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BDS4 Head and Neck Cancer symposium > Role of Dentist > Flashcards

Role of Dentist Flashcards

1
Q

What are the different steps in the dental journey for a patient with head and neck cancer?

A

Screening and referral
Investigations and Diagnosis
MDT planning
Dental pre-assessment
Cancer treatment
Dental support during tx
End of treatment
Restoration/Rehabilitation
Maintenance
*recurrence

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2
Q

What is the role of the GDP in treating patients with Head and neck cancer?

A

Soft tissue exams (do this every time)

Take photographs- own notes and for Oral med referral

Dental pre-assessment

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3
Q

What guidance should GDPs follow for head and neck cancer?

A
  • Scottish cancer referral guidelines
  • NICE
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4
Q

What are the red flags for cancer referral?

A

Stridor- emergency referral

Persistent unexplained head and neck lumps >3 weeks

Ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks

All red or mixed red and white patches of the oral mucosa persisting for >3 weeks

Persistent hoarseness lasting for >3 weeks (request a chest X-ray at the same time)

Dysphagia or odynophagia (pain on swallowing) lasting for >3 weeks

Persistent pain in the throat lasting for >3 weeks

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5
Q

What is done as part of the pre-treatment work up by OMFS for head and neck cancer?

A
  • CT scan- size, nearby anatomy
  • LN biopsy- is there node involvement?
  • CT scan of rest of body for metastases
  • Performance score- if patient is fit and well, it is likely that they will be successful with treatment
  • Stage and grading
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6
Q

Who are the members of the MDT for head and neck cancer?

A

Oncologist
Radiologist
Surgeons- ENT, plastics, OMFS
Clinical nurse specialist
SALT
Dietician
Restorative dental specialist (implant planning)
Physio
Psychologist

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7
Q

What is the pathway following referral for under suspicion of cancer by GP/GDP?

A

Patient should be seen in 2 weeks
- Within one month- diagnosis, special investigation, decision to treat
- Within 2 months (62 days)- start treatment

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8
Q

What is done in dental pre-assessment?

A

Full Exam

Radiographs- OPT and PA

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9
Q

What are the aims of the dental pre-assessment?

A
  • Identify existing diseases
  • Remove infection
  • Identify potential sources of disease- prevent unscheduled interruptions of cancer treatment
  • Discuss side effects of treatment
  • Establish good OH- expect for this to get harder
  • Enhanced prevention
  • Plan for oral rehabilitation- after treatment (dentures, bridges, implants)
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10
Q

What is provided by the dentist at dental pre-assessment?

A

Detailed oral hygiene – TBI, interdental cleaning

Fluoride: topical application, mouthwash (0.05% alcohol free), fluoride toothpaste

GC Tooth mousse – free calcium

Dietary advice that coincides with the dietitian – emphasis on oral comfort during treatment

PMPR to stabilise periodontal condition

Consider Chlorhexidine mouthwash and gel (alcohol free)

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11
Q

What treatment may a dentist want to carry out in light of dental pre-assessment?

A

Definitively restore carious teeth

Removal of trauma: adjust sharp edges on teeth/dentures

Impressions: construct fluoride trays, soft splints

Denture hygiene and instructions to avoid infection during cancer treatment

Extract teeth with dubious prognosis no less than 10 days before starting cancer treatment

Antibiotic prophylaxis if neutrophils are low and planning invasive treatment – liaise with medics

Orthodontics: discontinue and remove fixed appliances

Smoking and Alcohol advice

Restorative: Study casts for implant planning, pre-treatment records, planning for trismus

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12
Q

What treatments can be offered for head and neck cancer?

A

Surgical resection (remove tumour and margin of healthy tissue)
-> with or without reconstruction

Radiotherapy

Chemotherapy

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13
Q

What are the side effects of surgical treatment for head and neck cancer?

A

Alteration of normal anatomy affecting aesthetics and function

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14
Q

What kind of grafts can be used in surgical treatment of head and neck cancer?

A

 Skin can be used to recreate tongue
 Bone from leg can be used for jaw bone reconstruction

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15
Q

What are the side effects of chemotherapy?

A

Acute mucosal toxicity

Haematological toxicity- accentuated if delivered concurrently with radiation therapy

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16
Q

What is the role of the dentist during a patients treatment for head and neck cancer?

