Dental implications of managing oncology patients Flashcards
Oncology statistics
300,000 new cases per year
7500 new cases of oral cancer per year
Males (421) > females (376/100,000)
1200 cases of childhood oncology per year
Oral cancer types
90% squamous cell carcinoma Adenocarcinoma Teratoma Melanomas Rare lesions
Types of oropharyngeal oncology
Squamous cell carcinoma
- HPV positive
- HPV negative
Types of nasopharyngeal oncology
East Asia and Africa
-squamous cell carcinoma
-lymphoepithelioma
Both can be from Epstein-Barr virus
Types of salivary gland tumours oncology
Adenocarcinoma
Types of nasal and sinus cancers oncology
60% squamous cell carcinoma
10% adenocarcinoma
Lymphomas, plasmacytomas, melanoma
Head and neck oncology epidemiology
Low Socio-economic groups Smokers Increased Alcohol Consumption Poor users of Medical Services Increased rates of dental disease Poor dental attendance Dental phobia Virus Hormones Genetics
Oral implications of head and neck oncology
Direct as a result of the malignancy
Unwanted side effects of cancer therapy
90% Paediatric Oncology cases have oral complications
Survival rate continually improving
-implications for future dental treatment: longevity of the individual, QoL issues
Cancer therapy oral complications
Chemotherapy Radiotherapy to head and neck region Bone Marrow Transplantation (BMT)/Haemopoetic Stem Cell Transplantation (HSCT) -chemotherapy -total body irradiation Bisphosphonate Therapy Monoclonal Antibody Therapy
Oral care pathway
RCS England/ BSDH guidelines
Aim to minimise oral complications
90% H&N cancer pts have dental disease
Pre-treatment assessment, dental care in acute phase of cancer therapy, dental care post cancer therapy
Aims of pre-treatment assessment
Avoidance of unscheduled interruptions to 1. tx as result of dental problems
Pre-prosthetic planning/ treatment e.g., planning for primary implants/ imps for obturator
Planning for XLA for doubtful prognosis or at risk of dental disease in future and in an area at risk of osteoradionecrosis
XLA as early as possible in pt journey, at least 10 days prior to radiotherapy.
Planning for restoration of remaining teeth as required.
Preventive advice and treatment.
Assess potential for post treatment access difficulties e.g., trismus, microstomia
Oral Care Pathway - prevention
OHI & Dietary Advice ( +Smoking cessation) High dose fluoride toothpaste Saliva supplementation Regular scaling & polishing Topical Fluoride Mucositis
Dental Care in acute phase of cancer therapy
Avoided wherever possible -limit any dental treatment to emergency care only OH support Anti-fungals Denture care Mucositis -diet modifications -2% lidocaine mouthwash -treatment: Difflam (Benzydamine hydrochloride 15%), allopurinol
OH support in acute phase of cancer therapy
- professional hygienist support
- brushing, flossing, interdental cleaning
- alcohol free chlorhexidine
- anti viral therapy for children with HSCT
- maintain high dose F- toothpaste & saliva supplementation
- fluoride mouthrinses (0.05% NaF)
- topical Fluoride (2.2%)
Anti-fungals in acute phase of cancer therapy
Nystatin 100,000 units/ml, 7 days + 48 hours post resolution
Miconazole oral gel 24mg/ml – 10ml QDS
Fluconazole 50mg OD 7-14 days (Oropharyngeal candida)
( Azoles contraindicated with warfarin & statins )
Dental Care in acute phase of cancer therapy - radiotherapy
Dress
Extirpate pulps and dress
Dental Care in acute phase of cancer therapy - chemotherapy
Low platelet and white cell counts and anaemia
Plan care at optimum point in cycle
Monthly cycles
Dental Tx as close to start of next cycle as possible
Dental care post cancer therapy
Risk of uncontrolled dental disease following cancer therapy can continue for at least 12 months following Chemo, radiotherapy, total body irradiation and HSCT
> susceptibility to dental disease can be life long
Growth and development of facial structures and dentition should be closely monitored in children
Dental care post cancer therapy
Prevention and monitoring: children
- should be seen by specialist paediatric dentist and ortho to monitor development every 6 months
- routine care and preventive dentistry within GDS/ CDS (DBOH, monitor OH, topical fluoride, early intervention with caries)
- ortho 12 months after all clear
Dental care post cancer therapy
Prevention and monitoring: adults
