Chemotherapy and immunosuppression

Question 1

What is chemotherapy?

Answer 1

A treatment for cancer which uses drugs to stop the growth of cancer cells by wither killing the cells or stopping them from dividing.

Question 2

What are the uses of chemotherapy?

Answer 2

1. Completely curative on its own
2. Adjunctive (used with another form of therapy)
3. Maintenance (to ensure cancer does not return)
4. Palliative (to relieve symptoms and improve end of life quality)

Question 3

What are the 4 types of chemotherapy?

Answer 3

1) Cytotoxic
2) Hormonal
3) Targeted
4) Immunotherapy

Question 4

What is cytotoxic chemotherapy?

Answer 4

A therapy targeting rapidly dividing cells such as oral mucosa, bone marrow and hair follicles.
- It stops the cancer cells completing the cell cycle

Question 5

When do we want to carry out a dental extraction for someone undergoing chemotherapy?

Answer 5

Between the drug installments to allow the oral mucosa to heal

Question 6

What are the acute side effects of chemotherapy?

Answer 6

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

Question 7

What is hormonal chemotherapy?

Answer 7

Chemotherapy confined to the target organ but can only be used in cancers with a hormonal driver e.g. breast and prostate cancer

Question 8

What is targeted chemotherapy?

Answer 8

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.

Question 9

What is immunotherapy?

Answer 9

This boosts the immune system to destroy cancer cells

Question 10

What is maintenance chemotherapy?

Answer 10

After the first therapy, a patient needs to have maintenance chemotherapy.
This is for long term use and extends life and quality of life.

Question 11

What drug is a bone cancer patient likely to be on?

Answer 11

Bisphosphonates are used when cancer has metastasis to bone to suppress bone formation.
This then increases patient risk of osteoradionecrosis.

Question 12

What are the long term side effects of chemotherapy?

Answer 12

• Fatigue
• Nausea
• Vomiting
• Hair loss
• Neutropenia

Question 13

What are the 3 likely places that bone cancer spreads to?

Answer 13

Breast, lung and kidney

Question 14

Where is metastatic spread to the jaw likely to occur?

Answer 14

Mandibular molar region due to presence of the neuromuscular bundle

Question 15

What are the affects of chemotherapy dentally?

Answer 15

• Mucositis
• Infection risk
• Bleeding risk
• Taste disturbance
• Dryness of mouth

Question 16

What questions should we ask a maintenance chemotherapy patient before going ahead with dental treatment?

Answer 16

• 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?

Question 17

What are the definitions of immunodeficiency, immunosuppression and immunocompromisation?

Answer 17

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

Question 18

What are the definitions of immunodeficiency, immunosuppression and immunocompromisation?

Answer 18

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

Question 19

Give some examples of congenital immunodeficiency conditions?

Answer 19

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

Question 20

What are the acquired forms of immunodeficency?

Answer 20

• HIV
• Auto-immune conditions
• Sickle cell disease
• Diabetes
• Malignancy
• Obesity

Question 21

What drugs cause immunosuppression?

Answer 21

1) Steroids
2) Monoclonal antibodies
3) Chemotherapy drugs
4) Biologics

Question 22

How do steroids suppress the immune system?

Answer 22

Inhibits IL1, IL2, IL6, TNF, prostaglandins, chemokines and MCH2.

Question 23

What are the negative effects of steriods?

Answer 23

• Skin thinning
• Infections
• Osteoporosis
• Hyperglycaemia
• Hypertension
• Cataracts glucoma

Question 24

What is Cushing’s syndrome?

Answer 24

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.

Question 25

What is an Addisonian crisis?

Answer 25

The adrenal glands do not produce natural steroids that regulate blood pressure in times of stress.

Question 25

What is an Addisonian crisis?

Answer 25

The adrenal glands do not produce natural steroids that regulate blood pressure in times of stress.

Question 26

What is the oral side effect of cyclosporin?

Answer 26

Gingival overgrowth

Question 27

What are the general oral side effects of immuno-supressants?

Answer 27

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

Question 28

What are the two common oral cancers found in the mouth?

Answer 28

Oral squamous cell carcinoma

Basal cell carcinoma

Question 29

What questions should we ask an immunosuppressed person before treatment?

Answer 29

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

Question 30

What is the dental relevance of immune suppression?

Answer 30

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)