Head and Neck Cancer Flashcards
the role f the dentist and the dental team
- Early detection of soft tissue lesions
- Soft tissue screen on every pt at every appointment
- Pre-treatment assessment and dental care
- Minimal role during treatment unless special interest
- Maintenance of oral and dental health post-treatment
- Palliative care
dental team needs to ensure oral cancer
≠ Dental Disease
pt journey who has cancer in relation to dental care
screening and referral
investigations
dental pre-assessment
support through treatment
- Try to avoid invasive treatment whilst they are undergoing tx
restoration
maintenance and post tx management
head and neck referral guide
emergency referral
- emergency referral - stridor
head and neck cancer dental referral guidelines
Scottish Cancer Refferal Guide - head and neck
- NICE: Improving Outcomes in Head and Neck Cancers
- BAHNO/ Multidisciplinary Management Guidelines
- The Royal College of Surgeons of England/ The British Society for Disability and Oral Health
- Restorative Dentistry: Predicting and Managing Oral and Dental Complications of Surgical and Non-Surgical Treatment for Head and Neck Cancer
head and neck cancer
urgent suspcision of cancer referral for head and neck
- persistent unexplained head and neck lumps for >3 weeks
- ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks
- all red or mized red and white patches of the oral mucosa persisting for >3 weeks
- persistent hoarseness lasting for >3weeks (request chest X-ray as well)
- dysphagia or odynophagia (pain on swallowing) lasting for >3weeks
- persistent pain in the throart lasting for >3weeks
thyroid cancer
urgent suspcision of cancer referral for thyroid cancer
- solitary nodule increasing in size
- thyroid swelling in pre-pubertal pt
- thyroid swelling in 1 or more of the following risk factors:
- neck irradiation
- family history of endocrine tumour
- unexplained hoarseness
- cervical lymphadenopathy
aim of West of Scotland head and neck cancer managed clinical network
equitable management of pts across the West of Scotland to ensure that every pt will be dentally screened prior to entering tx
have dentist check of pt before pt with head and neck cancer tx begins
2013 – Scotland try to ensure that every pt be dentally rescreened prior to entering tx course
- Pt can refuse
impacts of oral cancer
- airway
- upper GI tract
- major senses
- visible cancer - can be difficult to hide
parts of pre-assessment and treatment dentally for cancer pt
- history taking - medical, dental social
- oral and dental assessment prior to start cancer therapy
- any necessary tx carried out
- pre-tx dental scaling by hygienist and OHI
- impressions for fluoride trays
- potentially make a soft splint for lowers - in case of severe ulceration - aid protection of soft tissues
why is pre-assessment history taking important
medical dental and social
need to find out as much as possible
what will be done as part of oral and dental assessment prior to cancer therapy
Radiographs (OPT/ Periapicals)
- Ensures don’t miss anything
- Bone levels, impacted 8s etc
why is any necessary dental tx carried out before cancer therapy begins
Dentally fit prior to oncological care
- Don’t want anything that is a potential source of infection
- Can be radical – RCT not allowed – risk fail
Availability of immediate treatment
- Need to see them timely – so cancer tx can be started ASAP
role of fluoride trays
aid in fluoride therapy for dentate cancer pts
3 pre tx dental assessment priorties
oral hygiene and fluoride
reduce tx complications
reduce post tx complications
why is oral hygiene and F instruction and maintenance important in pre tx dental assessment
won’t prevent mucositis happening but will shorten its duration
what complications are pre tx dental assessment trying to reduce
- Avoid unscheduled interruption of chemotherapy regimen
- Avoid exacerbation of mucositis
- Remove potential sources of infection
what post tx complications is the pre tx dental assessment trying to reduce
- Remove teeth of dubious prognosis – forward planning
- Institute preventive regime
- Plan rehabilitation
- E.g. bridge, denture (CoCr/Acrylic), implants
effect of radiotherapy on
skin and mucosa
erythema
ulceration
mucositis
effect of radiotherapy on
muscle and connective tissue
fibrosis of deeper layers -> trismus
if mouth opening less than 35mm it is very difficult to carry out any Tx
effect of radiotherapy
on saliva glands
dry mouth
effect of radiotherapy
teeth and supporting tissues
dental caries and sequelae
effect of radiotherapy
on bone
endarteritis obliterans O.R.N
little BV in bone close off - no blood flow there -> osteoradionecrosis
why is it key to have mouth as clean as possible prior to tx starting
chlorohexidine gel can be rubbed on if sore to brush due to mucositis - only effective on clean teeth at preventing plaque build up
can have a preventative region in place
most common site for squamous cell carcinoma
lateral border of tongue
Need gauze to hold tongue and manipulate to ensure doing soft tissue exam properly
radiotherapy tx of this SCC could result in
first
- Tumour nearly completely gone
- Teeth not in good condition – plaque
- Tongue sore – at erythematous stage
- As progresses through radiotherapy
later
- As progresses through radiotherapy get ulceration on side of tongue and cheek
- Plaque build-up further as so painful to brush
dentistry considerations during oncology tx
Oral ulceration and Oral infection e.g. develop an abscess suddenly
Emergency dental treatment only
-
Never treat pt during their oncology tx without liaison with medical team
- Is it safe to provide dental treatment?
