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Dental Management of a Complex Patient > Oral Cancer > Flashcards

Oral Cancer Flashcards

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
Q

Xylitol
 Sugar alcohol originally derived from —
 Commercially produced from —
 — causing bacteria are unable to metabolize it

A

birch trees
corn cobs (xylan)
Caries

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26
Q

Xylitol
 Ingesting — daily can decreased caries
 — of use more important than quantity
 Available as a (5)

A

6-8 grams
Frequency
packaged sweetener or in gums, mints,
candies and oral rinses

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27
Q

How much per piece
 Ice Breakers Ice Cubes – –/piece
 Epic gum – –/piece
 Epic mints – –/piece
 Spry gum – –/piece
 Xylimelts – –/piece

A

1g
1g
0.5
0.72
0.5g

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28
Q

Trident with Xylitol
 ONLY –/piece
 – is the primary sweetener

A

0.17g
Sorbitol

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29
Q

Issues with Xylitol
 Can cause — issues with some pts
 Primarily when over –g ingested/day
 Extremely — to dogs

A

gastric
50g
toxic

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30
Q

Sialogogues
(2)

A

 Cholinergic agonist
 Pilocarpine hydrochloride

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31
Q

Pilocarpine hydrochloride
 —mg tid
 Max dose —/day
 May take – weeks to see results

A

5-10
30mg
12

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32
Q

Fluoride Therapy
 (4)
 – minutes/day
 No food or drink for – minutes
 Best results when used prior to –

A

Rinse, brush, floss, fluoride trays
10
30
bedtime

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33
Q

Types of Fluoride
(2)

A

 1.1% Sodium fluoride
 0.4% Stannous fluoride

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34
Q

 0.4% Stannous fluoride
 Better for —
 May

A

root caries
stain the teeth brown

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35
Q

Mucositis

A

 Oral mucosa exposed to radiation becomes
edematous, erythematous, and ulcerated

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36
Q

Mucositis
 The condition can be extremely painful and cause
issues with (2)

A

mastication and swallowing.

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37
Q

Mucositis
 The signs and symptoms often arise after the
…

A

second week of therapy and may last a few weeks
after the completion of treatment

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38
Q

Mucositis
 Mild Pain
Tx (4)

A

 Maintain oral hygiene
 Use bland oral rinses
- Baking soda/water, with/without salt
 Use topical oral pain management
 Mild analgesics (OTC)

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39
Q

 Use topical oral pain management
(2)

A

 Caphosol
 Magic Mouthwash

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40
Q

 Magic Mouthwash
(2)

A

 Viscous lidocaine, Maalox, diphenhydramine
 With/without nystatin

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41
Q

Magic Mouthwash
makeup
(4)

A

 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)

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42
Q

Mucositis
Moderate pain
(2)

A

 Addition of moderate strength opioids
- Hydrocodone and oxycodone
 Altered diet (soft)

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43
Q

Mucositis
Severe pain
tx (2)

A

 Addition of strong opioids
- Oxycodone, morphine, oxymorphone
 May need nasogastric or PEG tube

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44
Q

Osteoradionecrosis (ORN)

A

 Radiation results in vascular changes in the bone
limiting the blood supply and the ability to heal
after trauma or extractions

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45
Q

Osteoradionecrosis (ORN)
 Associated with radiation doses above – Gy
 More common with the –

A

50
mandible

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46
Q

Osteoradionecrosis
 Prevention is the key
(3)

A

 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

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47
Q

 If a post radiation TE is necessary, hyperbaric oxygen
(HBO) therapy may be necessary
(2)

A

 20 dives prior to TE/10 dives after TE
 HBO is only needed once in a lifetime, not for each
procedure

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48
Q

If ONJ is present:
Stage 0
(2)

A

 No exposed bone, but pt. is symptomatic
 Radiographic changes may be present

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49
Q

If ONJ is present:
Stage 0
 Treatment:
(2)

A

 Periodic monitoring
 Systemic management (antibiotics and pain meds)

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50
Q

If ONJ is present:
Stage 1:
(1)

A

 Bone is exposed, asymptomatic, no infection present

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51
Q

If ONJ is present:
Stage 1:
 Treatment:
(5)

A

 Monitor closely for 8 weeks
 If no changes, continue to monitor quarterly
 Meticulous home care
 Antimicrobial oral rinses
 Remove loose sequestra if present

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52
Q

If ONJ is present:
Stage 2:
(2)

A

 Exposed bone with associated pain
 Purulent exudate may be present

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53
Q

If ONJ is present:
Stage 2:
Treatment:
(4)

A

 Same treatment as Stage 1
 Addition of systemic antibiotics(Penicillin, Clindamycin,
Doxycycline)
 Superficial debridement to relieve soft tissue irritation
 Possible hyperbaric oxygen therapy?

