Oral Cancer Flashcards
Name some risk factors for Oral cancer
- Tobacco use
- Alcohol use
- UV radiation (mostly for lips – the sun is on the lips the most)
- Viruses (hypopharyngeal cancer, HIV, HPV)
- Chronic irritation
- Heredity
- Syphilis
What are 4 common clinical signs of oral cancer?
- Ulceration
- Erythroplakia (red patch, red plaque)
- Infuriated growth (hard mass)
- Leukoplakia (white plaque/lesion)
Patient comes in with erythroplakia and leukoplakia on the floor of the mouth – what should you be wary of?
erythroplakia and leukoplakia on the floor of the mouth is indicative of pre-malignancy/malignancy
What is the dental professional’s most important role in terms of oral cancer? (Common basic fact)
Early detection
What is the prognosis of oral cancer based on?
The stage of the cancer at
the time of detection/initial diagnosis.
What is the TNM system?
T = tumor - size of tumor N = nodes - status of cervical lymph nodes M = metastasis - the presence or absence of cancer in other sites
Where does the lymph of the lip and the anterior of the jaw drain?
Submental node
Where does the lymph of the teeth and anterior tongue drain to?
Submandibular node
Where does the lymph of the posterior tongue drain to?
Cervical nodes
Where does the lymph of the posterior skin drain to?
The occipital node
What is special about the supraclavicular node?
Supraclavicular node lesions can be from anywhere such as lung cancer, breast cancer, or oral cancer.
Thus, if you find a supraclavicular node, it is not a good prognostic sign
Where are the most common metastatic targets of oral cancer?
- Lungs!
- Brain
- Liver
- Kidney
Name the different stages of cancer
Stage I - T1N0M0
Stage II - T2N0M0
Stage III - T3N0M0, T(1,2,3)N1M0
Stage IV - T4N(0,1)M0
T(0-4),N2,M0
T(0-4), N3,M0
T(0-4), N(0-4), M1
How should you begin diagnosis of cancer?
- Biopsy
- Diagnosis
- Staging
- CT Scans: Neck, Chest, Abdomen
- Liver function tests
- PET Scan - nuclear medicine scan, material goes into rapidly dividing cells and the patient gets scanned
- =]
What is the different between Incisional biopsy vs. Excisional biopsy
Incisional - take out part
- large lesions
- want to take only part to make sure of what it really is (don’t for unknown lesions)
Excisional - take out whole
- little lesions
- known lesions
What are different types of biopsy techniques?
Brush biopsy - brush the lesion and see organisms under microscope
Fine needle aspiration - cells sucked out and looked under microscope
Light enchanted examination - illuminates differently for malignant cells
Toluidine blue - cells taken up more actively by rapidly dividing cells, but not used anymore
What are the 3 different treatment modalities for oral cancer? What is the oral cancer team made of?
- Surgery
- Radiation
- Chemotherapy (chemo is usually only an adjunct – given before or after radiation, chemo alone is not curative)
* **chemo is curative for lymphomas
* **chemo is used to shrink tumor to make it more amenable to surgical process
Head and neck cancer team
- Head and neck cancer surgery
- Radiation oncologist
- Medical hematology oncology person
Why do head and neck surgeons or radiation oncologist refer patients to dentist before or after surgical treatment?
This is because they want infectious or infected teeth removed. If you attempt to do extractions or treat teeth after radiation –> more complications.
What are the side effects to radiation therapy?
- mucositis
- xerostomia
- radiation caries
- aguesia (lost of taste)
- osteoradionecrosis
When should you expect mucositis to occur
Mucositis is a side effect from radiation therapy
- It occurs on the 10th to 14th day
- painful
- necrotic surface layer
What is the treatment to mucositis?
- it is palliative
- viscous xylcaine (lidocaine)
- analgesics
What are the 2 subcategories for irradiation complications of the head and neck?
Direct radiation injury
Indirect radiation injury
What is direct radiation injury?
Direct radiation injury is mainly on the blood supply to the mandible and maxilla. There is a decrease in vascular flow (fibrosis of major arteries and arteriolar) so you have a decrease in nourishment of teeth and bone
List:
- destroys or damages susceptible cells causing loss or disruption of tissue function
- mucositis
- xerostomia (salivary gland dysfunction
- aguesia (loss of taste)
- trismus
- tooth and bone development
What is indirect radiation injury?
