Head and Neck Cancer Flashcards
What is the role of a GDP in cancer patients in terms of screening and referral?
- early detection through soft tissue examination
- photographs
- onwards referral
- pre-treatment assessment
What guidance can dentists refer to when treating cancer patients?
- scottish cancer referral guilelines
- NICE: improving outcomes in head and neck cancer
- british association of head and neck oncologists multidisciplinary management guidelines
What situations would make a dentist refer a patient on with suspected head and neck cancer?
- stridor (emergency referral required)
- persistant unexplained H&N lumps > 3 weeks
- ulceration or unexplained swelling of oral mucosa > 3 weeks
- all red/mixed red & white patches for > 3 weeks
- persistant hoarseness lasting for > 3 weeks
- dysphagia or odynophagia for > 3 weeks
- persistant throat pain > 3 weeks
What is stridor?
Noisy/laboured breathing
- requires emergency referral
What is odynophagia?
Pain on swallowing
What investigations are done on H&N referral patients?
- biopsy to confirm diagnosis
- CT scan to investigate extent of tumour
- lymph node biopsy
- CT scan to investigate metastasis
- baseline medical testing
- stage & grade cancer
Who is part of the multidisciplinary team?
- oncologist
- radiologist
- surgeon
- clinical nurse specialist
- SALT (speech & language therapist)
- dietician
- dentist
- physio
- physchologist
- occupational therapist
What is the aim of an MDT?
To provide patient with a collaborative, multi-professional environment facilitating effective care
What is involved in a cancer patients dental pre-assessment?
- full IN DEPTH examination
- radiographs ESSENTIAL (OPT and periapicals)
What are the aims of dental pre-assessment in cancer patients?
- identify existing oral disease & potential risk of disease
- remove infection/potential infection before treatment
- prepare patient for expected side effects of cancer therapy
- establish oral hygiene regime
- plan post-treatment care
Why is it essential to identify existing oral disease & potential risk of disease before starting cancer treatment?
to avoid unscheduled interruptions to primary treatment as a result of dental problems
What should dentists provide at the cancer pre-assessment?
- detailed oral hygiene
- fluoride (topical, mouthwash, toothpaste 2000ppm)
- GC tooth mousse
- dietary advice
- PMPR to stabilise perio condition
- consider chlorhexidine mouthwash & gel
- restore carious teeth
- removal of trauma
- impressions: construct fluoride trays, soft splints
- extraction of hopeless teeth
What side effect can result from surgical cancer treatment?
- alterations to normal anatomy
- function affected
- appearance affected
What side effect does cancer radiotherapy treatment have?
Unavoidable damage to normal tissues surrounding tumours
- altered function
What side effect does cancer chemotherapy have on the patient?
Acute mucosal and haematological toxicity
What side effects can head and neck cancer treatment have on the patient?
Effects on:
- respiration
- mastication
- swallowing
- speech
- taste
- salivary gland function
- mouth opening
What is the dentists role during cancer therapy?
- hygienist support
- oral & denture hygiene
- diet advice
- fluoride preparations
- examine for viral & fungal infections
- treatment/symptom relief of mucositis and xerostomia
What is oral mucositis?
SEVERE PAIN produced by mucositis
- begins 1-2 weeks after treatment starts (more common in chemotherapy)
- huge impact on OH
- severe impact on eating
How can oral mucositis be prevented/managed?
- Caphosol (neutral supersaturated calcium phosphate mouth rinse)
- Gelclair (polyvinyl sodium hyaluronate gel)
- mucoadhesive oral rinse
- soluble aspirin
- benzydamine hydrochloride (Difflam)
- zinc supplements
- aloe vera
- cryotherapy
- manuka honey
What symptoms/signs would suggest that a patient has a score of 2 for Mucositis?
- deep or raspy voice
- some pain upon swallowing
- dry or cracked lips
- tongue has a shiney appearance
- thick or ropey saliva
- reddened or coated mucosa WITHOUT ulceration
What signs would suggest that a patient has a score of 3 for Mucositis?
- difficult talking or painful speech
- unable to swallow
- ulcerated bleeding lips
- blistered or cracked tongue
- absent saliva
- ulcerated mucosa with or without bleeding
What infections are commun during cancer treatment?
Oral Candida Infections
What antifungals may be prescribed if a patient is suffering from candidiasis during cancer treatment?
- chlorhexidine mouthwash
- miconazole (topical)
- fluconazole (systemic)
- nystatin
What can sometimes become reactivated during cancer treatment?
Herpes Simplex Virus
What is the prodromal period during the reactivation of herpes simplex virus during cancer treatment?
pain prior to ulceration that needs urgent treatment with systemic antivirals
How is saliva affected in cancer patients?
Saliva consistency and character is affected
- becomes more viscous & acidic
What effects may a cancer patient suffering from xerostomia notice?
Difficulty with :
- chewing
- swallowing
- speech
- taste
- quality of life
What can be done to help cancer patient suffering with xerostomia?
- fluoride supplementation
- oral gel or lubricants to protect lips and soft tissues
- Pilocarpine HCl can enhance salivary secretions in patients who have dysfunctional salivary glands
- stimulation by sugar free chewing gum
- salivary replacement
What adverse effects can occur due to use of Pilocarpine HCl?
- sweating
- headache
- urine frequency
What are the causes for post cancer treatment trismus?
- post-surgical inflammation
- fibrosis of those tissues as a result of chemotherapy and radiotherapy
Why are caries a common occurrence in patients being treated for cancer?
- indirect effect of non-surgical treatment
- reduced salivary flow/salivary function
- poor OH due to painful mouth
What is one of the most severe and debilitating complications that can follow radiation therapy for head and neck cancer?
Ostoradionecrosis (ORN)
- area of exposed bone of at least three months duration in an irradiated site not due to tumour recurrence
How can ORN be prevented in cancer patients?
- removal of teeth with doubtful prognosis
- extractions completed at least 10 days prior to radiotherapy
- encourage healing with primary closure/sutures where possible
When are patients at an increased risk of ORN?
- total radiation dose exceeded 60Gy
- dose fraction was large with a high number of fractions
- local trauma as a result of tooth extraction, perio disease or ill-fitting prosthesis
- immunodeficiency
- malnourishment
what is stage 0 ORN?
mucosal defects only; bone exposed
what is stage I ORN?
radiological evidence of necrotic bone; dento-alveolar only
what is stage II ORN?
positive radiographic findings above ID canal with denuded bone intra-orally
what is stage III ORN?
clinically exposed radionecrotic bone, verified by imaging techniques, along with skin fistulas & infection
- potential or actual pathological fracture
