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Dental Management of a Complex Patient > Oral Cancer > Flashcards

Oral Cancer Flashcards

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1
Q

What therapies with be utilized?
(3)

A

 Surgery
 Radiation
 Chemotherapy

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2
Q

Surgery
(4)

A

 Biopsy/Radical Neck Dissection
 Mandibular resection/graft
 Maxillectomy/oro- antral communication
 Glossectomy

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3
Q

How will it be delivered?
(2)

A

 Fixed Beam Radiation
 Intensity Modulated Radiation Therapy (IMRT)

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4
Q

Fixed Beam Radiation Therapy

A

All the tissue between the portals receives the same
dose

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5
Q

Intensity Modulated Radiation
Therapy
(3)

A

 A constantly moving beam administers different
amounts of radiation to the tissues
 The tumor receives the highest amount of
radiation.
 Minimal amounts of radiation are applied to vital
structures. (spinal cord, salivary glands)

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6
Q

Fractionation
(2)

A

 The application of radiation therapy in smaller
consecutive doses to minimize the lethal effects and limit
the side effects of the therapy.
 The dose is usually administered 5 times a week for 5 to
7 consecutive weeks.

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7
Q

5 Rs of Fractionation

A

 Repair
 Redistribution
 Repopulation
 Reoxygenation
 Radiosensitivity

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8
Q

Repair

A

 Radiation causes sub-lethal damage to normal and
malignant cells

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9
Q

 The repair pathways are often blocked or impaired in the

A

malignant cells resulting in cell death.

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10
Q

Redistribution
 DNA is more sensitive during certain stages of cell
replication.
 Most stable

A

(G2 and M phases)
(S phase)

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11
Q

 Fractionation provides multiple opportunities to affect
the cells when they are in the — phase.

A

sensitive

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12
Q

Repopulation
 Rapid repopulation of the malignant cells can occur
approximately — weeks after the initial radiation dose.
 Fractionation over – weeks prevents the rapid
repopulation of these cells

A

4-5
5-7

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13
Q

Reoxygenation
 Tumor cells are more resistant to radiation in —
environments
 Fractionation increases the odds that that tumor cells will
be in a — field during radiation
 The outermost tumor cells are destroyed exposing the…

A

hypoxic
nutrient
“hypoxic” inner layers of tumor cells

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14
Q

Radiosensitivity
 Involves the recognition of certain proteins, receptors
and kinases that may make cells less —- to
radiation
 Recognizing the presence of the components may help
predict the success of — in certain cases

A

sensitive
radiation therapy

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15
Q

Treatment Prior To Radiation
 Complete —
 Establish a —
 Previous —
 — suspect teeth in the radiation field
 Complete —
 Fabricate —

A

dental/perio evaluation
baseline
dental experience/frequency
Extract
prophylaxis and restorative tx
custom fluoride trays

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16
Q

Indications for Extractions Prior to
Radiation Therapy
(4)

A

 Non-restorable caries or high caries rate
 Periodontal pocketing > 5mm
 Furcation involvement
 Impacted teeth

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17
Q

Radiation Complications
(6)

A

 Xerostomia/Dental Caries
 Mucositis
 Osteoradionecrosis
 Trismus
 Hypogeusia/Dysgeusia
 Nutritional Deficiency

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18
Q

Saliva production
 Parotid –
 Submandibular –
 Sublingual –

A

serous
serous/mucous
primarily mucous

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19
Q

Xerostomia
 Hypofunction can occur when exposed radiation
doses as low as

A

25 Gy

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20
Q

— glands are more sensitive to radiation than
— glands

A

Serous
mucous

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21
Q

The rapid formation and
progression of dental caries is
mainly attributed to the

A

reduced
quality and quantity of the saliva.

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22
Q

Treatments for Xerostomia
(6)

A

WATER
Salivary Substitutes
Minimize carbohydrate and alcohol intake
Alcohol Free Mouth Rinses
Listerine
Sugar-Free, Not Sugarless

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23
Q

Alcohol Free Mouth Rinses
(2)

A

Peridex: chlorhexidine gluconate 0.12%
Crest Pro Health: cetylpyridinium chloride (CPC) 0.07%

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24
Q

Listerine?

