agenesis, coronary/ radicular alterations.

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10
Q

Mucositis:
- what cells does it affect?
- how many days does it take to appear?
- description
- symptoms
- when does it disappear?
- treatment?

A
  • epithelial basal cells
  • 7-15 days (30Gy)
  • Enantema, atrophy of the mucosa, desquamation
  • painful and invalidating (patients won’t be able to eat or drink)
  • disappears after 15-21 days after radiotherapy ends
  • tx:
  • preventive and palliative
  • alkaline solutions of hydrogen peroxide and bicarbonate water
  • systemic analgesics
  • topical anaesthetics (lidocaine spray or gel)
  • sucralfate (covers ulcers)
  • superinfections (antibiotic, anti fungal, and antiviral)
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11
Q

Xerostomia:
- what cells does it affect?
- how many days does it take to appear?
- when does it disappear?
- treatment?

A
  • serous and ductal acinar cells
  • modified qualitiy and quantity of saliva
  • from 15 days after the after dose, greater than 15 Gy
  • reversible after 6-12 months
  • tx:
  • partial: pilocarpine, chewing gum without sugar
  • total: water rinses, glycerin, water and bicarbonate, artificial saliva, decreased caffeine consumption, Vaseline
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12
Q

Dysgeusia and BMS:
- what cells does it affect?
- how many days does it take to appear?
- when does it disappear?
- treatment?

A
  • papillae and taste buds
  • 15 days, precedes Mucositits
  • reversible after 2-4 months
  • tx: zinc supplements.
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13
Q

Trismus:
- what does it affect?
- how many days does it take to appear?
- treatment?

A
  • fibrosis of the masticatory muscles
  • 3-4 months
  • dry heat, anti-inflammatories, and muscle relaxants
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14
Q

Caries and dental hypersensitivity:
- what is it due to?
- how many days does it take to appear?
- description

A
  • due to the change of the buccal flora, by reduction of salivary secretion NOT by radiotherapy
  • affection to the cementoenamel junction, caries in V/L faces and cuspids of premolars and molars
  • aggressive advancement of caries
  • appears 3months after radiotherapy
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15
Q

Osteonecrosis:
- what does it affect?
- how many days does it take to appear?
- predisposing factors
- Clincal features
- when does it disappear?
- treatment?

A
  • areas of denuded bone submitted to previous radiation, exposed for more than 2 months.
  • appears every 2-5months after radiotherapy, precedes bone exposure.
  • predisposing factors: more than 60-75Gy. Application in a single field, use of brachytherapy, tumour near bone tissue, compact bone (80%mandible).
  • clinic: latent, cellulitis, suppuration, faecal odour, cutaneous fistula, pulsatile pain, exposed bone and/or sequestration of bone, hemorrhage, pathological fractures, difficulty chewing, swallowing, phonation, limitation of opening, risk remains their whole life
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16
Q

Radiation therapy causes:

A
  • vascular wall alteration
  • decreased blood supply
  • hypoxia
  • necrosis
  • loss of osteoblasts and osteoclasts
  • abnormal regeneration of connective and adipose cells
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17
Q

Dental germ development: in children and adults?

A
  • children and adolescents: dental agenesis, short and sharp roots, early apical closure, hypoplasia, or crown spot, inhibition of dentin formation, microdontia
  • in adults: destruction of odontoblasts, pulp fibrosis
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18
Q

When do you do extractions before radiation? What do you do to periodontal pockets and temporary teeth about to exfoliate? When are you going to do periodontal surgery? What are you going to do if they’re going to receive brachytherapy?

A

15-21 days before
Periodontal pockets larger than 7mm: extractions
In children extract teeth that are going to exfoliate
Periodontal surgery 6 months prior
Plumed device

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19
Q

If exo required during radiation?

A

Anaesthesia without VC, no intraligament anaesthesia (risk of osteonecrosis)

ATB 14 days before and 7 days after

Ciprofloxacin 500mg/12 hours + clindamycin 300mg/8hr

Suturing

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20
Q

After radiation:

A
  • Control every 2-3 months, checking plaque index periodontal status and strengthening hygiene.
  • Fluoride once a year, soft brushing
  • Teeth: does not directly cause lesions, if pulpal disorders
  • Late atypical caries (2-3m) for xerostomia, diet change and painful hygiene. From 3 months
  • No removable or complete prosthesis for one year
  • Quarterly application of chlorhexidine gel in curettes
  • No exo during a year
  • Endodontics will be avoided but are preferred to extractions. If it is necessary to make extractions, do with antibiotic coverage (48 hours before and 7-15 days later).
  • Trismus (3-6months later): muscular relaxers and mechanotherapy
  • Loss of taste (+3 months): supplement of zinc sulphate
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21
Q

Osteonecrosis after radiation:

A
  • Prevention, no traumas.
  • No exodontia until 6-12 months later, the risk remains indefinitely.
  • Better endodontics to exo.
  • Local anaesthetics are better without VC.
  • Antibiotic coverage.
  • Do not wear prosthetics before 3 months.
  • Not to be confused with osseous metastasis with the radiolucent area.
22
Q

Normal cells of very high reproductive cycle?