- Pick right time, bloods OK, ensure not make matters worse
- Do we need to delay chemo / radiotherapy?
- Try hard to avoid
ulcerations causes in oncology tx
traumatic ulceration
mucositis - radio or chemotherapy induced
what can be a good management startegy for sore ulceration in oncology pt
Get impression for soft splint when taking F tray impression easier to do then so ready if needed
mucositis causes ulceration
Inflammation and ulceration
- Severe pain
- Analgesia required
- Paracetamol may not be enough go onto opioid based analgesia to gain degree of comfort
Chemo- and radiotherapy - both look similar
Impact on
- Eating
- NG nasogastric tube
- PEG tube
- RIG – radiologically inserted gastrostomy tube
- OH
Exacerbating factors
impact of mucositis
Eating
- NG nasogastric tube
- PEG tube
- RIG – radiologically inserted gastrostomy tube
OH
due to severe pain
general avoidance measures to avoid mucositis
- Smoking
- Spirits
- Spicy foods - exacerbating
- Tea & coffee
- Non prescription M/W – particular those with alcohol
topical measures for mucosistis management (8)
- Topical Lignocaine
- Saline m/w
- Na Bicarb.
- Benzydamine HCL – alcohol containing so aware a stringent feel
- Gelclair
- Good for aphthous ulcers – may not be able to deal with mucositis
- Caphosol
- Saturated solution of electrolytes, sodium, sodium phosphate and calcium chloride and water
- Calcium ions – decrease inflammation, improve circulation and improve healing
- Phosphate ions – perhaps aid healing of ulcers
- Saturated solution of electrolytes, sodium, sodium phosphate and calcium chloride and water
- Tea Tree Oil Mouthwash – alcohol free
- From holland and barrett (now contains aloe vera as well)
- Not prescriptible – needs to be purchased
- Oral cooling – ice
caphosol
can be used in mucosistis management
Saturated solution of electrolytes, sodium, sodium phosphate and calcium chloride and water
- Calcium ions – decrease inflammation, improve circulation and improve healing
- Phosphate ions – perhaps aid healing of ulcers
gelclair
good for management of aphthous ulcers
may not be able to deal with mucositis
oral cooling with ice
mucositis management
- Hold them there for 5-10 mins – hard
- Shuts down the superficial BV and therefore less likely to cause ulceration
what should be used for pain relief in mucositis
narcotic analgesia (opioids generally)
prevention methods for mucositis (11)
- Aloe vera
- Amifostine – radioprotective agent of mucosa and salivary glands, but £££
- Chlorhexidine
- Cryotherapy
- Granulocyte-colony stimulating factor (GCSF) – stimulate bone marrow
- Intravenous glutamine – amino acid meant to delay mucositis - unclear
- Manuka Honey
- Keratinocyte growth factor
- Multiple biological activities that appeal to protect the mucosal epithelium and promote early regeneration of post radiotherapy
- Laser – very successful in children
- Polymixin/tobramycin/amphotericin antibiotic pastille/paste
- Sucralfate – mouthwash, decrease intensitiy mucositis
When taken together perhaps keep mouth cleaner, less full on MO – won’t stop mucositis but will prolong superimposition of infection
2 possible tx options for mucosists
low level laser light therapy - children more
morphine
oral candidosis
‘disease of the diseased’
- Oral carriage of yeasts common among cancer patients (47-87%).