Supervision for 12/12 by named clinician 3/12 Recall interval for at least 12 months -OH Reinforcement Topical Fluoride -application of chlorhexidine gel Prevention -caries -periodontal disease -mucositis -trismus
Dental care post cancer therapy
General considerations
Uncontrolled perio -culture - atypical pathogens Herpes -topical acyclovir Managing caries -keep simple -atraumatic -stepwise approach Prosthodontics Extractions
Dental care post cancer therapy
General considerations - prosthodontics
- avoid dentures
- duplication techniques
- consider fixed
Dental care post cancer therapy
General considerations - extractions
Avoid in irradiated pt –> ORN
- general incidence 7%
- hyperbaric oxygen (HBOT) incidence 4%
- antibiotic cover, incidence 6%
Risk factors for ORN
Total radiation dose exceeds 60Gy Dose fraction large + high number fractions Excess trauma Immunodeficiency Malnourished
What to do if faced with potential need to extract?
Antibiotic cover Amoxicillin/Coamoxiclav Metronidazole (if penicillin allergy) 0.2% chlorhexidine pre-rinse Adrenaline free LA Atraumatic Root canal treatment De-coronate & RCT HBOT - specialist care (rest you can do at GDS)
Dental care post cancer therapy
Requirements for denture wearers
Leave out at night – except for obturators in first 6 months Salivary substitutes > risk of oral candidiasis -Miconazole gel -Modified soft liners/tissue conditioners (Nystatin 500,000-1,000,000 units in Viscogel©, Tea tree oil in Coe Comfort©) -Fluconazole for persistent infections Replace poor dentures Tooth borne appliances
Dental care post cancer therapy
Management of ORN: staging
0: Mucosal defect
I: Radiological evidence of necrotic bone, mucosa intact
II: Radiographic findings + denuded bone visible
III: Exposed necrotic bone with infection + skin fistulas
Dental care post cancer therapy
Management of ORN
Referral to oral surgery/ special care dentistry, but maintain shared care Meticulous oral hygiene -brushing lesion -chlorhexidine gel Soft diet Gentle scaling/debridement of lesions Removal of dentures Monitor lesion by specialist -surgical intervention -high dose antibiotic regimes -HBOT
Dental care post cancer therapy
Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): types
BRONJ – Bisphosphonate related ONJ
ARONJ –Anti-resorptive Agent-induced ONJ
Dental care post cancer therapy
Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): bisphosphonates (including risks)
Oral or IV (Zoledronic Acid) Bone Metastatic Spread Risks -oral < IV 1/10,000-1/100,000 1/10 – 1/100 -length of therapy -extractions -oral surgery -intra oral trauma eg poor fitting dentures
Dental care post cancer therapy
Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): monoclonal antibodies (Mabs)
Derived from a single B Cell Lymphocyte clone
No batch to batch variance, therefore effect is more predictable
-Denosumab < Oc differentiation, activity and survival; inhibits bone resorption; SC injection 6 monthly
Dental care post cancer therapy
Prevention of medication related osteonecrosis of the jaws (MRONJ)
Meticulous oral hygiene RCT vs Extractions Removal/modification of dentures No periodontal surgery No implants
Management of medication related osteonecrosis of the jaws (MRONJ) if extractions unavoidable
Refer for specialist care
- atraumatic extractions
- achieve primary closure
- regular follow-up
Management of medication related osteonecrosis of the jaws (MRONJ): refer for specialist care, but maintain shared care
Meticulous oral hygiene -brushing lesion -chlorhexidine gel Soft diet Gentle scaling/debridement of lesions Removal/modification of dentures Monitor lesion by specialist -surgical intervention -high dose antibiotic regimes -HBOT
Head and neck MDT
*Multidisciplinary team* Anaesthetist with a special interest in head and neck cancer Gastroenterologists, radiologists, surgeons, and other health professionals with expertise in gastrostomy creation, feeding tube placement and support for patients who require tube feeding Ophthalmologist Pain management specialist Therapeutic radiographer Maxillofacial/dental technician Dental therapist/hygienist Benefits advisor Clinical psychologist Physiotherapist Occupational therapist Neurosurgeon (for skull base) Neuro-otologist (for skull base) Palliative care specialist (doctor or nurse) GMP GDP
Short term side effects of treatment
Mucositis: inflammation and ulceration of the mucosal lining of the oral cavity.