54
Q

If ONJ is present:
Stage 3:
 Exposed bone with pain and one of the following:
(3)

A

 Pathologic fracture
 Extra-oral fistula
 Necrotic lesion extends to the inferior border

55
Q

If ONJ is present:
Stage 3:
Treatment:
(3)

A

 Surgical debridement or resection
 Antibiotic therapy
 Possible hyperbaric oxygen?

56
Q

Trismus
 Primarily occurs when the — region is irradiated
 Usually noticed near the completion of — therapy

A

pterygoid
radiation

57
Q

Trismus
 Radiation may cause

A

spasms or fibrosis of the TMJ
and muscles of mastication resulting in a limited
range of motion

58
Q

 The effects of trismus usually are not permanent,
but may last for

A

several months after the
completion of radiation therapy

59
Q

Trismus
Treatment:
(3)

A

 Warm, moist heat
 Massage
 Physical therapy

60
Q

 Physical therapy
(3)

A

 Tongue depressors
 TheraBite
 Dynasplint

61
Q

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.

A

60
the taste may return.
Xerostomia and mucositis

62
Q

Hypogeusia/Dysgeusia
 May or may not improve depending on the (2) of radiation

A

site and
amount

63
Q

Hypogeusia/Dysgeusia
 Treatment:
(2)

A

 Water/salivary substitutes
 Constantly monitor for bacterial or fungal infections

64
Q

Oral Radiation and Removable
Appliances
(5)

A

 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
Q

Chemotherapy
 Definition

A

 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
Q

How is it administered?
(2)

A

 IV infusion
- Port-A-Cath
 Pill

67
Q

Effects of Chemotherapy
(5)

A

 Immune system suppression
 Mucositis
 Xerostomia
 Bleeding
 Hypogeusia/Dysgeusia

68
Q

Dental Tx Prior to Tx
(4)

A

 Complete dental examination
 Prophylaxis /SRP
 Extraction of teeth with non-restorable caries, poor
periodontal prognosis
 Complete any needed endodontic therapy

69
Q

Dental Tx During Chemo
(3)

A

 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
Q

Oral Surgery During Chemo
 Any invasive procedures (i.e., extractions) get
recent blood counts
 Absolute Neutrophil Count (ANC) -
 Platelet count -

A

> 1000/mm3
75,000/mm3

71
Q

Antibiotic Prophylaxis Considerations
 Presence of a —
 Neutrophils between —

A

Port-A-Cath
1,000 and 2,000/mm3

72
Q

Immunosuppression
 Prevention is key
(3)

A

 Brush and floss
 Chlorhexidine rinse (non-alcohol)
 Neutral rinse (baking soda and water)

73
Q

Immunosuppression
Treat opportunistic infections
 Fungal (Candida)
(2)
 Viral (Herpetic)
(2)

A

 Nystatin, Fluconazole

 Acyclovir, Famciclovir

74
Q

Mucositis
Mild Pain
(4)

A

 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
Q

Mucositis
Moderate pain
(2)

A

 Addition of moderate strength opioids
- Hydrocodone and oxycodone
 Altered diet (soft)

76
Q

Mucositis
Severe pain
(2)

A

 Addition of strong opioids
- Oxycodone, morphine, oxymorphone
 May need nasogastric or PEG tube

77
Q

Xerostomia
 Xerostomia usually resolves within …
 Xerostomia can provide the ideal environment of
…

A

a few months after treatment is completed
opportunistic infections

78
Q

Xerostomia
 Treatments
(5)

A

 Water, Water, Water
 Salivary substitutes
 Sugar-free or xylitol gum
 Monitor carbohydrate intake
 Sialogogues (pilocarpine)

