Oral Cancer Flashcards
What are the main etiological factors of oral cancer?
Tobacco
Alcohol
UV radiation
HPV-16 (oropharyngeal cancer)
Poor diet
Low socioeconomic status
Drugs- opioids and cannabis
Older age
What are the red flag symptoms that would warrant a 2 week referral letter to be done?
Unexplained head and neck lumps for longer than 3 weeks.
Unexplained mouth ulcers that persist for more than 3 weeks.
Mixed red and white patches for more than 3 weeks.
Persistent hoarseness for more than 3 weeks.
Throat pain and persistent pain on swallowing for more than 3 weeks.
What other symptoms may suggest something sinister?
Unexplained weight loss
Loose teeth- if the lesion is in the bone.
Persistent unilateral earache.
Trismus
Minor salivary gland tumour present as a lump on the surface.
Loss of motor supply to the tongue
Sino-nasal cancer- blood stained discharge from the nose.
Coughing up blood.
What is the TNM staging method for oral cavity cancer?
T- diameter of primary tumour, T1, T2, T3, T4.
N- determines if cancer cells have spread locally to lymph nodes and if so, the size of the nodes that are formed.
M- metastasis, looking for distant metastasis.
If metastasis has occurred, it is very difficult to treat.
What are the treatments for oral cancer?
Palliative care- symptom control, radiotherapy, medication to control symptoms, mouth care.
Surgery to remove primary tumour, then elective lymphadenopathy and reconstructive surgery.
Radiotherapy.
Chemoradiotherapy
Immunotherapy
What intra-oral signs and symptoms might suggest SSC?
Ulcerated
Uneven surface
Indurated
Rolled edges
Well defined margins
Exophytic
Speckled surface
Mixed red and white lesion
What healthcare professionals might be involved in the multi-disciplinary care of a head and neck cancer patient?
Oncology
OMFS
ENT
Pathologists
Speech and language therapists
Dietician
Special care dentist
Restorative dentist
GDP
Radiologist
Occupational therapist
Physiotherapist
What is the scan of choice in head and neck cancer patients?
MRI
Improved soft tissue definition
As a GDP, you take an OPT because you are suspicious there may be bone involvement, what would you look for?
Moth-eaten bone
Pathological fracture
Non-healing socket
Floating teeth but no history of perio
Unusual periodontal bone loss
Spiking resorption
Generalised widening of the PDL space and loss of lamina dura.
Loss of bony outline of anatomical features
What is the role of the pathologist in oral cancer?
Establish the diagnosis of cancer- subtype and grade
Outline the anatomic extent of the tumour- confirm completeness of excision
Identify prognostic markers
Final staging of the disease
Describe the patient journey from screening and referral to post-treatment.
Screening (probably by GDP) and referral to OMFS
OMFS will investigate and diagnose
MDT- treatment planning
Dental pre-assessment by the GDP- treatment and prevention carried out
Cancer treatment- dental support throughout this.
End of treatment
Restoration of mouth by GDP/restorative dentist
Maintenance and post-treatment management
Disease recurrence (always a possibility)
In your referral to OMFS, what would you include?
Patient name, CHI, DOB, address
Your name, contact number and practice address
Description of the lesion- where it is, the size, what it looks like, margins, colour.
What you want the OMFS department to do
Ensure to say it is urgent suspicion of oral cancer
Include clinical photographs.
What guidelines would you refer to for the criteria of suspicion of cancer?
Scottish Cancer Referral Guidelines
NICE: Improving outcomes in head and neck cancer
What investigations might OMFS carry out once they see the person you have referred?
Performance score- determine fitness of the patient
Biopsy to confirm the diagnosis
CT scan to investigate extent to tumour
Lymph node biopsy- will determine the stage
CT scan to investigate for metastasis
Stage and grade of tumour
What are the aims of the dental pre-assessment?
Identify areas of disease or potential disease
Prepare the patient for side effects of treatment
Eliminate infection and reduce risk of infection
Establish an adequate standard of oral hygiene, providing preventive care.