A

Menthol, Eucalyptol
Methyl salicylate, Thymol

not
sodium fluoride 0.02%

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25
Xylitol  Sugar alcohol originally derived from ---  Commercially produced from ---  --- causing bacteria are unable to metabolize it
birch trees corn cobs (xylan) Caries
26
Xylitol  Ingesting --- daily can decreased caries  --- of use more important than quantity  Available as a (5)
6-8 grams Frequency packaged sweetener or in gums, mints, candies and oral rinses
27
How much per piece  Ice Breakers Ice Cubes – --/piece  Epic gum – --/piece  Epic mints – --/piece  Spry gum – --/piece  Xylimelts – --/piece
1g 1g 0.5 0.72 0.5g
28
Trident with Xylitol  ONLY --/piece  -- is the primary sweetener
0.17g Sorbitol
29
Issues with Xylitol  Can cause --- issues with some pts  Primarily when over --g ingested/day  Extremely --- to dogs
gastric 50g toxic
30
Sialogogues (2)
 Cholinergic agonist  Pilocarpine hydrochloride
31
Pilocarpine hydrochloride  ---mg tid  Max dose ---/day  May take -- weeks to see results
5-10 30mg 12
32
Fluoride Therapy  (4)  -- minutes/day  No food or drink for -- minutes  Best results when used prior to --
Rinse, brush, floss, fluoride trays 10 30 bedtime
33
Types of Fluoride (2)
 1.1% Sodium fluoride  0.4% Stannous fluoride
34
 0.4% Stannous fluoride  Better for ---  May
root caries stain the teeth brown
35
Mucositis
 Oral mucosa exposed to radiation becomes edematous, erythematous, and ulcerated
36
Mucositis  The condition can be extremely painful and cause issues with (2)
mastication and swallowing.
37
Mucositis  The signs and symptoms often arise after the ...
second week of therapy and may last a few weeks after the completion of treatment
38
Mucositis  Mild Pain Tx (4)
 Maintain oral hygiene  Use bland oral rinses - Baking soda/water, with/without salt  Use topical oral pain management  Mild analgesics (OTC)
39
 Use topical oral pain management (2)
 Caphosol  Magic Mouthwash
40
 Magic Mouthwash (2)
 Viscous lidocaine, Maalox, diphenhydramine  With/without nystatin
41
Magic Mouthwash makeup (4)
 Diphenhydramine 12.5mg/5mL 1 part (120mL)  Maalox 1 part (120mL)  Viscous Lidocaine 2% 1 part (120mL)  Nystatin Susp. 100,000 U/mL 1 part (120mL)  (Optional)
42
Mucositis Moderate pain (2)
 Addition of moderate strength opioids - Hydrocodone and oxycodone  Altered diet (soft)
43
Mucositis Severe pain tx (2)
 Addition of strong opioids - Oxycodone, morphine, oxymorphone  May need nasogastric or PEG tube
44
Osteoradionecrosis (ORN)
 Radiation results in vascular changes in the bone limiting the blood supply and the ability to heal after trauma or extractions
45
Osteoradionecrosis (ORN)  Associated with radiation doses above -- Gy  More common with the --
50 mandible
46
Osteoradionecrosis  Prevention is the key (3)
 Extraction of questionable teeth prior to radiation therapy  Complete root canal therapy if it is an option  If a post radiation TE is necessary, hyperbaric oxygen (HBO) therapy may be necessary
47
 If a post radiation TE is necessary, hyperbaric oxygen (HBO) therapy may be necessary (2)
 20 dives prior to TE/10 dives after TE  HBO is only needed once in a lifetime, not for each procedure
48
If ONJ is present: Stage 0 (2)
 No exposed bone, but pt. is symptomatic  Radiographic changes may be present
49
If ONJ is present: Stage 0  Treatment: (2)
 Periodic monitoring  Systemic management (antibiotics and pain meds)
50
If ONJ is present: Stage 1: (1)
 Bone is exposed, asymptomatic, no infection present
51
If ONJ is present: Stage 1:  Treatment: (5)
 Monitor closely for 8 weeks  If no changes, continue to monitor quarterly  Meticulous home care  Antimicrobial oral rinses  Remove loose sequestra if present
52
If ONJ is present: Stage 2: (2)
 Exposed bone with associated pain  Purulent exudate may be present
53
If ONJ is present: Stage 2: Treatment: (4)
 Same treatment as Stage 1  Addition of systemic antibiotics(Penicillin, Clindamycin, Doxycycline)  Superficial debridement to relieve soft tissue irritation  Possible hyperbaric oxygen therapy?
54
If ONJ is present: Stage 3:  Exposed bone with pain and one of the following: (3)
 Pathologic fracture  Extra-oral fistula  Necrotic lesion extends to the inferior border
55
If ONJ is present: Stage 3: Treatment: (3)