- Oral candidosis a frequent clinical problem (8-94%).
thrush - extremely uncomfortable
viral infections in oncology tx
Reactivation of Herpes Simplex
- Often intra-oral and clinically atypical – all different
Painful oral ulceration of sudden onset.
More extensive, slow healing & aggressive
High index of clinical suspicion
- Often with prodromal pain comes before ulcers
- Treat as quick as possible with antiviral agents
post tx prevention dental care
- Diet
- OH
- Fluoride – 2800 or 5000ppmF; varnish
- Trismus – fibrosis of tissues particularly after radio
- Smoking
post tx dental monitoring
- Increased frequency of check-ups
- 6 months not useful as hopefully treatment finished by then
- Any issues – worsened or healed
- Key to see them more frequently
- 6 months not useful as hopefully treatment finished by then
- Dry mouth management - hard
- Prosthodontics – restore spaces
- Appropriate referral
dry mouth tx options for children
Tooth mousse
- decrease sensitivity, neutralise pH*
- Contains casein (milk protein), calcium and phosphate*
why does xerostomia occur in oncology tx
Salivary flow dec
- 50 – 60% in first week
- Further 20% in next 5 – 6 weeks
Saliva consistency and character
- Viscosity inc
- pH dec
- bad for highly mineralized enamel
recorvery from oncology tx caused xerostomia
over preiod of years
will not return to normal - radiotherapy often
chemotherapy can but takes time
xerostomia impact
- Quality of life
- Dysphagia
- Dysarthria
- Dysgeusia
- increase risk of
- Caries
- Periodontal disease
- Candidosis
- Sialadenitis
- Prosthodontic difficulties – hard to retain denture
management of xerostomia
Oralbalance, bioextra
Sugar free chewing gum – stimulate
Sip plain water
- Oral balance and saliva orthane – best
- never use Glandosene – acidic
dental effects of xerostomia
dental erosion
caries
- less saliva buffering
- change in diet/taste - supplements?
- swallowing impaired
- OH can be poorer as pain due to lack of saliva
radiation induced caries
Very prevalent
- Smooth surface cervical caries
Hard to restore
- Location
- Restorations dry out and fall out
- Continuing battle
- Cervical decay becomes circumferential and teeth snap off
2 prevention methods for radiation induced caries
fluoride trays
high F toothpaste - 2800 or 5000
periodontal disease in oncology care
difficult to maintain OH cancer pts
- tired,
- in pain,
- last thing on their mind
= result in bad oral health
see pt regularly (before and after chemo/radiotherapy, not during) to try and maintain periodontium
osteoradionecrosis effects
more common in mandible than maxilla
Know field of radiotherapy tx – help plan what will be affected
image
- Right mandible damage to bone
- Patient had radiotherapy for oropharyngeal tumour
- Went to own dentist and had tooth extracted
osteoradionecrosis prevention
- Remove teeth of doubtful prognosis in the radiotherapy field
- Can be hard for pt to accept as can be radical
- Esp if as trismus can mean hard to treat later on
- Can be hard for pt to accept as can be radical
- Prevention
- Extractions completed at least 10days prior to radiotherapy
- Chance of healing
- Try to do as much as possible to encourage healing – suture etc
- Liaise with oncologist
Skull base alveolar rhabdomyosarcoma
cancer that forms in the head and neck.
Symptoms include problems with the sense of smell, eye sight, hearing, swallowing, and facial weakness.
Treatment includes surgery, chemotherapy, and radiation therapy
who sees pt if they require extractions and are oncology pt
specialist
- Pre radiotherapy assessment
- Extract poor prognosed teeth
- Prevention
- Extractions carried out at least 2 weeks prior to RadioTx to allow healing →ORN.
Interruption of Radio/ chemo can have detrimental effects on cancer treatment.
