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
