Oral cancer symposium Flashcards
(76 cards)
1
Q
What are biopsy specimens fixed in prior to arriving in pathology
A
formaldehyde for at least 24h
2
Q
What are the aims of assessment pre-radiotherapy
A
- decide on which teeth need extraction - try and keep important teeth
- obtain primary closure for XLA
- reduce tori to ensure dental tolerance
- prevention - 5000ppm, jaw opening exercises etc
- baseline records
- planning for optimal rehab
3
Q
What are oral side effects of cancer tx
A
- mucositis
- taste
- xerostomia
- tooth structure changes - changes in pulp space (reducing chances of RCT)
- trismus
- ORN
- soft tissue changes
4
Q
What is ORN
A
- serious complication after radio/chemotherapy
- most common in OP cancer px especially tonsillar/retromolar region
- 5% incidence
- mandibular molar area most affected site
5
Q
What are prosthodontic options for rehabilitating HN cancer patients
A
- dentures - precision attachments
- implants
- bridges
6
Q
How should we maintain HN cancer px
A
- ensure absence of bleeding upon probing
- no excessive pocket depths
- success rate varies with bone quality, loading dynamics etc
7
Q
What are the uses of obturators in dentate px
A
- restore partition between oral and nasal cavities
- restore palatal contour
- replace needed dentition
- provide retention, stability, support for partial denture
- create partial denture designs that do not stress abutment teeth beyond their physiological tolerance
8
Q
What is the use of an obturator in a edentate patient
A
- restore partition between nasal and oral cavity
- resotre palatal contours
- replace necessary dentition
- provide retention, stability and support for the complete denture - obturator prosthesis
9
Q
What is an interim obturator
A
enables speech and swallowing during immediate post-op and healing periods
10
Q
What are primary dental implants
A
placed same time as tumour resection
prosthetic obturation of significant maxillary defects where retention of obturator likely to be compromised
11
Q
What are the advantages of placing implants at time of surgery
A
- implant surgery in radiotherapy compromised area is avoided, reduced risk of ORN
- initial implant healing takes place before irradiation
- px can benefit from support of implants at earlier stage of tx
- px saved from another surgical intervention
12
Q
What are disadvantages of primary implant placement
A
- delay or interfere with oncological therapy
- development of post tx complications
- lack of use of installed implants due to early tumour recurrence
13
Q
When can an OPT be useful in diagnosing oral cavity cancer
A
can show bone involvement
14
Q
If a neck lump is present, what is the initial imaging of choice
A
ultrasound
ultrasound guided biopsy
15
Q
When looking at an OPT, what features make us concerned in regards to cancer
A
- moth eaten bone
- pathological fractures
- nonhealing sockets
- floating teeth
- unusual periodonta bone loss
- spiculated periosteal reaction
- widening of PDL space
- loss of bony outlines for anatomical features
- thinning of cortico-endosteal margins
16
Q
When taking an ultrasound for neck lumps, what are we looking for
A
- rounded/enlarged lymph nodes - should be rugby ball shaped in normal person
- necrosis of nodes
- increased vascularity
- loss of hilum
- internal calcification
- extracapsular spread
17
Q
What type of biopsy is used in ultrasound guided biopsy
A
core biopsy is better
FNA only provides cells
avoid cystic fluid and areas of necrosis
18
Q
What is staging based on
A
TNM
19
Q
What does TNM stand for
A
tumour
nodes
metastasis
20
Q
How do we look for distant metastasis
A
need imaging in 3d with large field of view - ct or mri
want to image brain chest abdomen and pelvis
21
Q
What are the advantages of using CT for staging
A
quick
good for soft tissue and bone
iodinated contrast must be given to enhance tumour
22
Q
What are the disadvantages of CT for staging
A
requires testing to ensure kidney function for the iodine contrast
involves radiation
23
Q
What are the advantages of MRI for staging
A
- no ionising radiation
- good for soft tissue/bone marrow involvement
- better for perineural spread
24
Q
What is done when the primary tumour cant be detected
A
PET/CT scan is imaging of choice
PET looks for metabolically active tissues
false positives can occur due to active uscles or infection
25
Who is part of the MDT
* surgeons
* radiologists
* clinical oncologists
* SLT
