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xD3 Oral Surgery Ex1 > Chemo/Radiation (Lui) I 260-315 > Flashcards

Chemo/Radiation (Lui) I 260-315 Flashcards

1
Q

What are the 3 H’s of the tissue undergoing osteoradionecrosis?

A
  1. Hypocellular
  2. Hypoxic
  3. Hypovascular
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2
Q

What are 3 types of radiation therapy?

A
  1. External beam (older)
  2. Intersitial
  3. Proton beam (newer)
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3
Q

What is the term for avascular bone necrosis caused by the 3-H tissue effects of radiation therapy: hypoxic, hypo cellular, hypo vascular?

A

Osteoradionecrosis

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4
Q

Is ORN an infection of bone?

A

No

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5
Q

Are BRONJ and ORN the same thing?

A

No, BRONJ is an osteonecrosis caused by lack of bone turnover while ORN is osteonecrosis caused by the 3 H’s. The common point is that both are avascular bone.

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6
Q

What is another systemic consideration with ORN?

A

Radioation causes difference beyond bone: mucocitis, glossitis, leathery neck, xerostomia

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7
Q

What will head and neck radiation therapy in a lung patient do?

A

Inhibit growth

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8
Q

What is the goal of surgical resection?

A

Get bleeding bone at all margins

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9
Q

What can be reduced as a result of head and neck radiation?

A

Mouth opening due to the fibrosis of the muscles of mastication

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10
Q

What are 3 types of ORN?

A
  1. Early trauma-induced ORN
  2. Spontaneous ORN
  3. Late trauma-induced ORN
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11
Q

What is considered a high dose of radiation that increases the patient’s risk of ORN?

A

7200 cGy

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12
Q

What is considered a moderate dose of radiation, but keeps the patient under the clinical threshold for ORN?

A

6000-6400 cGy

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13
Q

What is the golden window with respect to treatment of a head and neck radiation patient?

A

During the 1st 4 months

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14
Q

If a patient receives a dose in excess of 6000cGy (e.g. 7400 cGy, what can be expected with respect to ORN?

A

There will be the 4 month golden window then the vector to ORN will cross the clinical threshold and the patient will be at increased risk for spontaneous ORN

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15
Q

If a patient receives moderate dose head and neck radiation, and an extraction is planned less than 2 year post therapy, will HBO therapy be indicated, and will there be any healing complications?

A

No to HBO, no to healing complications

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16
Q

When should pre-radiation dental treatment be performed on a patient scheduled for head and neck radiation?

A

At least 21 days prior

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17
Q

What are 3 indications for removing teeth 21 days prior to the initiation of head and neck radiation therapy?

A
  1. PA pathosis (but make sure you fill out the endodontic case difficulty assessment and get shift shot)
  2. Advanced periodontal disease
  3. Any mandibular teeth in direct path of radiation greater than 6000cGy
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18
Q

How many months post head and neck radiation should a patient wait to have any extractions done?

A

4 months post therapy

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19
Q

What is the term for the decreased injury vector during the first four months after head and neck radiation?

A

Golden window

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20
Q

How many months post radiation therapy will the 3 H’s begin?

A

Greater than 4 months

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21
Q

What protocol is indicated at more than 4 months post radiation treatment if planning surgery?

A

20/10 hyperbaric protocol

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22
Q

Describe 20/10 hyperbaric oxygen protocol

A

20 session at 2.4 ATM at 100% oxygen for 90 minutes each dive
5-6 days / week prior to surgery
10 sessions at same specifications post surgery

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23
Q

What is the goal of HBO therapy?

A

Increase oxygen gradient above 20mmHg so there will be angiogenesis into irradiated tissue via VEGF and bFGF

24
Q

Is the HBO therapy angiogenesis permanent or must it be repeated for each subsequent surgery in the irradiated area?

A

Permanent, will not require repeated HBO

25
Q

Is the 20/10 HBO protocol for a patient that has ORN or a patient that is at risk of ORN?

A

Patient at risk of ORN

26
Q

What is the HBO protocol for a patient with ORN?

A

30/10

27
Q

What is the patient with ORN and exposed bone considered?

A

Stage 1
30 dive = local debridement
10 dives = post op

28
Q

What is the patient with ORN whose bone does not soften but continues to be exposed after the 30 dives?

A

Stage 1 nonresponder

29
Q

What treatment is indicated for a Stage 1 non responder?

