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Dental Mgmt of Medically Compromised Pts > Oral Complications Associated with Radiation, Chemo, and Antiresorptive Meds > Flashcards

Oral Complications Associated with Radiation, Chemo, and Antiresorptive Meds Flashcards

1
Q

How many Grays of radiation causes ORN in an area?

A

Greater than 50 Grays

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2
Q

What are the 2 ways radiation is delivered?

A

 Fixed Beam Radiation

 Intensity Modulated Radiation Therapy (IMRT)

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3
Q

 All the tissue between the portals receives the same

dose

A

Fixed Beam Radiation Therapy

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4
Q

 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)

A

Intensity Modulated Radiation

Therapy

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5
Q

 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.

A

Fractionation

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6
Q

What are the 5 R’s of fractionation?

A 
 Repair
 Redistribution
 Repopulation
 Reoxygenation 
 Radiosensitivity
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7
Q

(5 R’s of fractionation)
 Radiation causes sub-lethal damage to normal and
malignant cells
 The repair pathways are often blocked or impaired in the
malignant cells resulting in cell death.

A

Repair

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8
Q

(5 R’s of fractionation)

 DNA is more sensitive during certain stages of cell
replication. (G2 and M phases)
 Most stable (S phase)
 Fractionation provides multiple opportunities to affect
the cells when they are in the sensitive phase.

A

Redistribution

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9
Q

(5 R’s of fractionation)

 Rapid repopulation of the malignant cells can occur
approximately 4-5 weeks after the initial radiation dose.
 Fractionation over 5-7 weeks prevents the rapid
repopulation of these cells

A

Repopulation

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10
Q

(5 R’s of fractionation)

 Tumor cells are more resistant to radiation in hypoxic
environments
 Fractionation increases the odds that that tumor cells will
be in a nutrient field during radiation
 The outermost tumor cells are destroyed exposing the
“hypoxic”inner layers of tumor cells

A

Reoxygenation

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11
Q

(5 R’s of fractionation)

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

A

Radiosensitivity

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12
Q

Indications for _____ Prior to Radiation Therapy
 Non-restorable caries or high caries rate
 Periodontal pocketing > 5mm
 Furcation involvement
 Impacted teeth

A

Extractions

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13
Q

Which salivary gland is spared the most in radiation therapy? What type of saliva does it produce?

A

Sublingual; mucous saliva

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14
Q

 Hypofunction can occur when exposed radiation
doses as low as 25 Gy
 Serous glands are more sensitive to radiation than
mucous glands

A

Xerostomia

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15
Q

Are serous or mucous salivary glands more sensitive to radiation?

A

Serous glands

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16
Q

The rapid formation and
progression of dental caries is
mainly attributed to the reduced
quality and quantity of the _____

A

saliva.

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17
Q

 Sugar alcohol originally derived from birch trees
 Commercially produced from corn cobs (xylan)
 Caries causing bacteria are unable to metabolize it

A

Xylitol

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18
Q

 Ingesting 6-8 grams daily can decreased caries
 Frequency of use more important than quantity
 Available as a packaged sweetener or in gums, mints,
candies and oral rinses

A

Xylitol

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19
Q

How. many grams of xylitol need to be ingested each day to get anti-caries effect?

A

6-8 g

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20
Q

 Can cause gastric issues with some pts
 Primarily when over 50g ingested/day
 Extremely toxic to dogs (pancreas issues)

A

Xylitol

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21
Q 
 Cholinergic agonist 
 Pilocarpine hydrochloride
 5-10mg tid
 Max dose 30mg/day
 May take 12 weeks to see results
-Side effect of med is salivary effects not primary effect
A

Sialogues

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22
Q

 5-10mg tid
 Max dose 30mg/day
 May take 12 weeks to see results
-Side effect of med is salivary effects not primary effect

A

 Pilocarpine hydrochloride

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23
Q

 Rinse, brush, floss, fluoride trays
 10 minutes/day
 No food or drink for 30 minutes
 Best results when used prior to bedtime

A

Fluoride Therapy

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24
Q

What type of fluoride is better for root caries but can stain the teeth brown?

