Oncology and Palliative Care Flashcards by Rodwan Halimi

How is decision made for treatment of cancer in cancer patients?

Based on histopathological examination.

Intention is to remove the cancer as much as possible without compromising the anatomy too severely.

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How is pathology removed from patient?

Margins of the lesion are removed .

Sometimes neck dissection is needed

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How is anatomy reconstructed following surgical resection?

Soft-tissue flaps

Bone-harvesting

Implants intraorally and extraorally

Prosthetics: Obturator or facial prostheses

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What is an obturator?

A prosthesis used to fill in the defect created by oral surgery and has a similar shape to the structures being replaced.

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What are the oral complications post surgery that can arise?

Loss of integrily of the oral cavity

Loss of teeth

Changes to soft tissues: Floor of the mouth

Pain

Function

Aesthetics/self esteem

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What is chemotherapy?

Treatment using cytotoxic drugs

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What does chemotherapy do?

Kills cells during the process of mitosis

Damages genetic material during DNA replication or at the point of cell division

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How is chemotherapy delivered?

Can be delivered intravenously or orally.

Usually a combination of medications is used with different actions

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What is the role of chemotherapy?

Shrink tumour before surgery/radiotherapy

To try and prevent recurrence after other therapies

Primary treatment for some cancers (lymphoma) can be used for head and neck SCCs

Treat metastatic cancer

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What are the side effects of chemotherapy?

Mucositis

Risk of infection

Thrombocytopaenia

Neutropaenia

Bone marrow suppression

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What is radiotherapy?

Use of high energy electromagnetic radiation or particles to disrupt integrity of malignant cells.

Therapeutic application aimed at inducing focal damage to DNA.

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How can radiotherapy be used in the treatment of cancer?

As a primary therapy for cancer treatment

To shrink a tumour prior to surgery

After surgery to treat lymph nodes

To destroy remaining tumour cells

Palliative therapy

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What is IMRT?

Using several sources of radiation around the head/body to irradiate the tumour by delivering an adequate dose without damaging the intermediate structures in the process.

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What are the oral complications of radiotherapy?

Fibrosis of tissues

Capillary changes and decreased vascularity

Increased tissue fragility

Reduced healing ability

Susceptibility to infection

Mucositis

Telangiectasia

Trismus

Xerostomia

Saliva changes

Oral discomfort

Taste alterations

Dentine hypersensitivity (softening of dentine)

Loss of periodontal attachment

Radiation caries (very unique presentation of caries that is circumferential, browning of teeth caries, yellowing of teeth)

Risk of ORN

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How are systemic cancer therapy patients typically treated?

Multidisciplinary team involved and special needs dentists + general dentists are important members of this team.

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What are the key roles of dentists in treating patients with systemic cancer therapy?

Training other health care professionals

Management of oral problems

Advocating for patient’s needs

Contributing to maintaining wellbeing of the patient

What should dentists do prior to cancer therapy?

Medical history

Liase with hospital dental clinic

Oral exam + radiographs

Dental treatment: Removal of calculus + plaque, removal of hopeless teeth, stabilise oral condition where possible.

Oral hygiene advice

What should dentists do during cancer therapy?

Maintain good oral hygiene

Daily topical fluoride application (consider custom trays)

Mouthrinses: saline, bicarb, magic mouthwash (bicarbonate and food colouring), sage tea

Jaw exercises to reduce trismus

Assist with management of oral side effects

What is mucositis?

Acute erythematous and ulcerative lesions of GI tract

Inflammation and bleeding of oral soft tissues

Pain

How is mucositis treated?

Lignocaine (topical)

Cannot prevent

Mouthwashes

How is mucositis graded?

Based on changes:

Grade 0: No changes

Grade 1: Soreness/erythema

Grade 2: Ulceration (solid foods

Grade 3: Liquid diet

Grade 4: No alimentation

What are the potential complications of oral mucositis?

Risk of septicaemia from oral cavity

Haemorrhage due to low platelets.

How is oral mucositis reduced/treated?

Pain management topical and systemic

Comfort, nutrition, hydration

Prophylaxis (prevent viral fungal and bacterial infections)

Treat dry mouth

Remove dental prostheses

Soft diet

Removal of oral secretions/debris

Haemorrhage control

Improved oral hygiene

Anti-fungal medications may be required

What are mouth swabs?

Swabs used to remove debris from tongue/soft tissues

How can oral cavity be decontaminated when a patient has mucositis?

Anti-fungal medications may be required Hydrogen peroxide not advisable Avoid alcohol based mouthwashes (pain) Avoid juices (destroys oral mucosa and increases risk of infection and caries)

What should be avoided when decontaminating the oral cavity when there is mucositis?

Hydrogen peroxide not advisable Avoid alcohol based mouthwashes (pain) Avoid juices (destroys oral mucosa and increases risk of infection and caries)

How can magic mouthwash be made?

1 tsp salt and 1 tsp bicarb and 150mL warm water

Why is saline used in magic mouthwash?

Mucolytic and antibacterial

Why is bicarb used in magic mouthwash?

Mucolytic and reduces acidity, has antifungal activity, and is a mild analgesic

Why is chlorhex used?

Anti-biofilm agent Broad anti-microbial action Lowers presence of oral infection in presence of significant ulceration and patients inability to maintain oral care

How is pain managed in mucositis?

Oral cryotherapy Topical analgesic agents Anti-inflammatory mouthwashes (NSAID, weak topical anaesthetic and antimicrobial, reduces intensity and duration of mucosal damage, delays need for systemic pain management)

What are the functions of saliva?

Lubrication Digestion Mucosal repair Buffering capacity Remineralisation Anti-microbial

How can dry mouth be managed?

Water (spray, bottle, ice-chips) Saliva stimulation (Pilocarpine or sugarfree chewing gum) Salivary substitutes: Replace or supplement natural saliva, increases comfort, decreases infection risk, can be used as frequent as required, available in various formulations (mouthrinse, gel, spray, gum) Be careful of pH of the products GC dry mouth gel is pH 7 (biotene has pH4.2)

What oral hygiene products should be used for patietns with dry mouth?

High fluoride toothpaste (neutrafleur5000) Biotene products Recaldent/GC (Tooth mousse plus and tooth mousse) Lip care Avoid alcohol-based mouthwashes

What conditions besides cancer can require palliative care?

End stage HIV/AIDS Dementia End-stage motor conditions Acquired brain injury Elderly

What is palliative dentistry?

Management of patients with progressive far advanced disease where oral cavity has been compromised directly or indirectly by disease

How should palliative dentistry be done for palliative care patients?

Focus on immediate quality of life. Pain relief and comfort are the priority.

What are the most common causes of discomfort in palliative dentistry

Xerostomia Mucositis Dysphagia Ulceration Taste alteration halitosis Oral candidiasis Angular cheilitis Denture stomatitis Discomfort Poor-fitting dentures