A

Hygienist support

Oral and Denture hygiene

Antibacterial MW (alcohol free) e.g. Chlorhexidine – short term alternative to brushing

Diet advice

Fluoride preparations (topical, toothpaste, MW, fluoride
trays)

High risk of viral and fungal infections – examine for this and prophylaxis or treatment prescribed by cancer team

Treatment/Symptom relief of mucositis, xerostomia

Emergency dental treatment: liaise with cancer team (delay cancer treatment?)

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17
Q

What is the most common part of mouth for oral cancer?

A

Lateral border of the tongue

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18
Q

What is mucositis?

A

inflammation and ulceration of mucosa
-> more commonly associated with chemo

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19
Q

When does mucositis caused by chemo tend to start, how long does it last?

A

Begins 1-2 weeks after treatment starts
-> Lasts until ~6 weeks after treatment is complete

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20
Q

What are the issues with mucositis?

A
  • Patient may be admitted into hospital- issues with eating, swallowing, talking
  • PEG fed
  • Severe pain- given opiates (morphine)
  • May get secondary infection superimposed
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21
Q

What medical treatments can be used to prevent and manage Oral mucositis?

A
  • Caphosol
  • Gelclair
  • Mugard
  • Difflam- benzydamine (contains alcohol- so can be sore initially)
  • Soluble aspirin
  • Aloe vera (with tea tree oil)
  • Zinc supplements
  • Crytho-therapy
  • Ice chips/lollies
  • Manuka honey
  • Lidocaine mouthwash 2%
  • Low level laser therapy (only for radiotherapy induced)
  • Strong analgesics
  • Saline/bicarbonate mouth rinse
  • To prevent- OH, check no ill fitting dentures, IV keratinocyte growth factor
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22
Q

What are the features of grade one mucositis?

A

Normal voice

Normal swallowing

Smooth moist lips

Tongue- pink and moist with papillae

Watery saliva

Mucous membranes- moist and pink

23
Q

What are the features of grade 2 mucositis?

A

Deeper or raspy voice

Some pain on swallowing

Dry/cracked lips

Coated tongue, loss of papillae

Thick or ropy

Mucous membrane- reddened or coated

24
Q

What are the features of grade 3 mucositis?

A

Pain on speech- difficulty talking

Unable to swallow

Ulcerated/bleeding lips

Blistered/cracked tongue

Absent saliva

Mucous membranes- ulceration and bleeding

25
Q

What antifungals can be prescribed by GDP for treatment of opportunistic candidiasis in patients undergoing cancer treatment?

A

Chlorhexidine mouthwash, gel

Miconazole - topical

Fluconazole – systemic

Nystatin (less effective)

-> may be prescribed prophylactically

26
Q

Why does traumatic ulceration occur in cancer patients, what can be done to help prevent it?

A

Occurs due to dry, tender delicate mucosa
-> Can give soft splint to prevent teeth contacting mucosa

27
Q

Why is reactivation of herpes virus in cancer patients considered atypical?

A

Widespread lesions throughout mouth, slow healing, aggressive

28
Q

What should be done in the prodrome period inn herpes reactivation?

A

Urgent prescription of antivirals

29
Q

How does cancer treatment affect salivation?

A

Reduced salivary flow 50-60% in first week with a further 20% in next 5-6 weeks
- Might be due to salivary gland removal
- Continues after treatment
- Often never recovers

30
Q

What changes to saliva is caused by cancer tx?

A

Becomes more viscous and acidic

31
Q

What are the effects of xerostomia?

A

Issues with:
chewing
swallowing (dysphagia)
speech (dysarthria)
taste (dysgeusia)
quality of life

Higher risk of:
caries
periodontal disease
candida
sialadenitis
prosthodontic difficulties

32
Q

What are the features and functions of pilocarpine?

A

Encourages residual function of salivary glands
- 5mg TDS orally
- Does not help when medication stopped
- Side effects not well tolerated- sweating, headache, urinary frequency

33
Q

How does radiotherapy cause xerostomia?

A

Ionising radiation damages salivary glands

34
Q

How is Xerostomia managed?

