Oncology Flashcards
When would you refer a possible cancer
Stridor – Emergency referral required
Persistent unexplained head and neck lumps >3 weeks
Persistent unexplained head and neck lumps >3 weeks
All red or mixed red and white patches of the oral mucosa persisting for >3 weeks
Persistent hoarseness lasting for >3 weeks (request a chest X-ray at the same time)
Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks
Persistent pain in the throat lasting for >3 weeks
What are the investigation used to check for cancer
New patient assessment within OMFS
Biopsy to confirm diagnosis
CT Scan to investigate extent of tumour
Lymph node biopsy
CT Scan to investigate for metastasis
Baseline medical testing – Performance Score
Stage and grade cancer
What should every pretreatment assessment include
A dental assessment
What are the aims for a pre-assessment
Identify existing oral disease and potential risk of disease – we want to avoid unscheduled interruptions to primary treatment as a result of dental problems
Remove infection and potential infection before the start of cancer therapy.
Prepare the patient for expected side effects of cancer therapy.
Establish an adequate standard of oral hygiene to meet the increasing challenges during cancer therapy.
Develop a plan for maintaining oral hygiene, providing preventive care, completing oral rehabilitation and follow-up.
Establish the necessary multidisciplinary collaboration within the cancer centre
To plan post-treatment prosthetic oral rehabilitation
What would you provide in a pre-assessment
- Remove any current source or potential source of infection
- Institute prevention
Detailed oral hygiene – TBI, interdental cleaning
Fluoride: topical application, mouthwash (0.05% alcohol free), fluoride toothpaste
GC Tooth mousse – free calcium
Dietary advice that coincides with the dietitian – emphasis on oral comfort during treatment
PMPR to stabilise periodontal condition
Consider Chlorhexidine mouthwash and gel (alcohol free)
Definitively restore carious teeth
Removal of trauma: adjust sharp edges on teeth/dentures
Impressions: construct fluoride trays, soft splints
Denture hygiene and instructions to avoid wear during cancer treatment
Antibiotic prophylaxis if neutrophils are low and planning invasive treatment – liaise with medics
Orthodontics: discontinue and remove fixed appliances
Smoking and Alcohol advice
Restorative: Study casts for implant planning, pre-treatment records, planning for trismus
Extract teeth with dubious prognosis no less than 10 days before starting cancer treatment
What teeth would you remove before cancer treatment starts
Teeth in direct association with the tumour, in the direct path of the radiation beam, or teeth with doubtful prognosis
What else would you provide as well wit extraction of teeth before cancer treatment
high dose intravenous bisphosphonate treatment
What treatment is provided for cancer
Surgical resection with or without reconstruction
Radiotherapy
Chemotherapy
Adjuvant radiotherapy or chemoradiotherapy may be required following surgical resection
What are cancer treatment side effects
Surgical tumour resection can produce alterations to the normal anatomy which adversely affect function and outward appearance
Radiotherapy causes unavoidable radiation damage to normal tissues surrounding the tumour, affecting the function of these tissues both in the short-term (during and immediately after treatment) and long-term (for months and years after treatment or lifelong)
Chemotherapy causes acute mucosal and haematological toxicity, with the former being accentuated if chemotherapy is delivered concurrently with radiation therapy
Head and neck cancer treatment can have adverse effects on respiration, mastication, swallowing, speech, taste, salivary gland function, mouth opening and the outward appearance of the head and neck region
As a dentist during cancer treatment what is it important to do
Avoid dental treatment as risk of pancytopenia
What is the dentist role during cancer treatment
Hygienist support
Oral and Denture hygiene
Antibacterial MW (alcohol free) e.g. Chlorhexidine – short term alternative to brushing
Diet advice
Fluoride preparations (topical, toothpaste, MW, fluoride trays)
High risk of viral and fungal infections – examine for this and prophylaxis or treatment prescribed by cancer team
Treatment/Symptom relief of mucositis, xerostomia
Emergency dental treatment: liaise with cancer team (delay cancer treatment?)
What would ypu do if brushing became painful
If brushing becomes very painful a soft brush (e.g. TePe Special Care Toothbrush) can be substituted, particularly for those patients receiving chemotherapy where their platelet levels are low
What dental issue arrises during cancer treatment and how long does it last and what does it do
Oral Mucositis
Begins 1-2 weeks after treatment starts
Lasts until ~6 weeks after treatment is complete
Severe pain produced by mucositis may inhibit oral hygiene measures.
