Oncology

Question 1

Give 7 examples of symptoms requiring head and neck cancer referral?

Answer 1

Stridor (high pitch wheezing) - emergency, airway obstruction
Persistent unexplained head and neck lumps (>3 weeks)
Ulceration or unexplained swelling of the oral mucosa persisting for > 3 weeks
All red or mixed red and white patches of the oral mucosa persisting >3 weeks
Persistent hoarseness lasting > 3 weeks (chest x ray)
Dysphagia/ odynophagia for > 3 weeks
Persistent pain in throat > 3 weeks

Question 2

What are the stages of investigation and diagnosis after cancer referral?

Answer 2

New patient assessment in OMFS
Biopsy
CT scan (extent of tumour)
Lymph node biopsy
CT scan (metastasis?)
Baseline medical testing (performance score helps plan treatment)
Stage and grade cancer

Question 3

How long should it take between referral by GDP and start of definitive cancer treatment?

Answer 3

62 days

Question 4

What is included in a pre-treatment assessment?

Answer 4

Full exam
Radiographs (OPT and periapicals)

Identify existing disease/ potential risk of disease
Oral hygiene and diet advice
Denture advice - dont wear during treatment
Fluoride application
PMPR to stabilise perio condition
Remove active disease (definitive restorations)
Impressions (so can construction a soft splint/ fluoride tray for during treatment)
Remove fixed ortho

Question 5

When should extractions be carried out in relation to strarting cancer treatment?

Answer 5

At least 10 days before

Question 6

What are some side effects of cancer treatment?

Answer 6

Altered anatomy
Radiation damage
Oral mucositis
Candida infections
Traumatic ulcer (from dry mouth)
Reactive Herpes Simplex

Question 7

What are some management options for oral mucositis?

Answer 7

Gelclair
Benzydamine hydrochloride (numbing, alcohol can sting at first)
Cryotherapy (cooling)
Aloe vera? Manuka honey? Tea tree oil mouthwash?
Low level laser therapy for children receiving radiotherapy
Morphine and opioids as analgesics
Remove sharp edges on teeth
2% lidocaine mouthwash prior to eating

Question 8

Name some preventative antifungals prescribed by cancer team?

Answer 8

Chlorohexidine (mouthwash)
Miconazole (topical)
Fluconazole (systemic)

Nystatin- does not appear to be effective

Question 9

What is the management of traumatic ulcer action during cancer treatment?

Answer 9

Soft splint

Question 10

What is the prodromal period of herpes simplex virus?

Answer 10

Pain prior to ulceration (can sometimes feel in the branch of affected nerve) - this needs urgent treatment with systemic antivirals

Question 11

What are some common dental problems following cancer treatment?

Answer 11

Xerostomia
Trismus
Erosion
Caries
Periodontal disease
ORN

Question 12

Describe the change in saliva after cancer treatment?

Answer 12

Reduced salivary flow (50-60% in first week)
Becomes viscous and acidic (no clearing effect)
Recovery over years/ not at all

Question 13

What is Sialadenitis?

Answer 13

Inflammation of salivary glands (overcompensating in xerostomia)

Question 14

What causes Xerostomia after cancer treatment?

Answer 14

Ionising radiation causing damage to salivary tissue in the radiotherapy fields

Question 15

Describe the management of xerostomia?

Answer 15

Oral gel/ lubricants - eg Vaseline to protect lips
Pilocarpine HCl (not popular with patients) - enhance salivary production, 5mg 3x daily, effect declines after cessation of treatment
Stimulation (chewing gum)

Saliva replacement- frequent sips of water, gels have longer duration of benefit

Question 16

Which saliva replacement should be limited to the use in edentulous patients?

Answer 16

Glandosane - very acidic

Question 17

What are some causes of trismus post cancer treatment?

Answer 17

Post-surgical inflammation
Fibrosis of tissues (scarring)
Tumour recurrence

Question 18

What are some causes of post cancer treatment caries?

Answer 18

Indirect effect of non-surgical treatment- reduced/ altered saliva, high protein and calorie diet.

Question 19

What is ORN?

Answer 19

An area of exposed bone of at least 3 months duration in an irradiated site and not due to tumour recurrence.

Question 20

What steps are involved in the prevention of ORN?

Answer 20

Remove teeth of doubtful prognosis in radiotherapy field
Extractions 10 days before radiotherapy
Encourage healing with primary closure

Consider RCT/ crown amputation.

Pentoxyfylline (antioxidant agent- encourages blood vessels and decreases inflammation, 800mg/ day) and Vitamin E (1000 u/ day)

Question 21

Which patients are most at risk of ORN?

Answer 21

Total radiation >60Gy
Dose fraction was large with high number of fractions
Local trauma (especially in mandible as less vascular), uncontrolled perio, ill-fitting pros
Immunodeficient
Malnourished

Question 22

What is oral mucositis?

Answer 22

A severely debilitating condition characterised by erythema, oedema and ulceration of oral mucosa. Complication of radiotherapy to head and neck/ chemo

Question 23

When does mucositis symptoms begin after starting treatment?

Answer 23

1-2 weeks after treatment starts

Question 24

How long do mucositis symptoms last after treatment is complete?

Answer 24

6 weeks after completing treatment

Question 25

Why is risk of erosion increased following cancer treatment?

Answer 25

Low saliva pH, use of glandosane, drinking acidic drinks due to dry mouth

Question 26

What is radiation induced caries?

Answer 26

An indirect effect of non surgical treatment (chemo and radiotherapy)
As a result of reduced salivary flow/ altered function in combination with high protein and calorie diet
May affect incisal edges/ cervical margins

Question 27

What is involved in the reconstruction of a pt with ORN?

Answer 27

Obturator - dont leave out at night for the first 6 months, daily cleaning