* dietician
* restorative dentists
* clinical support nurses
26
What are the tx options for HN cancer
* nil (palliative)
* surgery alone
* radiotherapy alone
* chemotherapy
* dual or triple modality (including immunotherapy)
27
What is the role of the GDP in screening
* early detection through soft tissue exam
* photos
* onward referral
* pre tx assessment
28
What are high risk sites for HN cancer
* tongue
* floor of mouth
* oropharynx
29
What is the classic appearance of SCC
* solitary deep ulcer
* rolled margins on the lateral margin of the tongue
* palpation of the margin of the ulcer will reveal firm, indurated tissues
30
What are suspicious mucosal changes
* ulceration
* swelling
* erythroplakia
* speckled leukoplakia
31
What are potentially malignant conditions
* leukoplakia
* speckled leukoplakia
* erythroplakia
* submucous fibrosis
* lichen planus
* keratosis
32
What are the different HN cancer referral guidelines
* scottish referral guidelines for susepcted cancer
* NICE guidelines
33
What do the scottish referral guidelines say you should refer as urgent suspicion of cancer referral
* Stridor --> emergency referral
* Persistent unexplained head and neck lumps for >3 weeks
* Unexplained ulceration or unexplained swelling/induration of the oral mucosa persisting for >3 weeks
* All unexplained red or mixed red and white patches of the oral mucosa persisting for >3 weeks
* Persistent (not intermittent) hoarseness lasting for >3 weeks. If other symptoms are present to suggest suspicion of lung cancer, refer via lung cancer guideline
* Persistent pain in the throat or pain on swallowing lasting for >3 weeks
34
What investigations will a new px on OMFS get when they are suspected of HN cancer
* New px assessment
* Biopsy to confirm
* CT scan to investigate extent of tumour
* Lymph node biopsy
* CT scan to investigate for metastasis
* Baseline medical testing - performance score
* Stage and grade cancer
35
When should the HN team see a patient after referral from the dentist
2 weeks
36
When should diagnosis be reached by
28 days from referral
37
When should decision to tx be reached by
28 days
38
When should definitive tx be started
62 days from referral
39
What are aims of the pre-assesment
* identify existing oral disease and potential risk of disease
* remove infection and potential infection before start of therapy
* prepare px for expected side effects of cancer therapy
* establish an adequate standard of OH to meet increasing challenges during cancer therapy
* develop a plan for maintaing OH, providing preventative care, completing oral rehab and follow up
* establish necessary multidisciplinary collobration with cancer centre
* plan post tx prosthetic oral rehab
40
What should a GDP provide in a pre-assessment
* detailed OHI
* fluoride
* diet advice
* PMPR
* consider CHX
* restore carious teeth
* remove trauma
* impressions for fluoride trays and soft splints
* denture hygiene instrucions
* extraction of dubious prognosis teeth
* AB prophylaxis if neutrophils are low and planning invasive tx
* orthodontics
* smoking and alcohol advise
* restorative tx - study casts for implant planning
41
When is the latest teeth should be extracted prior to cancer tx
no later than 10 days
42
What should be checked prior to providing invasive tx
neutrophil checks
43
What are the possible cancer tx
* surgical resection with or without reconstruction
* chemo therapy
* adjuvant radiothreapy or chemotherapy may be required
44
What is the side effect of surgical tumour resection
alterations to normal anatomy
effects function and appearance
45
What is the side effect of radiotherapy
* radiation damage to normal tissues surrounding tumour
* affecting function of these tissues both in short and long term
46
What is the side effect of chemotherapy
* acute mucosal and haematological toxicity
* former being accenuated if chemotherapy is delivered concurrently with radiation threapy
47
What is the role of the dentist in cancer therapy
* hygiene support
* antibacterial mouthwash to aid brushing e.g CHX
* diet advice
* fluoride preparation
* high risk of viral and fungal infections
* tx of mucositis, xerostomia
* emergency dental tx could result in delaying cancer tx
48
When does oral mucositis start and end
* starts 1-2 wks after tx begins
* lasts until 6 wks after tx is complete
49
What are the symptoms of oral mucositis
* may inhibit OH measures
50
What can be used to prevent and manage mucositis