A

F supplementation to prevent caries

Oral gel/lubricants- vaseline and emollients (cetraben)

Regular sips of water

Chewing gum

Acidic pastilles- beware of erosion

Saliva replacements- oral balance, saliva orthana, biotene
-> care as these contain animal products

35
Q

What is trismus?

A

Restricted/limited mouth opening

36
Q

What are the causes of Trismus?

A

Post-surgical inflammation

Fibrosis of those tissues as a result of chemotherapy and radiotherapy

Reduction of mouth opening due to tumour recurrence

37
Q

What is the course of trismus following radiotherapy treatment?

A

Trismus that follows radiotherapy can occur rapidly over the first 9 months after treatment, tends to be progressive and may be irreversible

38
Q

What can trismus affect a patients ability to do?

A

Eat

Speak/laugh

Yawning

Sexual intimacy

Access for oral self care and access for oral care by any dental professional

39
Q

How is trismus treated?

A

Physical therapy modalities
-> passive and active stretching exercises

Use of devices for stretching the muscles of mastication -> Therabite and and stacked tongue depressors

40
Q

What are the cause of dental erosion in cancer patients?

A
  • Poor saliva
  • Use of glandosane
  • Drinking acidic drinks or foods due to taste issues
41
Q

What causes caries in patients receiving cancer treatment?

A

Xerostomia

Difficulty performing OH- pain, ulcers, mucositis

Diet change- food sticks and plaque builds up due to lack of clearance, taste changes

42
Q

What pattern does radiation caries follow?

A

Cervical margins of teeth, incisal edges, can be around full neck

-> rapidly progressing

43
Q

What is the issue with radiation caries?

A

Difficult to restore- teeth flex more at cervical margins

44
Q

What causes patient with cancer to get periodontal disease?

A

Patients have more pressing concerns than oral hygiene during and after treatment

Can be affected by depression and poor self care

45
Q

What is ORN?

A

An area of exposed bone of at least three months duration in an irradiated site and not due to tumour recurrence

46
Q

How is ORN prevented?

A
  • Remove teeth of poor prognosis within radiotherapy field (at least 10 days prior to treatment)
  • Atraumatic technique- periotomb
  • Enhanced prevention
  • Consider SDA
  • Prophylactic hyperbaric oxygen therapy for extractions
  • AB given before during and after extractions
  • Close extraction site with sutures to encourage primary closure
  • Consider root treatment and crown amputation
  • Consider pentoxyphilline (antioxidant- encourages BV formation and reduces inflammation) 800mg per day and Vit E 1000 IU per day
47
Q

WHat are the risk factors for ORN

A

Patient’s total radiation dose exceeded 60Gy

Dose fraction was large with a high number of fractions

Local trauma as the result of a tooth extraction (especially mandibular extractions)

Uncontrolled periodontal disease

Ill-fitting prosthesis

Patient is immunodeficient/malnourished

48
Q

What are the stages of ORN?

A

0- mucosal defects only, bone exposed
1- radiographic evidence of necrotic alveolar bone
2- Postive radiographic finding above ID canal with denuded bone intra-orally
3- clincially exposed radionecrotic bone verified with imaging with skin fistulas, fractures

49
Q

What may 2 Small white lines on an OPT be?

A

Surgical staples used to close blood vessels

50
Q

What restorative material is preferred in cancer patients?

A

Resin based
-> avoids excess removal of tooth tissue

SSC

51
Q

What options are there for rehabilitation in cancer patients?

A

Implants- must be able to look after them and have motivation (must be specialist)
-> failure usually avoided if <45gy

Avoid dentures where possible- but may be required to help them chew and gain weight

52
Q

What is an obturator, what is required?

A

Denture with plug for hole or gap created by surgery
- Helps with vocal resonance and breathing
- First 6 months- don’t remove obturator at night to allow area around to heal
- Daily cleaning required

53
Q

What is palliative care and its aims?

A

For patients who do not respond to cancer treatment
 Keep patient comfortable and pain free
 May have to attend a hospice

54
Q

What is done in terms of dental care following cancer treatment?

A

Discharge to GDP from special care- when initial side effects have stopped
 If difficult- shared care, second opinions
 Even compliant patients still have risks

BDS4 Head and Neck Cancer symposium (5 decks)

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