79
Q

Bleeding
(3)

A

 Chemotherapy can drastically decrease the platelet
count
 Avoid invasive dental procedures if at all possible
 Gentle brushing and flossing

80
Q

Hypogeusia/Dysgeusia
 The effects are usually temporary.
 Effects may be related to other complications:
(3)

A

 Mucositis
 Xerostomia
 Bacteria or fungal infections

81
Q

Bone Marrow Transplant
 Chemotherapy is used to …
 — are then transplanted to
repopulate the bone marrow

A

destroy the bone marrow
Hematopoietic stem cells

82
Q

Types of Transplants
(3)

A

 Autologous
 Allogeneic
 Syngeneic

83
Q

 Autologous

A

 The pts own bone marrow or stem cells are removed
and preserved for transplantation.

84
Q

 Allogeneic

A

 Bone marrow or stem cells from a HLA (Human
leukocyte antigen) matched individual are used for
transplantation.

85
Q

 Syngeneic

A

 Bone marrow or stem cells from an identical twin are
used for transplantation.

86
Q

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:

A

 Oral hygiene, emergency, and supportive care
 Oral hygiene, emergency, and xerostomia management
 Routine dental care

87
Q

Graft-Versus-Host-Disease
 Occurs primarily with — transplants
 Treatment involves severe —

A

allogeneic
immunosuppression

88
Q

Graft-Versus-Host-Disease
Oral manifestations:
(4)

A

 Mucositis
 Infections (bacterial, fungal, viral)
 Mucosal atrophy
 Xerostomia

89
Q

Antiresorptive Medications
(2)
Antiangiogenic Medications

A

 Bisphosphonates
 RANK Ligand Inhibitors

90
Q

Bisphosphonates
 Initially used for the treatment of (3)
 More recently, they have been used as an
adjunctive treatment of —
 Decrease — activity

A

osteoporosis,
Paget’s disease, and osteogenesis imperfecta
cancer
osteoclastic

91
Q

Bisphosphonates (Non-Nitrogen)
 Oral only
 Etidronate – (1)
 Clodronate – (3)

A

Didronel
Bonefos, Clasteon, Loron

92
Q

Bisphosphonates (Non-Nitrogen)
 Primarily used for the treatment of —
 — potency
 Prevents osteoclast proliferation by

A

Paget’s disease
Low
inhibiting ATP
(adenine triphosphate) dependent enzymes

93
Q

Bisphosphonate
(Nitrogen Containing)
 Oral or IV
 Mechanism of action
(2)

A

 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
Q

Oral Nitrogen Containing
Bisphosphonates
Approved for use in the treatment of (2)

A

Paget’s disease
and osteoporosis

95
Q

Approved for use in the treatment of Paget’s disease
and osteoporosis
(3)

A

 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)

96
Q

IV Nitrogen Containing
Bisphosphonates
 Used in the treatment of osteoporosis
(1)
 Used in the treatment of bone metastases
(2)

A

 Zolendronate (Reclast) – 5mg/year

 Zolendronate (Zometa) – 4mg/3 weeks
 Pamidronate (Aredia) – 90mg/3 weeks

97
Q

Antiresorptive Agents
 Denosumab (Monoclonal antibody)
 Osteoporosis –
 Bone Metastases –

A

Prolia – 60mg/6 months
Xgeva – 120mg/4 week

98
Q

Antiresorptive Agents
Mechanism of action
(2)

A

 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
Q

ANTIANGIOGENIC MEDICATIONS
 Tyrosine kinase inhibitor
(2)

A

 Sunitinib (Sutent)
 Sorafenib (Nexavar)

100
Q

ANTIANGIOGENIC MEDICATIONS
 Humanized monoclonal antibody
(1)

A

 Bevacizumab (Avastin)

101
Q

ANTIANGIOGENIC MEDICATIONS
Mechanism of action

A

 Recognizes and blocks vascular endothelial growth
factor (VEGF), a protein necessary for angiogenesis

102
Q

ANTIANGIOGENIC MEDICATIONS
Used in the treatment of (3)

A

gastrointestinal tumors,
renal cell carcinomas, and neuroendocrine tumors

103
Q

Drug Related Risks
Potency
(5)

A

 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
Q

 IV bisphosphonates (4% to 12%)
(2)

