General

Question 1

Discuss and describe the stages of ASA Classification of Physical Health

Answer 1

Has five classes:
I: Patient is a completely healthy fit patient
II: Patient with mild or well-controlled systemic disease
III: Patient with severe systemic disease, however not incapacitating
IV: Patient with incapacitating disease that is constant threat to life
V: Moribund patient not expected to live 24 hour with or without surgery

Severely medically compromised patients (beyond ASA III) are best treated in specialised clinics

Question 2

Define autoimmune disease and discuss the aetiology, diagnosis and 2 general categories into which these conditions are separated

Answer 2

• Autoimmune diseases are a broad range of related diseases in which a person’s immune system produces an inappropriate response against its own cells, tissues and/or organs, resulting in inflammation and damage

Aetiology
• Is unknown
• Most likely inherited tendency, in which other factors (infections, medications) trigger the onset of disease

Diagnosis:
• Combination of clinical history, blood tests (auto antibodies, inflammation, organ function), radiographs and biopsy of affected tissues

2 categories:
Localised (organ specific)
• Affects mainly one specific part of body
• Often managed by organ-specific medical specialists (Endocrinologists, Neurologists)
• Eg: Addison’s disease (adrenal), Crohn’s disease (gastrointestinal tract), Grave’s disease (thyroid), Guillain-Barre syndrome (nervous system)

Systemic
• Multiple parts of the body affected. Broadly classified into rheumatologic/connective tissue disease and vasculitis (inflammation of blood vessels)
• Eg. Systemic Lupus Erythematosus (skin, joints, kidneys, heart, brain, red blood cells, other), Rheumatoid arthritis (joints), Scleroderma (skin), Rheumatic fever

Question 3

Describe dental treatment PRIOR to cancer treatment

Answer 3

· Care prior to initiating cancer treatment, thorough hard and soft tissue examination and radiographs to reduce oral complications, osteoradionecrosis, periapical pathology, periodontal disease and dental decay
· Commence dental treatment 14 days prior to cancer therapy
· Identify and treat existing infections, problem teeth, tissue injury and trauma
· Stabilize or eliminate potential sites of infection
· Evaluate dentures for comfort and fit
· In children, extract loose teeth and teeth that are expected to loosen during therapy
· Instruct patient on OH, fluoride, diet, need to avoid tobacco and alcohol
· Other considerations: removal of orthodontic bands may be required depending on cancer treatment and extraction of permanent teeth is considered if they pose a future problem (to prevent extraction induced osteoradionecrosis)

Question 4

Describe dental management during cancer treatment, and understand the ranges that would cause appointments to be postponed

Answer 4

· Consult with GP who will assess recent blood counts, platelet count, clotting factors, and neutrophils counts as these need to be sufficient to prevent haemorrhage and infection
· Possible antibiotic prophylaxis if patient has implanted central venous catheter or port
· Oral surgery usually recommended 7-10 days before next round of immunosuppressive chemotherapy

Oral health procedures usually postponed when:
· Platelet counts < 50,000 per mm
· Clotting factor levels (INR)> 2.5
· Neutrophil count < 1000

Question 5

List recommendations made for patients who undergo radiation therapy to prevent/ manage trismus (6)

Answer 5

· Frequent stretching exercises to keep muscles functioning
· Encourage frequent sips of water
· Use liquids to soften and thin foods
· Recommend sugarless chewing gum 
· Saliva substitute
· Fluoride

Question 6

Describe the role of the OHT and dental considerations for patients undergoing bone marrow therapy (6)

Answer 6

· Delay elective dental procedures for at least 1 year
· Monitor oral infection on the tongue and oral mucosa
· Dry mouth
· Plaque control
· Tooth demineralization/ Dental caries
· Infection
· Carefully screen for second malignancies in oral regions

• Unlikely to seek elective dental care due to immunosuppression following treatment
• Suppression resolves when hematologic status improves. May take up to 1-2 years, extending time of oral complications
• DO to consult with oncologist prior to any oral health procedures – including prophylaxis

Question 7

List the oral consequences of head and neck radiation treatment (5) and use of supplemental fluoride

Answer 7

· High dosage radiation treatment causes life-long risk of
· Invasive surgical procedures including extractions (irradiated bone) should be avoided

Oral consequences
· Reduced quantity and quality of saliva (xerostomia)
· osteoradionecrosis
· Altered oral soft tissues
· dentures may need to be reconstructed
· Friable tissues (tissues tears, sloughs and bleeds easily)

Supplemental fluoride program
· Trays should be fabricated so that all tooth structures are covered and should extend at least 3mm beyond the margins
· Several days prior to therapy, patient should start a 5 minute application of fluoride
· Trays should be checked regularly and new trays constructed as needed