* caphosol
* sodium hyaluronate gel
* mucoadhesive oral rinse
* soluble aspirion
* difflam
* zinc supplements
* alovera
* cryotherapy
* manuka honey
51
How can mucositis be classified
52
What antifungal is not effective at preventing candida infections due to cancer tx
nystatin
53
What are antifungals that can be prescribed
* CHX
* miconazole - topical
* fluconazole - systemic
* nystatin
54
How can canecr tx result in traumatic ulceration
* teeth rubbing delicate intra oral tissues
55
How does reactivation of herpes simplex virus present in those undergoing cancer tx
* prodromal period - pain prior to ulceration
* often intraoral and clinically atypical
* more extensive, slow healing and aggressive
* high index of clinical suspicion
56
How is saliva effected by cancer tx
* reduced salivary flow
* saliva becomes more viscious and acidic causing damage to teeth
* recovery may be slow/not at all
57
What is the impact of xerostomia
* chewing
* swallowing (dysphagia)
* speech (dysarthria)
* taste (dysgeusia)
* QoL
58
What are the risks of xerostomia
* caries
* periodontal disease
* candida
* sialadenitis
* prosthodontic difficulties
59
What is the cancer induced xerostomia caused by
ionising radiation producing damage to the salivary glands
60
What tx can we give px for xerostomia
* oral gels and lubricants
* pilocarpine - enhance slaivary secretions
* sugar free gum
* salivary replacements
* avoid glandosane
61
What are the causes of trismus following cancer tx
* post surgical inflammation
* fibrosis of those tissues as a result of tx
* reduction in mouth opening due to tumour recurrence should be excluded
62
Why are cancer tx px more prone to caries
* combination of xerostomia, OH, diet, taste etc
63
How does radiation induced caries present
* indirect effect of nonsurgical tx
* result of reduced salivary flow and altered salivary function in combo with high protein and calorie diet
* rapidly developing
* widespread caries that can often be circumferential
* may effect incisal edge
* hard to restore
64
What is ORN defined as
area of exposed bone of at least 3 months duration in an irradiated site and not due to tumour recurrence
one of the most severe and debilitating complications following radiation therapy for HN cancer
65
How do we prevent ORN
* remove teeth of doubtful prognosis in the radiotherapy field prior to tx
* prevention
* extraction completed at least 10 days prior to radiotherapy
* encourage healing with primary closures and sutures where possible
* hyperbaric oxygen?
* antibiotic prophaylxis until completion of healing --> coamoxiclav or amoxycillin
66
When are px at particular risk of ORN
* total radiation dose exceeded 60Gy
* dose fraction was larger with a higher number of ractions
* local trauma as a result of tooth extractions, uncontrolled periodontal disease or an ill fitting denture
* immunodeficient px
* malnourished px
67
When a px is high risk of ORN, and a tooth is carious, what should you consider
* rct
* restoration/crown amputation
68
What is stage 0 ORN
* mucosal defects only, bone exposed
69
What is stage I ORN
* radiological evidence of necrotic bone, dento-alveolar only
70
What is stage II ORN
* positive radiographic findings above ID cancl with denuded bone intraorally
71
What is stage III ORN
* clinically exposed radionecrotic bone
* skin fistulas and infeciton
* potential or actual pathological fracture
72
What is prevention and tx for px post cancer tx
* regular exams
* avoid invasive tx that could truamatise bone
* consider decoronation
* use atrumatic techniques where possible
* caries management - try to keep teeth around
* full or partial coverage crowns when px show good OH
* avoid routine restorative tx until px in remission
* antimicrobials for acute condition
73
What prosthesis can px be given for reconstruction
* implants
* dentures
74
When are implants less likely to succeed in HN cancer px
* reduced success in irradiated bone
* failure less likely with radiation dose <45Gy
* requires maintenance - self care and professional support
75
When should dentures be used
* avoid when possible
* esential they will aid ability to chew, social adaptation etc
* dneture hygiene essential
76
What advise should px be given regarding obturators
* review regularly
* do not leave out at night for first 6 months psot tx
* may be worn at night for comofort and function after 6 months too
* daily cleaning mandatory
