Orofacial Pain and Cancer Flashcards
What kind of orofacial pain is seen in cancer?
Acute OFP (due to primary tumour, metastatic disease, systemic cancer, distant non-metastatic cancer, therapy)
Chronic OFP
What is the role of the dentist in OFP caused by cancer?
Recognize cause of the pain and refer promptly and appropriately.
Pain management is multi-factorial and dentist can optimize pre-treatment conditions to reduce chance of mucositis and other complications
What kind of pain is associated with primary tumours?
Can be the presenting complaint of a patient thinking they bit their tongue and it never healed.
Could be advanced stage of disease.
What does pain indicate about a primary tumour?
Pain is a poor prognostic indicator associated with stage 3 or 4 cancers
What does pain in a salivary gland neoplasm indicate?
Pain is usually an indicator of malignancy. A painless lump is often benign
What are the indicators of nasopharyngeal malignancies and which factors mean increased likelihood of finding nasopharyngeal malignancies?
Discomfort in maxilla, oral cavity, and teeth. It is rare and related to ebstein-barr virus.
TMD, odontogenic infections with trismus, and parotid lesions are more likely to have nasopharyngeal malignancies.
Aching, dull, pressing or intermittent pain.
What are the typical signs of osteosarcoma of the jaw?
Swelling of the jaw and pain.
VERY RARE
What are the symptoms of an osteoma?
Always painful
Relieved by aspirin
Benign
How do intracranial malignancies typically present? What imaging should be taken for these?
Most commonly present as trigeminal neuralgia and worsening with time.
Progressive neurological deficits which may be subtle especially if posterior fossa tumour.
MRI for these patients
How does OFP associated with metastases present clinically?
It is rare and when present is most often present in the mandible (39%) on the angle or ramus.
Breast and prostate most common cancers to metastasize to mandible.
Rarely soft tissue metastases from lung or attached gingiva.
Which systemic malignancies can lead to OFP?
Lymphoma
Leukemia
Multiple myeloma
All can affect the head and neck region
What causes pain associated with systemic malignancies?
Periosteum and gingival infiltration.
Multiply myeloma causes multiple osteolytic lesions as well as odontogenic pain adjacent to tooth roots.
What are the features of OFP secondary to non-metastatic malignancy?
Referred pain
Most often lung primary
Facial pain is almost always unilateral
Pain is often severe, aching, continuous, and progressive commonly localized to:
Ear (84%)
Jaws (48%)
Temporal region (38%)
What therapy can cause the pain associated with cancers?
Surgical procedures
Chemo
Radiotherapy
Infection
What pain management is given pre-operatively to patients undergoing surgery?
Pre-op are given lyrica to reduce post op pain.
How does chemotherapy lead to pain?
Mucositis
Ulceration, erosion, and erythema
Affects labial mucosa, buccal mucosa, tongue, FOM, soft palate
Affects 40% of patients standard chemo
Haemopoeitic malignancies often experience it.
75% of patients with high dose.
Does chemotherapy associated pain go away?
It is usually self-limiting unless it is complicated by infection.
How is chemotherapy induced pain treated to reduce symptoms?
Mouthwashes are given to patients to control discomfort. carafate or sulcrafate is often given to patients with mucositis and given prior to eating to maintain adequate levels of nutrition
What are the features of radiotherapy induced pain? How does it compare to chemo induced pain?
Causes mucositis that is more intense and prolonged than chemotherapy mucositis.
Site depends on the primary beam.
Lasts 6 - 8 weeks.
Permanent impairment compared to chemo
Combo of CT and RT leads to worse pain.
How can mucositis be managed by dentists?
Ensure predental check
Meticulous oral hygiene
Remove sharp structures
Flossing is important to prevent bacteraemia not a cause of it
Start with neutrafleur5000 and then change to sodium lauryl sulfate to manage plaque.
Supportive therapy such as mouthwash, antmicrobials and PEG
Why is infection more common in patients on chemo/radio?
Impaired immune barriers
Exacerbation of latent infections
Changes in flora secondary to treatment
How should infection be treated for mucositis in chemo/radiotherapy?
Prevention is key
Treatment needs to be swift.
What chronic OFP is associated with treatment?
Chronic mucosal changes
Neuropathic pain
Musculoskeletal pain
Who most commonly get chronic mucosal pain?
More often in radiotherapy
What are the potential complications of radiotherapy/chemo?
40% of patients have sensitivity 1 year post radiotherapy.
Transformation to lichenoid reaction
Chronic graft vs host disease due to transplants and lichenoid lesions
Neurological sensitivity or epithelial atrophy.
Delayed healing and frequent ulceration due to HypoxiaHypovascularityHypocellularity theory. DENTURES NEED TO STAY OUT
How is graft vs host disease treated?
Active treatment with topical corticosteroids
Long term management (high risk of malignant transformation)
What are the features of neuropathic pain caused by cancer or its treatment?
10% of HNC patients develop neuropathic pain
Hyperalgesia/allodynia/parasthesia
Can be due to CT, RT, or surgery. Surgery most commonly affects the facial nerve or the mandibular nerve.
What are the features of ORNJ?
Not painful until it is large and secondarily infected.
How should ORNJ be treated?
Surgical debridement
HBOT?
Antimicrobials?
vitE?
What causes medication related osteoradionecrosis of the jaw?
Bisphosphonates, Denosumab, antiangiogenic, corticosteroids,(more drugs being implicated)
Inhibit osteoclastic activity & angiogenesis
IV more likely to cause it than oral.
Why are drugs that cause MRONJ used for cancer?
Used to halt the progression of boney malignancies
Amongst other things
10% patients MM
What causes trismus in radiotherapy patietns?
Often due to muscle fibrosis in low and high dose.