 Surgical debridement or resection  Antibiotic therapy  Possible hyperbaric oxygen?
56
Trismus  Primarily occurs when the --- region is irradiated  Usually noticed near the completion of --- therapy
pterygoid radiation
57
Trismus  Radiation may cause
spasms or fibrosis of the TMJ and muscles of mastication resulting in a limited range of motion
58
 The effects of trismus usually are not permanent, but may last for
several months after the completion of radiation therapy
59
Trismus Treatment: (3)
 Warm, moist heat  Massage  Physical therapy
60
 Physical therapy (3)
 Tongue depressors  TheraBite  Dynasplint
61
Hypogeusia/Dysgeusia  Permanent taste loss may occur with a cumulative dose of --- Gy.  At lesser dosages,  (2) may also contribute to the alterations in taste.
60 the taste may return. Xerostomia and mucositis
62
Hypogeusia/Dysgeusia  May or may not improve depending on the (2) of radiation
site and amount
63
Hypogeusia/Dysgeusia  Treatment: (2)
 Water/salivary substitutes  Constantly monitor for bacterial or fungal infections
64
Oral Radiation and Removable Appliances (5)
 Wait 6-9 months after the completion of radiation to fabricate dentures and RPDs  Educate the patient  Limit the amount of use  Place silicone liners (GC Reline)  Set a 3-month recall
65
Chemotherapy  Definition
 a form of cancer treatment that involves taking one or more of a type of drug that interferes with the DNA (genes) of fast-growing cells. These drugs are further subdivided into specific classes such as alkylating agents, antimetabolites, anthracyclines, and topoisomerase inhibitors.
66
How is it administered? (2)
 IV infusion - Port-A-Cath  Pill
67
Effects of Chemotherapy (5)
 Immune system suppression  Mucositis  Xerostomia  Bleeding  Hypogeusia/Dysgeusia
68
Dental Tx Prior to Tx (4)
 Complete dental examination  Prophylaxis /SRP  Extraction of teeth with non-restorable caries, poor periodontal prognosis  Complete any needed endodontic therapy
69
Dental Tx During Chemo (3)
 Avoid any dental treatment if possible during chemotherapy  Pts usually reach their “nadir” (lowest blood counts) 7-14 days after a course of chemo  If treatment is needed, blood counts are usually best just prior to their next course of chemo
70
Oral Surgery During Chemo  Any invasive procedures (i.e., extractions) get recent blood counts  Absolute Neutrophil Count (ANC) -  Platelet count -
>1000/mm3 >75,000/mm3
71
Antibiotic Prophylaxis Considerations  Presence of a ---  Neutrophils between ---
Port-A-Cath 1,000 and 2,000/mm3
72
Immunosuppression  Prevention is key (3)
 Brush and floss  Chlorhexidine rinse (non-alcohol)  Neutral rinse (baking soda and water)
73
Immunosuppression Treat opportunistic infections  Fungal (Candida) (2)  Viral (Herpetic) (2)
 Nystatin, Fluconazole  Acyclovir, Famciclovir
74
Mucositis Mild Pain (4)
 Maintain oral hygiene  Use bland oral rinses  Baking soda/water - With/without salt  Use topical oral pain management - Caphosol - Magic Mouthwash -- Viscous lidocaine, Maalox, diphenhydramine --- With/without nystatin  Mild analgesics (OTC)
75
Mucositis Moderate pain (2)
 Addition of moderate strength opioids - Hydrocodone and oxycodone  Altered diet (soft)
76
Mucositis Severe pain (2)
 Addition of strong opioids - Oxycodone, morphine, oxymorphone  May need nasogastric or PEG tube
77
Xerostomia  Xerostomia usually resolves within ...  Xerostomia can provide the ideal environment of ...
a few months after treatment is completed opportunistic infections
78
Xerostomia  Treatments (5)
 Water, Water, Water  Salivary substitutes  Sugar-free or xylitol gum  Monitor carbohydrate intake  Sialogogues (pilocarpine)
79
Bleeding (3)
 Chemotherapy can drastically decrease the platelet count  Avoid invasive dental procedures if at all possible  Gentle brushing and flossing
80
Hypogeusia/Dysgeusia  The effects are usually temporary.  Effects may be related to other complications: (3)
 Mucositis  Xerostomia  Bacteria or fungal infections
81
Bone Marrow Transplant  Chemotherapy is used to ...  --- are then transplanted to repopulate the bone marrow
destroy the bone marrow Hematopoietic stem cells
82
Types of Transplants (3)
 Autologous  Allogeneic  Syngeneic
83
 Autologous
 The pts own bone marrow or stem cells are removed and preserved for transplantation.
84
 Allogeneic