A

Oral epithelium, bone marrow, hair follicle, and oro digestive epithelium

23
Q

Most used drugs for head and neck cancer?

A

Methotrexate
5-fluorouracil
Cisplatin
Bleomycin

24
Q

Direct vs indirect action of chemotherapy?

A
  • direct toxic action: on oral epithelium, mucositis, and hyposialias
  • indirect toxic action: on bone marrow, immunosuppressant and hemorrhagic diathesis
25
Q

Mucositis after chemotherapy:
- when does it appear?
- drugs with greater capacity
- degrees

A
  • 7-10 days after chemotherapy (the later it starts like 20 days/less severe).
  • The intensity depends on:
  • The previous dental state
  • The treatment itself
  • Drugs with greater capacity: methotrexate, doxorubicin, flu-5, busulfan, bleomycin, carbo and cisplatin.
  • More non-keratinised mucosal involvement (higher rate of renewal).
  • Degrees (WHO 1979)
  • Grade 0 → normal
  • Grade 1 → generalised erythema, saliva
  • Grade 2 → erythema, ulcers, can ingest solids
  • Grade 3 → large ulcers, oedematous gum, and thick saliva can result in fluid, difficulty speaking and pain (patient cannot swallow food)
  • Grade 4 → very large ulcers, bleeding gums, infections, no saliva, no swallowing, and severe pain (alimentation is not possible)

Ulcerative mucositis in 40% of patients and half of them change oncological treatment.

26
Q

Prophylactic measures before chemotherapy?

A
  • Removal of removable prostheses
  • Withdrawal of orthodontic aparatology
  • Use of alcohol-free mouthwashes:
    a. 0.12% chlorhexidine
    b. Bicarbonatesalinesolution
    c. Hydrogen peroxide water diluted equally
  • Soft foods and at room temperature
  • Low carbohydrate diet
  • Meticulous hygiene, surgical brush, fluoridated paste, oral irrigators. Always stabilise the patient’s oral health previously
27
Q

What decreases ulcerations during chemotherapy?

A
  • folic acid
  • chlorhexidine 0.12%
  • triamcinolone acetonide or fluocinolone in orabase
  • carbenoxolone
  • sucralfate
28
Q

Is xerostomia common during chemotherapy and what does it appear with?

A

No, appears with adrimycin

29
Q

How to treat infection during chemotherapy?

A
  • fungi: clotrimazole 25mg/8hr, nystatin, ketoconazole, fluconazole
  • bacteria: broad spectrum ATB
  • viral: acyclovir ointment 5 times a day
30
Q

Chemotherapy is always affecting the bone marrow:

A
  • more affected polymorph nuclear (6-8hrs)
  • then platelets (5-7 days)
  • erythrocytes (120 days)
31
Q

Platelets:

A

Normal value: 150,000 - 450,000
- less than 75,000: do tx
- between 50,000 and 75,000: transfusion and hospital
- less than 50,000 platelets and less than 100 neutrophils: no dental tx

32
Q

Neutrophils:

A
  • more than 2000: with ATB if there’s a possible infection
  • 1000-2000: always with ATB
  • less than 1000 neutrophils and less than 50,000 platelets: no dental tx
33
Q

Leukemia:

A

Proliferation of lymphoid or myeloid basal cells with infiltrations in the bone marrow and/or peripheral blood, as well as in other organs and tissues

  • unknown cause:
  • inc irradiated risk
  • chemical agents
  • virus
  • tobacco
  • exposure to electromagnetic changes
34
Q

3 types of leukemia:

A
  • 2-5 years: lymphoblastic leukemia
  • 30 years of acute leukemia and chronic myeloid
  • > or equal to 50 years of chronic lymphoid leukemia
35
Q

Oral manifestations of leukemia:

A
  • more frequent in acute leukemia (+ in lymphoid than myeloid)
  • Cervical
  • Lymphadenopathy
  • Pale oral mucosa
  • Oral gingivorrhagia
  • Petechiae and/or ecchymosis
  • Ulcers, gingival hypertrophy
  • Paresthesias
  • Bone injuries
  • Dental mobility
  • Oral infections (candidiasis, necrotising ulcerative gingivitis)
36
Q

