Oncology Flashcards
What is required of a pre-cancer treatment assessment to make someone dentally fit?
Identify all existing oral disease and potential risk of disease
Remove infection and potential infection
Prepare pt for possible side fx
Develop plan for maintaining oral hygiene
Plan post treatment prosthetic oral rehab
What treatment should I provide during pre cancer treatment?
Detailed OHI
Fluoride delivery
Diet advice that coincides with dietician - focus on comfort during treatment
PMPR to stabilise perio and consider chlorhexadine
Restore all carious teeth
Remove any trauma - sharp edges of dentures for e.g.
Impressions to construct fluoride trays or soft splints
Denture hygiene
XLA teeth at least 10 days before cancer treatment begins
Consider antibiotic prophylaxis if low neutrophils - liaise with physician
What are some possible side FX of cancer treatment?
Mucositis - due to high turnover of oral epithelium
HSV reactivation due to immunosuppression (aciclovir)
Candida infection - opportunistic
What is the gold standard narrow spectrum antibiotic used in dentistry now?
Phenoxymethylpenicillin
If a patient was to develop a dental infection mid chemotherapy, what concerns would there be?
Platelet count - bleeding risk
Further Infection
Get a full blood count and coagulation screening
What is mucositis?
How manage?
Chemotherapy / radiotherapy targets oral epithelium
Severe pain which can inhibit eating and OH measures
Treat with:
gelclair
Aloe Vera
Soluble aspirin
Morphine or opioids as analgesic
Rinse with saline water
Lidocaine mouthwash prior to eating
Why might candida develop in an oncology patient?
How treat?
Candida is opportunistic, cancer patients are immuncompromised
Chlorhexadine
Miconazole topical
Fluconazole systemic
How might ulceration occur to oncology patient? How treat?
Sensitive oral mucosa damaged by sharp or rubbing area
Treat with soft splint from impressions
Why might HSV reappear in oncology patient? How manage?
Immunosuppression patient allows re activation of latent virus
Has a prodromal period of pain prior to ulceration
Needs treated immediately with systemic antivirals such as aciclovir
Why might a cancer patient have xerostomia?
How treat?
Cancer treatment reduces salivary flor 50-60% in first week, leading to dry mouth due to damage to salivary glands
Saliva becomes more viscous and also more acidic
Treat with fluoride supplementation due to increased caries risk
Also treat with oral gel or lubricants on soft tissues e.g. Vaseline
Pilocarpine HCL can enhance salivary production if some functioning gland remains - 5mg 3 x daily
Why might an oncology patient present with gross caries?
Radiation-induced caries which is rapidly developing
Coupled with xerostomia and high protein high calorie diet for cancer patients
What is ORN? How does it occur?
Osteoradionecrosis
It is exposed necrotising bone exposed by radiation therapy, resulting in need for XLA of teeth in radiotherapy field
When might a cancer patient be discharged to a GDP from hospital?
Side fx settled
Carious food intake stopped
Good OH reestablished
Fluoride is tolerated comfortably
How is someone made dentally fit?
Detailed oral hygiene
Topical fluoride application
GC tooth mousse
Diet advice with dietician
PMPR to stabilise perio
Consider chlorhexadine mouthwash
Definitive restorations
Removal of any trauma
- sharp edges
Removal of any source of infection / poor prognosis teeth
- no less than 10 days before starting tx
Impressions for fluoride trays
AB prophylaxis - low neutrophils?
Smoking and alcohol advice
Dentist role during cancer therapy?
Hygienist support
Oral and denture hygiene
Chlorhexadine MW if brushing not possible
Diet advice
Fluoride delivery all the time
- topical
- trays etc
Relief of symptoms
- xerostomia
- mucositis
- soft splints to prevent trauma
Emergency dental tx
- liaise with cancer team if pt has infection
Aetiology mucositis?
1-2 weeks after tx starts and lasts around 6 weeks after treatment is complete
How manage mucositis?
Neutral, supersaturated calcium phosphate mouth rinse (Caphosol)
Sodium hyaluronate gel (gelclair)
Mucoadhesive oral rinse (mugard)
Benzydamine mouthwash (difflam)
Lidocaine ointment / mouth rinse 2%
Remove sharp edges / poorly fitting dentures
Soft splints
Ice (oral cooling)
How can mucositis be assessed?
Voice
Swallowing
Lips
Tongue
Saliva
Mucous membrane
What viral issues may arise during cancer tx?
Reactivation of HSV
- prodromal period!!!!
- pain prior to ulceration and must recieve urgent treatment with systemic antivirals
Cancer tx effects on saliva?
50-60% reduction in salivary flow
- further 20% in next 5-6 weeks
Saliva becomes more viscous and acidic!
- damage to dentition
Recovery over years or not at all
Why is saliva reduced in cancer pts? How tx?
Ionising radiation to the salivary tissue in the radiotherapy field
- fluoride supplements due to caries risk
- oral gel / petroleum jelly to coat soft tissues
- pilocarpine
- Sugar free chewing gum / regular small sips
- biotene saliva replacements
How can trismus occur post cancer tx?
Post surgery inflammation
Fibrosis of tissue due to tx
(Tumour recurrence causing limited opening must be excluded)
Characteristics of post cancer tx trismus?
Tx?
Following radiotherapy:
- occur rapidly in first 9 months
- tends to be progressive and may be irreversible
Physical therapy
- passive and active stretching
- therabite
- trismus screw
- stacked tongue depressors
What is an ORN diagnosis?
Area of exposed bone
- at least 3 months
- in radiotherapy field
- not due to tumour recurrenc