A

Stanous fluoride

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25
Q

 Oral mucosa exposed to radiation becomes
edematous, erythematous, and ulcerated.
 The condition can be extremely painful and cause
issues with mastication and swallowing.
 The signs and symptoms often arise after the
second week of therapy and may last a few weeks
after the completion of treatment

A

Mucositis

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26
Q 
 Mild Pain
 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)
A

Mucositis tx

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27
Q

 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)

A

Magic mouthwash used for mucositis

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28
Q 
 Moderate pain
 Addition of moderate strength opioids
 Hydrocodone and oxycodone
 Altered diet (soft)
 Severe pain
 Addition of strong opioids
 Oxycodone, morphine, oxymorphone
 May need nasogastric  or PEG tube
A

Mucositis tx

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29
Q

 Radiation results in vascular changes in the bone
limiting the blood supply and the ability to heal
after trauma or extractions
 Associated with radiation doses above 50 Gy
 More common with the mandible

A

Osteoradionecrosis (ORN)

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30
Q

Is Osteoradionecrosis (ORN) more common in max or mand?

A

Mand

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31
Q

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

A

Osteoradionecrosis

32
Q

 Stage ___ ORN
 No exposed bone, but pt. is symptomatic
 Radiographic changes may be present
 Treatment
 Periodic monitoring
 Systemic management (antibiotics and pain meds)

33
Q

 Stage ___ ORN

 Bone is exposed, asymptomatic, no infection present
 Treatment:
 Monitor closely for 8 weeks
 If no changes, continue to monitor quarterly
 Meticulous home care
 Antimicrobial oral rinses
 Remove loose sequestra if present

A

 Stage 1:

34
Q

 Stage ___ ORN

 Exposed bone with associated pain 
 Purulent exudate may be present
 Treatment:
 Same treatment as Stage 1
 Addition of systemic antibiotics(Penicillin, Clindamycin, 
Doxycycline)
 Superficial debridement to relieve soft tissue irritation
 Possible hyperbaric oxygen therapy?
A

 Stage 2:

35
Q

 Stage ___ ORN

 Exposed bone with pain and one of the following:
 Pathologic fracture
 Extra-oral fistula
 Necrotic lesion extends to the inferior border
 Treatment:
 Surgical debridement or resection
 Antibiotic therapy
 Possible hyperbaric oxygen?
A

 Stage 3:

36
Q

 Primarily occurs when the pterygoid region is irradiated
 Usually noticed near the completion of radiation therapy
 Radiation may cause spasms or fibrosis of the TMJ
and muscles of mastication resulting in a limited
range of motion
 The effects usually are not permanent,
but may last for several months after the
completion of radiation therapy

37
Q 
 Treatment of \_\_\_\_\_:
 Warm, moist heat
 Massage
 Physical therapy 
 Tongue depressors
 TheraBite
 Dynasplint
38
Q

 Permanent taste loss may occur with a cumulative dose

of ___ Gy.

39
Q

 Permanent taste loss may occur with a cumulative dose
of 60 Gy.
 At lesser dosages, the taste may return.
 Xerostomia and mucositis may also contribute to the
alterations in taste.
 May or may not improve depending of the site and
amount of radiation
 Treatment:
 Water/salivary substitutes
 Constantly monitor for bacterial or fungal infections

A

Hypogeusia/Dysgeusia

40
Q 
Radiation indications for \_\_\_\_
 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
A

Removable appliances

41
Q

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.

A

Chemotherapy

42
Q

Tx indication for ____ pts
 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

43
Q

When should you tx a pt in relation to chemo doses?

A

20-21 days post chemo bc of high blood counts

44
Q

What should the ANC be for an invasive procedure for chemo pt?

45
Q

What should the platelet count be for an invasive procedure for chemo pt?

46
Q

What are the 2 indication for ABX prophy pre dental treatment?

A

 Presence of a Port-A-Cath

 Neutrophils between 1,000 and 2,000/mm3

47
Q 
 Prevention is key
 Brush and floss
 Chlorhexidine rinse (non-alcohol)
 Neutral rinse (baking soda and water)
 Treat opportunistic infections
 Fungal (Candida)
 Nystatin, Fluconazole
 Viral (Herpetic)
 Acyclovir, Famciclovir
A

Immunosuppression

48
Q

Does xerostomia persist or resolve in chemo pts

A

Usually resolves

49
Q

Are the effects of taste loss/change permanent or temporary in chemo pts?

50
Q

 Chemotherapy is used to destroy the bone marrow
 Hematopoietic stem cells are then transplanted to
repopulate the bone marrow

A

Bone marrow transplant

51
Q

 The pts own bone marrow or stem cells are removed

and preserved for transplantation.