Clinical management of leukemia:

A

In remission: yes dental tx
Advanced stages: only emergencies
Always before chemotherapy

In the acute state:
- Emergency only
- Platelet count
- Antibiotic prophylaxis
- Non-alcoholic rinses
- Prevention in dental extractions
- Fungal infection

37
Q

Lymphomas: 3 types:

A

Non-Hodgkin’s lymphoma (NHL)
Hodgkin’s disease
Burkitt’s lymphoma

38
Q

Oral manifestations of lymphomas:

A
  • Lymph node location fast size
  • Absence of infectious focus
  • Non-painful
  • Lymphadenopathy
  • Elastic and firm consistency
  • Diameter: 1cm superior
  • Duration: 1 month

Non-Hodgkin’s lymphomas in extra ganglionic areas and at the head and neck level

39
Q

Clinical management of lymphoma:

A
  • Preliminary analysis (leukocytes and platelets)
  • Dental treatment before QT and RT
  • Antibiotic and antimycotic prophylaxis
  • Prevent haemorrhages
  • Biopsies; increase unexplained and chronic lymph nodes
40
Q

Myelomas:

A

Malignant neoplasm in which plasma cells from a single cell clone proliferate and can develop in a disseminated form (multiple myeloma) or as a solitary lesion (solitary myeloma or plasmacytoma).

41
Q

Oral manifestations of myelomas:

A
  • Significant pain in the area where the lesions proliferate
  • Pathological fractures
  • X-ray well-delimited rounded or oval osteolytic lesions, typical “punch” or mottled areas
  • More frequent in the posterior jaw area
  • Paresthesias
  • High susceptibility to bacterial infection
  • Haemorrhages
42
Q

Lymphomas vs myelomas: which one is painful?

A

Myelomas

More frequent in posterior jaw areas

43
Q

Myelomas clinical management:

A

Don’t treat in acute phases, not in QT cycles
ATB prophylaxis, analytic, evaluate bleeding time

44
Q

What are the complications in patients receiving chemotherapy, and which should be considered when it comes to dental treatment:

A

a. Oral aphthous lesions
b. Infection tendency
c. Tendency to kidney failure
d. Appearance of osteonecrosis
e. The tendency to hypotension

A and B?

45
Q

A patient who has been treated with radiotherapy for a colon tumor, how long should we wait before we can extract a tooth ?:

A

A. Minimum two or three months
B. Minimum three months
C. We will not treat you until you have a discharge from your oncologist.
D. Minimum one year
E. Minimum one month

D

46
Q

Which of the following post-radiotherapy complications is not reversible?

A

a. Hyposialia
b. Mucositis
c. Dysgueusla
d. Gingival hyperplasia
e. Glossodynia (BMS)

?

I think A

47
Q

A caries appeared as a consequence of an antineoplastic tx with radiotherapy in the neck in a patient of 70 years, it’s considered:

A

Medium complication

48
Q

What will be the complications of a patient who is receiving cycles of chemotherapy and have to undergo a dental treatment?

A

a. Bleeding tendency
b. Hypotensive tendency
c. Tendency to kidney failure
d. Tendency to gingivitis
e. Hypertensive trend

A

49
Q
  1. If we have to perform an extraction of a 34 that is very deteriorated to a patient who is on chemotherapy. Obviously, he asks for an analysis and observes that his patient has a platelet count of 100,000 / mm3 and a neutrophil count of 1,500 / mm3. Given these figures, how would we act?
A

a. The platelet series should be transfused
b. Should be transfused from the white series
c. We would refer the patient to the hospital to perform the extraction
d. I can do the extraction but I have to give an antibiotic
e. It has a low number of platelets, so it would delay the extraction

D

50
Q

68 year old patient comes remited from the oncological doctor for a revision, he has a history of hypertension, hes just finished chemotherapy and hes going to recieve radiotherapy for a tongue tumor. Indicate the correct answer:

A

A. We will start doing all the extractions needed , with
antibiotic prophylaxis, obturations and root canal treatment necessarys.
B. We will do periodontal surgery of pockets of over 7mm
C. we can leave apical foci as long as theyre asymptomatic
D. On kids we will be expectant towards temporal teeth that have mobility
E. We will postpone all surgery because during radiation the cicatrization is better

A

51
Q
  1. If we have to do a periodontal surgery, which situations can interfere on the dental treatment on a patient with leucemia?
A

a. Thrombocytopenia.
b. Anemia.
c. More susceptibility to infections.
d. Immunosuppression.
e. All of the above.

E

Special Patients (9 decks)

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