 Bone marrow or stem cells from a HLA (Human leukocyte antigen) matched individual are used for transplantation.
85
 Syngeneic
 Bone marrow or stem cells from an identical twin are used for transplantation.
86
Dental Treatment  Treatment prior to treatment is similar to that of other chemotherapy patients  After BMT:  0-100 days:  100-365 days:  After 365 days:
 Oral hygiene, emergency, and supportive care  Oral hygiene, emergency, and xerostomia management  Routine dental care
87
Graft-Versus-Host-Disease  Occurs primarily with --- transplants  Treatment involves severe ---
allogeneic immunosuppression
88
Graft-Versus-Host-Disease Oral manifestations: (4)
 Mucositis  Infections (bacterial, fungal, viral)  Mucosal atrophy  Xerostomia
89
Antiresorptive Medications (2) Antiangiogenic Medications
 Bisphosphonates  RANK Ligand Inhibitors
90
Bisphosphonates  Initially used for the treatment of (3)  More recently, they have been used as an adjunctive treatment of ---  Decrease --- activity
osteoporosis, Paget’s disease, and osteogenesis imperfecta cancer osteoclastic
91
Bisphosphonates (Non-Nitrogen)  Oral only  Etidronate – (1)  Clodronate – (3)
Didronel Bonefos, Clasteon, Loron
92
Bisphosphonates (Non-Nitrogen)  Primarily used for the treatment of ---  --- potency  Prevents osteoclast proliferation by
Paget’s disease Low inhibiting ATP (adenine triphosphate) dependent enzymes
93
Bisphosphonate (Nitrogen Containing)  Oral or IV  Mechanism of action (2)
 Prevents binding of essential proteins to the cell membrane leading to apoptosis  Prevents adhesion of the osteoclasts to the hydroxyapatite crystals by altering the cell cytoskeleton
94
Oral Nitrogen Containing Bisphosphonates Approved for use in the treatment of (2)
Paget’s disease and osteoporosis
95
Approved for use in the treatment of Paget’s disease and osteoporosis (3)
 Alendronate (Fosamax)  Risedronate (Actonel)  Ibandronate (Boniva)
96
IV Nitrogen Containing Bisphosphonates  Used in the treatment of osteoporosis (1)  Used in the treatment of bone metastases (2)
 Zolendronate (Reclast) – 5mg/year  Zolendronate (Zometa) – 4mg/3 weeks  Pamidronate (Aredia) – 90mg/3 weeks
97
Antiresorptive Agents  Denosumab (Monoclonal antibody)  Osteoporosis –  Bone Metastases –
Prolia – 60mg/6 months Xgeva – 120mg/4 week
98
Antiresorptive Agents Mechanism of action (2)
 Tumor cell promote the release of RANK Ligand from the osteoblast within turn promote the production of osteoclasts  Denosumab binds to the RANK Ligand an prevents osteoclast proliferation
99
ANTIANGIOGENIC MEDICATIONS  Tyrosine kinase inhibitor (2)
 Sunitinib (Sutent)  Sorafenib (Nexavar)
100
ANTIANGIOGENIC MEDICATIONS  Humanized monoclonal antibody (1)
 Bevacizumab (Avastin)
101
ANTIANGIOGENIC MEDICATIONS Mechanism of action
 Recognizes and blocks vascular endothelial growth factor (VEGF), a protein necessary for angiogenesis
102
ANTIANGIOGENIC MEDICATIONS Used in the treatment of (3)
gastrointestinal tumors, renal cell carcinomas, and neuroendocrine tumors
103
Drug Related Risks Potency (5)
 Oral non-nitrogen containing bisphosphonates  Oral nitrogen containing bisphosphonates (0.4% to 4%)  IV bisphosphonates (4% to 12%)  XGEVA  IV bisphosphonates plus an antiangiogenic medication
104
 IV bisphosphonates (4% to 12%) (2)
 Aredia  Zometa
105
Drug Related Risks Duration  Increased risk after -- months
18
106
Local Risk Factors  Surgery/trauma (3)
 Dental extractions  Osseous surgery (periodontal, apicoectomy)  Implant placement
107
Local Risk Factors  Anatomy (3)
 Mandible vs. Maxilla (2:1 ratio)  Tori, exostoses  Mylohyoid ridge
108
Demographic Factors  Age:  Race:
 9% increased risk of MRONJ with each passing decade  Caucasian
109
Systemic Factors Primary cancer diagnosis  highest risk  2nd highest risk  Concurrent (2) diagnosis
Multiple myeloma Breast cancer osteopenia or osteoporosis
110
Prior to starting therapy (3)
 Extract non-restorable and questionable teeth along with alveoplasty, tori removal, etc.  Complete necessary periodontal therapy  Complete any endodontic and restorative work
111
Wearing Removable Appliances (4)
 Limit the amount of use  Place silicone liners if necessary (GC reline)  Educate the patient  3-month recall intervals
112
While on Antiresorptive/Antiangiogenic Agent Therapy If any surgery or invasive procedures are necessary,