Infection: chemotherapy induced neutropenia makes the patient susceptible to bacterial, viral, and fungal infections. Oral candidal infections are extremely common following chemo or radiotherapy.
Xerostomia: dry mouth resulting from a decrease in the production of saliva as a result of radiotherapy.
Long-term treatment side effects
Altered anatomy
Rampant dental caries: thought to be result of < salivary flow as well as possible direct radiogenic damage to the ADJ
Trismus: may be caused by surgical scarring or by radiotherapy induced fibrosis of MoM
Mastication difficulties: if significant number of opposing pairs of teeth are lost
Osteoradionecrosis: hypovascularity and necrosis of bone followed by trauma induced or spontaneous mucosal breakdown, leading to a non-healing wound.
Xerostomia
Preventative management
Maintenance of good oral hygiene by effective tooth brushing; flossing daily.
Dietary Advice with regard to caries prevention.
Daily topical fluoride application (2800ppm or 5000ppm fluoride toothpaste) in custom-made trays or brush-on. Daily fluoride mouthrinse.
Daily use of GC Tooth Mousse TM containing free calcium
Saliva replacement therapy/ use of frequent saline rinses
Jaw exercises to reduce trismus (therabite).
Rehab for H&N cancer: soft tissue and mandibular recon
Flaps
Rehabiliation for head and neck cancer
Multidisciplinary decision-making should include the patient, surgeon (often in conjunction with plastics) and dental prosthodontist/restorative specialist.
Prosthetics or reconstructive options
-reconstructive should be considered as the defect becomes larger and more complex
Palatal obturator
A palatal obturator is a prosthesis that totally occludes an opening such as an oronasal fistula They are similar to dental retainers, but without the front wire
Implants for H&N cancer
Wide variation between UK centres Pre vs Post RXT Primary vs secondary First line of care vs care when conventional removable failed Fixed vs Removable ISPs
Maxillofacial prosthesis
Need to have a competent maxillofacial technician Correct materials Possible alternate application for “dental” implant Similar prosthodontically driven tx plan Often conducted by plastics Eyes -can have custom painted iris -motorised Ears Noses Cheeks
Fabrication - maxillofacial prosthesis
The mohs procedure had pulled the nasal septum to the right hand side due to scar tissue formation.
Accepted position and worked to maximise the aesthetics from a face-on and lateral view.
the glasses were also tried on with the wax try in to ensure the prosthesis would not lift away from the nasal base.
A small acrylic plate was made to attach the soft silicone prosthesis to, in the area of the bridge of the nose to allow for a strong attachment to the glasses.
maxillofacial prosthesis - fit
The prosthesis was constructed separate from the glasses in the lab.
A primary try in was conducted and shades taken for extrinsic staining.
At fit, small adjustments were made to the amount of silicone flaring over the skin of the cheek with a scalpel.
After painting the finishing touches to the extrinsic staining at the chair-side, the glasses were attached to the prosthesis using cold cure PMMA resin, after roughening the frame with an acrylic bur
When to put primary implants in
Where there is continuity of the mandible
In patients who require the prosthetic obturation of significant maxillary defects
Where retention of the obturator is likely to be compromised
In pts undergoing rhinectomy or orbital exenteration.