Multiple extractions may affect the fit of RadioTx mask.
how to prevent osteoradionecrosis post radiotherapy
Any other treatment option other than extraction?
- decoronate?
Liaise with oncologist – field and dose
Prevention: Pentoxyfylline/Vitamin E ?
- 4-6 weeks post radiotherapy 400mg Pentoxyfylline and 1000 international units of Vitamin E daily
- Hopefully push some BV back into life – resurrect and encourage healing
issue here
long term (5 years) osteoradionecrosis
- Lost several teeth
- Mandible is completely destroyed on both sides (worse on right)
- Still retains some functional upper teeth
infected osteoradionecrosis
Evident inside mouth with fistula to outside of mouth
- Never healed – epithelium lined tract
- Food through PET tube to stomach
IORN between 4-35%.
- Improved detection methods for Actinomyces*
- e.g. group devised a nested PCR approach and found evidence of Actinomyces 20/31 (64.5%).
dental implants and oncology pts
- Revolutionising rehabilitation
- Reduced success of implants in irradiated bone
- Need careful assessment and lots of pre-planning
- Maintenance – crucial to keep implants as clean as possible
- Self care
- Professional support
Risk of implant placement in irradiated bone is similar to risk of ORN if extracting teeth
brachytherapy
radioactive rods inserted into tissue
palliative care role of dental team
Tongue cancer here – unresponsive to all Tx
- Tumour is fungating, smelling, bleeding, friable, unpleasant
- Role for dental team to manage to keep mouth clean
- Need to know how to manage tissues and aspirators
- Role for dental team to manage to keep mouth clean
Go into hospices to aid
dental problems and planning for oncology pt who is in palliative care
- As common in this group as in other sectors of population
- Not immune toothache, perio etc
- Treatment plan according to stage of illness
- Routine treatment possible if well enough to attend
- Minimum intervention in terminal stages
- functional and comfortable
discuss
diagnosed later
- Remaining dentition in poor condition*
- OH poor*
- Large tumour*
- Enlarged tongue*
- Ulceration*
- Need to extract lower teeth – hard as he couldn’t move tongue – down with LA*
discuss this pt
6-12 months radiotherapy attending GDP for denture
- Large ulcerations still on tongue – dorsum, lateral borders and down back*
- What causing ulceration on the heavily keratinised surface of tongue?
- Uncomfortable, hard to clean, eating hard*
trismus
- Fibrosis of muscles of mastication
- endarteritis of tissues affected with reduction in their blood supply
- area irritated becomes hard
- endarteritis of tissues affected with reduction in their blood supply
- Progressive and Irreversible
- Can try and stretch – tongue depressors, therabite
trismus impact on (5)
- Eating
- Speaking
- OH
- Dentures
- Dental treatment
- May be exacerbated by surgically induced microstomia e.g. lip and buccal cancer*
- which may in turn be exacerbated by adjuvant radiotherapy*
role of dental team in cancer pt management
4 phases
-
Before cancer treatment
- Prevention of chemo/ radioRx complications – dentally fit
- Plan rehabilitation
-
During cancer treatment
- Mucositis
- Emergency treatment
- be available but always liaise with cancer team
-
After cancer treatment
- Prevention
- Rehabilitation
- Long-term care and monitoring
1-2 years share care with special care and GDP (special care can take over for time if needed)
Recent pt, male, 64 years
- T2 N0 SCC uvula and tonsil
- Hypertensive controlled 162/97
- Type 2 diabetic & osteoarthritis
- Radical DXT
- GORD, hiatus hernia, angina, IHD
- BMI = 45
- Atrial fibrillation – warfarin range 1.9 – 6.8
- Under care 5 GG&C hospitals
- taxi driver and carer for wife
discuss before and after
before
- Teeth stained
- Plaque
- Calculus
- Caries
- Few lower teeth
after
- Lower denture in situ
- Upper teeth – scaled and managed
- OHI regime in place
- Saw regularly – maintained for a while, but eventually lost all
- Work in conjunction with QEUH Maxo facial department*
-
Looks like reasonably full complement of lower teeth
- Reality had no teeth on left side at all
- Soft splint made so he can speak better
- Cover teeth on RHS and made to look like teeth on LHS
