Chemotherapy and immunosuppression Flashcards
What is chemotherapy?
A treatment for cancer which uses drugs to stop the growth of cancer cells by wither killing the cells or stopping them from dividing.
What are the uses of chemotherapy?
- Completely curative on its own
- Adjunctive (used with another form of therapy)
- Maintenance (to ensure cancer does not return)
- Palliative (to relieve symptoms and improve end of life quality)
What are the 4 types of chemotherapy?
1) Cytotoxic
2) Hormonal
3) Targeted
4) Immunotherapy
What is cytotoxic chemotherapy?
A therapy targeting rapidly dividing cells such as oral mucosa, bone marrow and hair follicles.
- It stops the cancer cells completing the cell cycle
When do we want to carry out a dental extraction for someone undergoing chemotherapy?
Between the drug installments to allow the oral mucosa to heal
What are the acute side effects of chemotherapy?
Hair loss
Mouth sores
Problems with GI tract - nausea and constipation
Tingling feeling due to affecting nerves
Bruising and bleeding
Fatigue
Drop in white blood cell count - increasing risk of infection
What is hormonal chemotherapy?
Chemotherapy confined to the target organ but can only be used in cancers with a hormonal driver e.g. breast and prostate cancer
What is targeted chemotherapy?
Targeted chemotherapy targets:
- DNA changes limited to cancer cells
- Protein only found in cancer cells
- Proteins increased in cancer cells
It can trigger the immune system to kill the cancer cells or use factors to stop cancer cells undergoing angiogenesis or can carry toxins into the cancer cells.
What is immunotherapy?
This boosts the immune system to destroy cancer cells
What is maintenance chemotherapy?
After the first therapy, a patient needs to have maintenance chemotherapy.
This is for long term use and extends life and quality of life.
What drug is a bone cancer patient likely to be on?
Bisphosphonates are used when cancer has metastasis to bone to suppress bone formation.
This then increases patient risk of osteoradionecrosis.
What are the long term side effects of chemotherapy?
- Fatigue
- Nausea
- Vomiting
- Hair loss
- Neutropenia
What are the 3 likely places that bone cancer spreads to?
Breast, lung and kidney
Where is metastatic spread to the jaw likely to occur?
Mandibular molar region due to presence of the neuromuscular bundle
What are the affects of chemotherapy dentally?
- Mucositis
- Infection risk
- Bleeding risk
- Taste disturbance
- Dryness of mouth
What questions should we ask a maintenance chemotherapy patient before going ahead with dental treatment?
- Are they generally well?
- Have they had any recent infection?
- Are they bleeding or bruising easily?
- Do they often have blood tests?
- Are their doctors concerned about them?
- Have they recently had their teeth checked and treated?
What are the definitions of immunodeficiency, immunosuppression and immunocompromisation?
Immunodeficient = state where the immune system is below optimum level
Immunosuppression = act of artificially depressing the immune system
Immunocompromised = those at risk due to reduced immune function
What are the definitions of immunodeficiency, immunosuppression and immunocompromisation?
Immunodeficient = state where the immune system is below optimum level
Immunosuppression = act of artificially depressing the immune system
Immunocompromised = those at risk due to reduced immune function
Give some examples of congenital immunodeficiency conditions?
Selective IgA deficiency Ectodermal dysplasia Severe combine immunodeficiency Di George Syndrome Ataxia Telangectasia Wiskott Aldrich Syndrome Agammaglobulinaemia Hyper IgM syndrome Chediak Higashi Syndrome Cyclic Neutropenia
What are the acquired forms of immunodeficency?
- HIV
- Auto-immune conditions
- Sickle cell disease
- Diabetes
- Malignancy
- Obesity
What drugs cause immunosuppression?
1) Steroids
2) Monoclonal antibodies
3) Chemotherapy drugs
4) Biologics
How do steroids suppress the immune system?
Inhibits IL1, IL2, IL6, TNF, prostaglandins, chemokines and MCH2.
What are the negative effects of steriods?
- Skin thinning
- Infections
- Osteoporosis
- Hyperglycaemia
- Hypertension
- Cataracts glucoma
What is Cushing’s syndrome?
May be due to an adrenal gland producing too many steroids or commonly due to administration of steroids to dampen down the immune system.
Symptoms = thin arms and legs and obese area of body.
- Increases risk of infection, slower to heal, bruising (affecting collagen leading to blood vessel rupture).
We avoid these symptoms by giving steroids also with steroid sparing drugs to help reducing the impact of the side effects.
What is an Addisonian crisis?
The adrenal glands do not produce natural steroids that regulate blood pressure in times of stress.
What is an Addisonian crisis?
The adrenal glands do not produce natural steroids that regulate blood pressure in times of stress.
What is the oral side effect of cyclosporin?
Gingival overgrowth
What are the general oral side effects of immuno-supressants?
Delayed healing
Infection
Candida infection can occur (widespread suggests someone is immune suppressed)
Decrease in signs of infection!
Herpes simplex - viral condition that takes advantage of poor immunity to remerge
Accelerated periodontal disease
Leukoplasia (white patches occurring on lateral border of tongue due to Epstein barr virus)
Increased risk of malignancy due to generalised immune suppression
What are the two common oral cancers found in the mouth?
Oral squamous cell carcinoma
Basal cell carcinoma
What questions should we ask an immunosuppressed person before treatment?
Are they generally well Any unusual infections Do you heal normally How often do the doctors take blood tests, more frequent means they immune suppression is more unstable Are your doctors concerned about you
What is the dental relevance of immune suppression?
1) May need to delay elective treatment
2) Oral manifestations such as gingival hyperplasia (cyclosporin)
3) Delayed wound healing
4) Increases risk of malignancy - squamous cell carcinoma
5) Increases risk of infection - any infection needs to be treated aggressively with antibiotics
6) Anything surgical may need prophylactic antibiotics - not given routinely but may be appropriate
7) People who are on steroids for a long time get reduced steroids production in the body so can lead to reduced blood pressure and if the patient is then under a lot of stress, they can sometimes collapse
8) As dentists, we may need to suspect that a patient has immunosuppression - recurring infections, periodontal disease (necrotising periodontal disease)