There is direct exposure to the salivary gland –> xerostomia –> dry mouth creates bacteriological profile of teeth –>susceptible to decay
List:
- radiation caries
- osteoradionecrosis (ORN)
What is radiation mucositis?
It is where epithelium is lost due to normal function, but not replaced due to slowing or cessation of cell replication and maturation
When does radiation mucositis typically begin and resolve?
Begins in the 1st or 2nd week of therapy
Resolves in 2-3 weeks after last radiation treatment
How do you treat radiation mucositis?
- Viscous lidocaine
- Magic mouth rinse
- benzidamine rinse
- kepivance (keratinocytes growth factor -KGF- which stimulates the growth of cells that line the surface of the mouth)
How do you treat/manage xerostomia?
Sialalogs (cholinergic agonists)
- pilocarpine (Saladin) 5-10mg TID - evoxac 30mg TID
Where is radiation caries usually found?
Most common on the cervical and Incisal edge OR cusp tip decay
True or false: radiation caries and normal caries are similar in their decay patterns
False – radiation caries do not follow normal decay patterns (not pit and fissure caries)
What is the most important treatment measure to radiation caries?
Oral hygiene
- gold standard is fluoride trays with neutral pH 1% fluoride gel
When does aguesia (loss of taste) or dysgeusia (alteration of taste) begin?
Begins in 1st - 2nd week and may be permanent
What is osteoradionecrosis?
It is an open area of exposed bone within a field of previous radiation that is present for at least 3 months.
Result of obliterative endarteritis, the reduction of blood flow to an area of bone secondary to head and neck radiation
Thus, it is exposed bone or death of bone caused by radiation
***This is not the same as MRONJ
Where is osteoradionecrosis most common?
It is most common in the mandible
What are 3 reasons as to why osteoradionecrosis happens?
- Spontaneously when radiation is not calibrated properly (too intense) – bone dies –> loss of periosteal covering –> exposed bone
- Poor fitting prosthesis –> denture creates a sore spot
- Post-radiation extractions –> taking out teeth in a radiated field – MOST COMMON REASON
How do you manage ORN?
- Conservative debridement of exposed bone
- Hyperbaric oxygen therapy
- Possible antibiotic therapy
- Best method is prevention
What procedures does pre-radiation management incorporate?
- Evaluation – panoramic, bite wing, clinical exam
- Cleaning
- Restorations
- Removal of ally questionable teeth
- Removal of tori, sharp mylohyoid ridges, and exostoses
- Oral hygiene instruction and fluoride trays
If oral surgery needs to be performed before radiation – what are the pre-requisites before radiation therapy?
There should be primary closure and surgical sites should be well healed or at least covered with granulation tissue.
The healing time should be at least 7-10 days
What are the post-radiation management procedures?
- Re-evaluation 2-4 weeks post RT
- OHI and fluoride tray
- evaluation of prosthesis
- 3 month recall for dentate
- clean, restoration, etc – no need for antibiotics
- If extraction necessary – gold standard is pre and post hyperbaric oxygen therapy
What are the risk and benefits to hyperbaric oxygen therapy?
The benefit is that the area in your jaw that is hypo vascular and hypo oxygenated we super influx the area with oxygen. The barrier between normal tissue and radiation tissue is semi-permeable. So neovascularization will undergo and there will be budding from oxygen rich area to poor area –> better prognosis
Risk - oxygen therapy is systemic so you could spread cancer cells
What IV bisphosphonates can cause osteonecrosis of the jaw (ONJ)?
- pamidronate (avedia)
- zoledronate (zometa)
- alendronate (fosamax)
If you are getting treated with IV bisphosphonates, what is recommended adjunctively?
- Maintain OHI
- Check and adjust removable appliances
- Aggressively manage dental infections non-surgically
How do you manage bisphosphonate related ONJ?
- antibiotics and oral rinse with chlorohexidine
- stopping bisphosphonates before surgery does not help
- Hyperbaric oxygen does not help
- surgical treatment does not help
What is the most common Oral malignancy?
- Squamous cell carcinoma (90%)
- Salivary gland neoplasia (5%)
- Lymphoma (3%)