Severe impact on eating – NG, PEG fed
what is the WHO mucositis grading
0 – None
I – Mild Oral soreness and erythema
II – Moderate Oral erythema, ulcers, solid diet tolerated
III – Severe Oral ulcers, liquid diet only
IV – Life Threatening Oral alimentation impossible
what prevention and management is there for oral mucositis
Neutral supersaturated calcium phosphate mouth rinse (Caphosol),
Polyvinyl pyrrolidine/sodium hyaluronate gel (Gelclair),
Mucoadhesive oral rinse (Mugard),
Soluble aspirin,
Benzydamine hydrochloride (Difflam)
Zinc supplements may prevent
Aloe Vera
Cryotherapy
Manuka Honey
Difflam: 15ml four to eight times daily starting before radiotherapy and continuing during and for two to three weeks afterwards is recommended
Low level laser therapy in radiotherapy without chemotherapy
Rinses such as normal saline and sodium bicarbonate
Good OH will not prevent symptoms but can help it resolve faster
Morphine and Opioids required as analgesics
Remove sharp edges to teeth/poorly fitting dentures
Intensive Oral Hygiene
Oral Cooling (ice)
2% lidocaine mouthwash used prior to eating,
Tea tree oil mouthwash
Intravenous keratinocyte growth factor-1 (palifermin) for high dose chemotherapy – preventative measure
What is other dental issues that can arrise
Candida infections
Traumatic ulcerations
Reactivation of herpes simplex
Xerostomia
Trismus
Dental erosion
Caries
Radation induced caries
perio
ORN
How to treat candida infections
Preventative antifungals often prescribed by cancer team
Antifungals:
Chlorhexidine mouthwash, gel
Miconazole - topical
Fluconazole – systemic
Nystatin- Does not appear to be effective
talk about xerostomia
Reduced salivary flow 50-60% in first week with a further 20% in next 5-6 weeks.
Saliva consistency and character is affected: saliva becomes more viscous and acidic (damage to dentition)
Recovery may happen over a number of years or not return at all.
Xerostomia affects: chewing, swallowing (dysphagia), speech (dysarthria), taste (dysgeusia) and quality of life
Higher risk of: caries, periodontal disease, candida, sialadenitis, prosthodontic difficulties
What causes the xerostomia and how is it treated
Caused by ionising radiation damage to salivary tissue in the radiotherapy fields
Oral gel or lubricants (e.g. petroleum jelly based products (Vaseline) or emollients (Cetraben) are useful to coat and protect the lips and soft tissues
Pilocarpine HCl, a can enhance salivary secretions in patients who have some functional salivary glands. Oral administration of pilocarpine HCl 5mg three times daily is effective
For many patients, saliva replacement is the only option. Many use frequent sips of water, Avoid the use of acidic saliva replacements in dentate patients (e.g. Glandosane)
Saliva orthana (contains porcine mucin; contains fluoride)
Biotene Oral Balance Gel (new formulation not acidic; contains milk, egg white)
BioXtra Gel (contains milk, egg white; contains fluoride)
Talk about trismus
Trismus that follows radiotherapy can occur rapidly over the first 9 months after treatment, tends to be progressive and may be irreversible
Treatment: physical therapy modalities e.g. passive and active stretching exercises, and the use of devices for stretching the muscles of mastication e.g. Therabite and and stacked tongue depressors
Why is there erosion and caries
Erosion Can be due to low saliva pH, use of glandosane, drinking acidic drinks due to dry mouth
Caries from: Combination of xerostomia, oral hygiene being difficult to perform
Talk about radation induced caries
Indirect effect of non-surgical treatment (chemotherapy and radiotherapy)
Result of reduced salivary flow and altered saliva function in combination with the high protein and calorie diet
Very common despite our best efforts
Rapidly developing
Widespread caries can result that is often circumferential around the teeth and
may affect incisal edges
What is ORN
Osteoradionecrosis
An area of exposed bone of at least three months duration in an irradiated site and not due to tumour recurrence it is one of the most severe and debilitating complications following radiation therapy for head and neck cancer
What are the stats of ORN
total incidence of ORN after tooth extraction in irradiated patients to be 7%.
When extractions were performed in conjunction with prophylactic Hyperbaric oxygen therapy the incidence was 4%
Extractions in conjunction with antibiotics gave an incidence of 6%
How is ORN prevented
Remove teeth of doubtful prognosis in the radiotherapy field
Extractions completed at least 10days prior to radiotherapy
Liaise with oncologist
Encourage healing with primary closure / sutures where possible
When is a patient under particular risk of ORN
The total radiation dose exceeded 60Gy
The dose fraction was large with a high number of fractions
There is local trauma as the result of a tooth extraction (especially mandibular extractions), uncontrolled periodontal disease or an ill-fitting prosthesis.
The person is immunodeficient
The person is malnourished
What treatment is there for ORN
Pentoxyfylline and Vitamin E
What are the 4 stages of ORN
Stage 0: mucosal defects only, bone exposed
Stage 1: radiological evidence of necrotic bone, dento alveolar only
Stage 2: positive radiogrpahic findings above ID canal with denuded bone intraorally
Stage 3: Clinically exposed radionecrotic bone