A

 Autologous

52
Q

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

A

 Allogeneic

53
Q

 Bone marrow or stem cells from an identical twin are

used for transplantation.

A

 Syngeneic

54
Q

No elective treatment for bone. marrow transplant until how long after bone. marrow transplant?

A

1 year after

55
Q

 Occurs primarily with allogeneic transplants
 Treatment involves severe immunosuppression
 Oral manifestations:
 Mucositis
 Infections (bacterial, fungal, viral)
 Mucosal atrophy
 Xerostomia

A

Graft-Versus-Host-Disease

56
Q

What are the 2 forms of antiresorptive meds?

A

Bisphosphonates

RANK ligand inhibitors

57
Q

 Initially used for the treatment of osteoporosis,
Paget’s disease, and osteogenesis imperfecta
 More recently, they have been used as an
adjunctive treatment of cancer
 Decrease osteoclastic activity

A

Bisphosphonates

58
Q

 Oral only
 Etidronate –Didronel
 Clodronate –Bonefos, Clasteon, Loron
 Primarily used for the treatment of Paget’s disease
 Low potency
 Prevents osteoclast proliferation by inhibiting ATP
(adenine triphosphate) dependent enzymes

A

Non-nitrogen bisphosphonates

59
Q

 Oral or IV
 Mechanism of action
 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

A

Nitrogen containing bisphosphonates

60
Q 
 Approved for use in the treatment of Paget’s disease 
and osteoporosis
 Alendronate (Fosamax)
 Risedronate (Actonel)
 Ibandronate (Boniva)
A

Oral Nitrogen Containing

Bisphosphonates

61
Q 
 Used in the treatment of osteoporosis
 Zolendronate (Reclast) –5mg/year
 Used in the treatment of bone metastases
 Zolendronate (Zometa) –4mg/3 weeks
 Pamidronate (Aredia) –90mg/3 weeks
A

IV Nitrogen Containing

Bisphosphonates

62
Q

Are oral bisphosphonates used for treatment of metastatic cancers?

63
Q

 Osteoporosis –Prolia –60mg/6 months
 Bone Metastases –Xgeva –120mg/4 weeks
 Mechanism of action
 Tumor cell promote the release of RANK Ligand from
the osteoblast with in turn promote the production of
osteoclasts
 Denosumab binds to the RANK Ligand an prevents
osteoclast proliferation

A

 Denosumab (Monoclonal antibody)

64
Q 
\_\_\_\_\_ meds
 Tyrosine kinase inhibitor
 Sunitinib (Sutent)
 Sorafenib (Nexavar)
 Humanized monoclonal antibody
 Bevacizumab (Avastin)
A

Antiangiogenic meds

65
Q

_____ meds
 Mechanism of action
 Recognizes and blocks vascular endothelial growth
factor (VEGF), a protein necessary for angiogenesis
 Used in the treatment of gastrointestinal tumors,
renal cell carcinomas, and neuroendocrine tumors

A

Antiangiogenic meds

66
Q

What primary cancer has the greatest risk for MRONJ?

A

Multiple myeloma

67
Q

____% of the bisphosphonate is excreted by the kidneys

within hours of ingestion or infusion

68
Q

___% of bisphosphonates are deposited in the skeleton

69
Q

 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

A

Osteocytes

70
Q

 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

A

Osteoclasts

71
Q 
 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
A

Osteoblasts

72
Q 
\_\_ month presurgical holiday
 Osteoclasts are the only reservoir for the 
bisphosphonates
 Allows for 4 life cycles
 Minimal remaining bisphosphonate
73
Q

 Average __ month postsurgical holiday (ideally 8
months)
 Necessary time needed for bones to return to “resting”
state
 No needed alteration in bisphosphonate therapy if
planned correctly

74
Q 
\_\_\_\_\_\_ and the Body
 Osteoclasts decreased by 85% in 3 days
 ½ life is 25 days
 80% degraded in 2 months
  only affects the RANK ligand
 Not incorporated in the bone
75
Q

What is the Denosumab drug vacation timeline?

A

2 months before

4 months after (8 is better)

76
Q

 Measures serum levels of C-terminal telopeptide
 Metabolite of bone matrix degradation
 Marker for osteoclastic activity
 Normal is >300 (average 400-550)
 150 or less is at risk for MRONJ
-Does not denote location of breakdown of osteoclasts

A

CTX testing

77
Q

 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)

Dental Mgmt of Medically Compromised Pts (12 decks)

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