a 3 month “drug holiday” should be completed prior to therapy and use of the antiresorptive/antiangiogenic agents should not be started again until after osseous healing has occurred
113
 --% of the bisphosphonate is excreted by the kidneys within hours of ingestion or infusion  Remaining --% deposited in the skeleton
50 50
114
Bisphosphonates and the Resting Bones Osteocytes (4)
 Make up 85% of resting bone  Have a long life span  Have a low affinity for bisphosphonates  Bisphosphonates loosely bind to the surface and are removed within days
115
Bisphosphonates and the Resting Bones Osteoclasts (4)
 Make up 2-4% of resting bone  Have a life span of 2 weeks  8x the affinity for bisphosphonates  Upon death of osteoclasts, bisphosphonates are reabsorbed by the skeleton or excreted by the kidneys
116
Bisphosphonates and the Resting Bones Osteoblasts (4)
 Make up 10-12% of resting bone  Have a life span of 2 months  4x the affinity for bisphosphonates  Bisphosphonates are incorporated into the bone instead of being released
117
 Bisphosphonates are primarily distributed in areas of...  Stem cell development into --- minimized  Increase in ... Therefore....
active bone remodeling osteoclasts osteoclast apoptosis
118
 In remodeling areas, an increase in bisphosphonates disrupts the
synergistic makeup of the basic multicellular unit (BMU)  Osteoclasts, osteoblasts, osteocytes, and local vascular supply
119
The Alternative Vacation Based on the Physiology 2 month presurgical holiday  --- are the only reservoir for the bisphosphonates  Allows for 4 life cycles  Minimal remaining ---
Osteoclasts bisphosphonate
120
The Alternative Vacation Based on the Physiology Average 4 month postsurgical holiday (ideally 8 months)  Necessary time needed for bones to return to “---” state  No needed alteration in --- therapy if planned correctly
resting bisphosphonate
121
Denosumab and the Body  Osteoclasts decreased by --% in 3 days  ½ life of denosumab is -- days - --% degraded in 2 months  Denosumab only affects the --- - Not incorporated in the bone
85 25 80 RANK ligand
122
The Denosumab Vacation  2 month presurgical holiday - --% degradation  Average 4 month postsurgical holiday (ideally 8 months) - No needed alteration in --- therapy if planned correctly
80 denosumab
123
CTX testing  Measures serum levels of --- - Metabolite of bone matrix degradation  Marker for --- activity  Normal is ---  -- or less is at risk for MRONJ
C-terminal telopeptide osteoclastic >300 (average 400-550) 150
124
Diagnosis of MRONJ 3 things necessary (3)
 Current or previous antiresorptive medication therapy  Exposed necrotic bone for longer than 8 weeks  No history of radiation to the jaws
125
If MRONJ is present: Stage 0 (2)  Treatment (2)
 No exposed bone, but pt. is symptomatic  Radiographic changes may be present  Periodic monitoring  Systemic management (antibiotics and pain meds
126
If MRONJ is present: Stage 1: (1)  Treatment: (3)
 Bone is exposed, asymptomatic, no infection present  Monitor closely for the first 8 weeks - If no change, monitor every 3 months  Meticulous home care  Antimicrobial oral rinses - Peridex
127
If MRONJ is present: Stage 2: (2)  Treatment: (3)
 Exposed bone with associated pain and erythema  Purulent exudate may be present  Same treatment as Stage 1 - Addition of systemic antibiotics(Penicillin, Clindamycin, Doxycycline)  Pain Management  Superficial debridement to relieve soft tissue irritation
128
If MRONJ is present: Stage 3:  Exposed bone with pain and one of the following: (3)  Treatment: (3)
 Pathologic fracture  Extra-oral fistula  Necrotic lesion extends to the inferior border  Surgical debridement or resection  Antibiotic therapy  Possible hyperbaric oxygen?
129
Another Alternative Forteo (4)
 Recombinant parathyroid hormone teriparatide  Binds to osteoblasts and promotes proliferation  Daily injections for up to 2 years - > 2 years of use may lead to osteogenic sarcoma  Expensive ($560/month)
130
Forteo  Resolve --- in osteoporotic patients  May be used to treat ---  Contraindicated in pts. with...
MRONJ osteoporosis bone metastases or previous radiation (risk of osteogenic sarcoma)

Dental Management of a Complex Patient (13 decks)

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