A

 Aredia
 Zometa

105
Q

Drug Related Risks
Duration
 Increased risk after – months

A

18

106
Q

Local Risk Factors
 Surgery/trauma
(3)

A

 Dental extractions
 Osseous surgery (periodontal, apicoectomy)
 Implant placement

107
Q

Local Risk Factors
 Anatomy
(3)

A

 Mandible vs. Maxilla (2:1 ratio)
 Tori, exostoses
 Mylohyoid ridge

108
Q

Demographic Factors
 Age:
 Race:

A

 9% increased risk of MRONJ with each passing decade
 Caucasian

109
Q

Systemic Factors
Primary cancer diagnosis
 highest risk
 2nd highest risk

 Concurrent (2) diagnosis

A

Multiple myeloma
Breast cancer

osteopenia or osteoporosis

110
Q

Prior to starting therapy
(3)

A

 Extract non-restorable and questionable teeth along
with alveoplasty, tori removal, etc.
 Complete necessary periodontal therapy
 Complete any endodontic and restorative work

111
Q

Wearing Removable Appliances
(4)

A

 Limit the amount of use
 Place silicone liners if necessary (GC reline)
 Educate the patient
 3-month recall intervals

112
Q

While on
Antiresorptive/Antiangiogenic Agent
Therapy
If any surgery or invasive procedures are
necessary,

A

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
Q

 –% of the bisphosphonate is excreted by the kidneys
within hours of ingestion or infusion
 Remaining –% deposited in the skeleton

A

50
50

114
Q

Bisphosphonates and the Resting
Bones
Osteocytes
(4)

A

 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
Q

Bisphosphonates and the Resting
Bones
Osteoclasts
(4)

A

 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
Q

Bisphosphonates and the Resting
Bones
Osteoblasts
(4)

A

 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
Q

 Bisphosphonates are primarily distributed in areas of…
 Stem cell development into — minimized
 Increase in …
Therefore….

A

active bone remodeling

osteoclasts
osteoclast apoptosis

118
Q

 In remodeling areas, an increase in bisphosphonates
disrupts the

A

synergistic makeup of the basic
multicellular unit (BMU)
 Osteoclasts, osteoblasts, osteocytes, and local vascular
supply

119
Q

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 —

A

Osteoclasts
bisphosphonate

120
Q

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

A

resting
bisphosphonate

121
Q

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

A

85
25
80
RANK ligand

122
Q

The Denosumab Vacation
 2 month presurgical holiday
- –% degradation
 Average 4 month postsurgical holiday (ideally 8
months)
- No needed alteration in — therapy if planned
correctly

A

80
denosumab

123
Q

CTX testing
 Measures serum levels of —
- Metabolite of bone matrix degradation
 Marker for — activity
 Normal is —
 – or less is at risk for MRONJ

A

C-terminal telopeptide
osteoclastic
>300 (average 400-550)
150

124
Q

Diagnosis of MRONJ
3 things necessary
(3)

A

 Current or previous antiresorptive medication therapy
 Exposed necrotic bone for longer than 8 weeks
 No history of radiation to the jaws

125
Q

If MRONJ is present:
Stage 0
(2)
 Treatment
(2)

A

 No exposed bone, but pt. is symptomatic
 Radiographic changes may be present

 Periodic monitoring
 Systemic management (antibiotics and pain meds

126
Q

If MRONJ is present:
Stage 1:
(1)
 Treatment:
(3)

A

 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
Q

If MRONJ is present:
Stage 2:
(2)
 Treatment:
(3)

A

 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
Q

If MRONJ is present:
Stage 3:
 Exposed bone with pain and one of the following:
(3)
 Treatment:
(3)

A

 Pathologic fracture
 Extra-oral fistula
 Necrotic lesion extends to the inferior border

 Surgical debridement or resection
 Antibiotic therapy
 Possible hyperbaric oxygen?

129
Q

Another Alternative
Forteo
(4)

A

 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
Q

Forteo
 Resolve — in osteoporotic patients
 May be used to treat —
 Contraindicated in pts. with…

A

MRONJ
osteoporosis
bone metastases or
previous radiation (risk of osteogenic sarcoma)

Dental Management of a Complex Patient (13 decks)

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