A

Surgical debridement = 10 dives post-op

30
Q

A patient with ORN and one of the following: pathologic fracture, or, procutaneous fistula, or, ostelysis to the inferior border of the mandible, is what stage?

A

Stage III

31
Q

What is the treatment protocol for a Stage III ORN patient?

A

Continuity resection, jaw stabilization, soft tissue flap if needed

32
Q

If there is no exposed bone and out of the 4 month golden window, what HBO therapy is indicated: 20/10 or 30/10?

A

20/10

33
Q

What is the goal of HBO therapy for ORN?

A

Treat vital radiation-injured tissue

34
Q

What is the goal of surgery for ORN?

A

To remove non-vital bone

35
Q

What is to be expected in a Stage 1 (exposed bone) responder after the 30 dives?

A

Granulation tissue formation

36
Q

What is done once the granulation tissue has formed after the 30 dives in a Stage I responder with exposed bone?

A

Locally deride the soft necrotic exposed bone

37
Q

What is expected in a Stage I responder after the local debridement and the 10 dives post op?

A

Exposed bone covered by mucosa 1-2 months post-op

38
Q

What stage is the patient in if no granulation tissue forms after 30 dives?

A

Stage II

39
Q

What is done in a Stage II patient?

A

Alveolectomy and decertification of B/L cortices to bleeding vital bone and close with primary closure then 10 dives

40
Q

A Stage II non responder goes into what category?

A

Stage III, they have had 40 dives by this time

41
Q

If the patient goes straight into Stage III by falling into one of the 3 categories (pathologic fracture, procutaneous fistula, or osteolysis to the inferior border of the mandible) will they require an HBO protocol prior to surgery?

A

Yes 30/10 protocol

42
Q

A stage III patient with fixation should expect tissue healing and maturation in how many months post op?

A

3-4 months post op

43
Q

What would be 2 contraindications for HBO therapy?

A
  1. The patient can’t equalize ear pressure

2. Advanced COPD

44
Q

Why do patients get an eye exam prior to HBO therapy?

A

Oxygen toxicity can cause eye problems

45
Q

If a patient had chemotherapy, when will their neutrophils be lowest, increasing their risk of opportunistic infection?

A

7-10 days post chemo

46
Q

What is the platelet count allowing extraction of a single tooth with Gel foam and sutures?

A

50,000 / microliter

47
Q

What is the major side effect of almost all chemotherapy?

A

Bone marrow suppression causing pancytopenia (anemia, neutropenia, thrombocytopenia)

48
Q

The myelosuppression caused by chemotherapy is reversible and should return to normal how long after chemotherapy is stopped?

A

6-8 weeks

49
Q

A patient with mild neutropenia (ANC 1000-1500 / mm3) is at what risk of infection and do they require prophylactic antibiotics?

A

Mild infection risk.

Do not require prophylactic antibiotics for minor oral surgery.

50
Q

A patient with moderate neutropenia (ANC 500-999 / mm3) is at what risk of infection and do they require prophylactic antibiotics?

A

Moderate infection risk.

7 day course of prophylactic antibiotics for invasive procedures.

51
Q

A patient with severe neutropenia (ANC less than 500 / mm3) is at what risk of infection and do they require prophylactic antibiotics?

A

Life-threatening sepsis infection

Prophylactic antibiotics for minor oral surgery.

52
Q

What must a patient be given if they have a central venous catheter for chemotherapy infusion?

A

Prophylactic antibiotics prior to surgery

53
Q

What is the formula for absolute neutroophil count?

A

WBC x (%neutrophils and % bands)

54
Q

What are bands?

A

Immature neutrophils

55
Q

What is Dr Lui’s summary of osteomyelitis?

A
  1. Decreased blood flow
  2. Seen in diabetes and disease that decrease the immune response
  3. Pathogenesis: starts in medullary bone and goes out
  4. Clinical presentation: pain and swelling
56
Q

What is Dr Lui’s summery of ORN?

A
  1. Pathogenesis by the 3 H’s (hypo cellular, hypo vascular, hypoxic)
  2. 20/10 HBO if less than 4 months post radiation therapy
  3. 30/10 HBO protocol if exposed to bone
  4. Oral side effects of head and neck radiation: glossitic, mucocitis, skin changes, xerostomia
57
Q

What is Dr Lui’s summary of Chemotherapy?

A

ANC 1000-1500: no antibiotics required
ANC 500-999: 1 week antibiotics post-op
ANC below 500: consider delaying treatment

xD3 Oral Surgery Ex1 (4 decks)

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