Plan post-treatment prosthetic rehabilitation
What sort of factors would make a tooth likely to be extracted because of poor prognosis?
Non-vital
Infection
In line with radiation therapy
Deep caries
Deep perio pockets
Failed root treatment
Extensive bone loss around tooth
At the pre-assessment, what do you need to do/consider?
XLA teeth of dubious prognosis
Definitively restore carious teeth
Detailed OHI- fluoride toothpaste, fluoride mouthwash, fluoride varnish
Prepare patient for side effects of treatment
Impressions for study casts and fluoride trays/splints
Perio treatment
Denture hygiene instruction
Diet advice
Smoking and alcohol advice
Remove sharp edges on teeth and dentures
What are the common intra-oral side effects of radiotherapy?
Radiation caries- buccal surfaces, cervical margins, incisal edges, places you wouldn’t usually see caries.
- because of the radiation itself and the dry mouth, diet.
Erosion
Dry mouth
Perio disease
Trismus
ORN
What are the common intra-oral side effects of chemotherapy?
Increased bleeding risk
Increased infection risk- candidosis, Herpes simplex reactivation
Oral mucositis
Taste disturbance
If dental treatment is required throughout cancer treatment, what would you do?
Contact cancer team for advice.
What level of neutrophils would warrant you giving a patient antibiotic prophylaxis?
1x10^9/L
What is Oral mucositis?
begins 1-2 weeks after treatment starts and lasts until 6 weeks after treatment finishes.
Severe pain caused by the mucositis.
Severe impact on eating- too painful to swallow.
What can you prescribe to a patient with oral mucositis?
0.15% Benzydamine hydrochloride spray
Neutral supersaturated calcium phosphate mouth rinse
- Caphosol
Polyvinyl pyrolidine/sodium hyaluronate gel
- Gelclair
Soluble aspirin
Aloe vera
Manuka honey
10% lidocaine spray prior to eating.
Also 5% lidocaine ointment
Oral cooling- ice
Morphine and opioids as analgesia.
Encourage good OH
May want to prescribe 0.2% Chlorhexidine when OH is limited due to pain.
What would you do if a cancer patient presented with oral candidiasis?
Local measures to be done in the first instance
- Denture hygiene advice, OH advice, 0.2% chlorhexidine mouthwash and gel.
If drug treatment required
- Systemic Fluconazole 50mg capsules, 1 capsule per day for 7 days.
- Topical Miconazole 20mg/g, pea sized amount 4 times a day after food.
If azoles are contraindicated- use Nystatin.
What can be done to help with oral ulceration?
Smooth edges of sharp teeth and dentures
Lower splint
What treatment is required for reactivation of Herpes Simplex virus?
In immunocompromised individuals prescribe systemic Acyclovir- 200mg, 1 tablet 5 times a day for 5 days.
In the first instance tell the patient to continue to stay hydrated, soft diet and chlorhexidine mouthwash, can also prescribe hydrogen peroxide.
What would you prescribe for Xerostomia?
Stay hydrated
Chew sugar free chewing gum
Vaseline for lips
Saliva orthana (has pig products in it)
BioXtra (has egg white in it)
Glandosane (only in edentulous patients)
Saliva replacement spray/gel
Pilocarpine can be prescribed- adverse effects.
How does Xerosotmia affect the mouth?
Increased risk of caries
Difficulty speaking
Difficulty swallowing
Difficulty chewing
Taste disturbance
Management of Trismus, ORN
See oral surgery lectures
What factors put individuals at a higher risk for ORN?
Radiation dosage greater than 60 grams
Dose fraction was large with high number of fractions
Local trauma as a result of extraction
Patient is immunodeficient
Patient is malnourished
What could you give the patient to reduce the risk of ORN prior to an extraction?
800mg per day of Pentoxyfylline
Vitamin E
Antibiotics
What are the common intra-oral side effects of radiotherapy?
Xerostomia
Radiation caries
Trismus
Acceleration of perio disease
