Role of Dentist Flashcards
What are the different steps in the dental journey for a patient with head and neck cancer?
Screening and referral
Investigations and Diagnosis
MDT planning
Dental pre-assessment
Cancer treatment
Dental support during tx
End of treatment
Restoration/Rehabilitation
Maintenance
*recurrence
What is the role of the GDP in treating patients with Head and neck cancer?
Soft tissue exams (do this every time)
Take photographs- own notes and for Oral med referral
Dental pre-assessment
What guidance should GDPs follow for head and neck cancer?
- Scottish cancer referral guidelines
- NICE
What are the red flags for cancer referral?
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
What is done as part of the pre-treatment work up by OMFS for head and neck cancer?
- 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
Who are the members of the MDT for head and neck cancer?
Oncologist
Radiologist
Surgeons- ENT, plastics, OMFS
Clinical nurse specialist
SALT
Dietician
Restorative dental specialist (implant planning)
Physio
Psychologist
What is the pathway following referral for under suspicion of cancer by GP/GDP?
Patient should be seen in 2 weeks
- Within one month- diagnosis, special investigation, decision to treat
- Within 2 months (62 days)- start treatment
What is done in dental pre-assessment?
Full Exam
Radiographs- OPT and PA
What are the aims of the dental pre-assessment?
- 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)
What is provided by the dentist at dental pre-assessment?
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)
What treatment may a dentist want to carry out in light of dental pre-assessment?
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
What treatments can be offered for head and neck cancer?
Surgical resection (remove tumour and margin of healthy tissue)
-> with or without reconstruction
Radiotherapy
Chemotherapy
What are the side effects of surgical treatment for head and neck cancer?
Alteration of normal anatomy affecting aesthetics and function
What kind of grafts can be used in surgical treatment of head and neck cancer?
Skin can be used to recreate tongue
Bone from leg can be used for jaw bone reconstruction
What are the side effects of chemotherapy?
Acute mucosal toxicity
Haematological toxicity- accentuated if delivered concurrently with radiation therapy
What is the role of the dentist during a patients treatment for head and neck cancer?
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?)
What is the most common part of mouth for oral cancer?
Lateral border of the tongue
What is mucositis?
inflammation and ulceration of mucosa
-> more commonly associated with chemo
When does mucositis caused by chemo tend to start, how long does it last?
Begins 1-2 weeks after treatment starts
-> Lasts until ~6 weeks after treatment is complete
What are the issues with mucositis?
- Patient may be admitted into hospital- issues with eating, swallowing, talking
- PEG fed
- Severe pain- given opiates (morphine)
- May get secondary infection superimposed
What medical treatments can be used to prevent and manage Oral mucositis?
- 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
What are the features of grade one mucositis?
Normal voice
Normal swallowing
Smooth moist lips
Tongue- pink and moist with papillae
Watery saliva
Mucous membranes- moist and pink
What are the features of grade 2 mucositis?
Deeper or raspy voice
Some pain on swallowing
Dry/cracked lips
Coated tongue, loss of papillae
Thick or ropy
Mucous membrane- reddened or coated
What are the features of grade 3 mucositis?
Pain on speech- difficulty talking
Unable to swallow
Ulcerated/bleeding lips
Blistered/cracked tongue
Absent saliva
Mucous membranes- ulceration and bleeding
What antifungals can be prescribed by GDP for treatment of opportunistic candidiasis in patients undergoing cancer treatment?
Chlorhexidine mouthwash, gel
Miconazole - topical
Fluconazole – systemic
Nystatin (less effective)
-> may be prescribed prophylactically
Why does traumatic ulceration occur in cancer patients, what can be done to help prevent it?
Occurs due to dry, tender delicate mucosa
-> Can give soft splint to prevent teeth contacting mucosa
Why is reactivation of herpes virus in cancer patients considered atypical?
Widespread lesions throughout mouth, slow healing, aggressive
What should be done in the prodrome period inn herpes reactivation?
Urgent prescription of antivirals
How does cancer treatment affect salivation?
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
What changes to saliva is caused by cancer tx?
Becomes more viscous and acidic
What are the effects of xerostomia?
Issues with:
chewing
swallowing (dysphagia)
speech (dysarthria)
taste (dysgeusia)
quality of life
Higher risk of:
caries
periodontal disease
candida
sialadenitis
prosthodontic difficulties
What are the features and functions of pilocarpine?
Encourages residual function of salivary glands
- 5mg TDS orally
- Does not help when medication stopped
- Side effects not well tolerated- sweating, headache, urinary frequency
How does radiotherapy cause xerostomia?
Ionising radiation damages salivary glands
How is Xerostomia managed?
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
What is trismus?
Restricted/limited mouth opening
What are the causes of Trismus?
Post-surgical inflammation
Fibrosis of those tissues as a result of chemotherapy and radiotherapy
Reduction of mouth opening due to tumour recurrence
What is the course of trismus following radiotherapy treatment?
Trismus that follows radiotherapy can occur rapidly over the first 9 months after treatment, tends to be progressive and may be irreversible
What can trismus affect a patients ability to do?
Eat
Speak/laugh
Yawning
Sexual intimacy
Access for oral self care and access for oral care by any dental professional
How is trismus treated?
Physical therapy modalities
-> passive and active stretching exercises
Use of devices for stretching the muscles of mastication -> Therabite and and stacked tongue depressors
What are the cause of dental erosion in cancer patients?
- Poor saliva
- Use of glandosane
- Drinking acidic drinks or foods due to taste issues
What causes caries in patients receiving cancer treatment?
Xerostomia
Difficulty performing OH- pain, ulcers, mucositis
Diet change- food sticks and plaque builds up due to lack of clearance, taste changes
What pattern does radiation caries follow?
Cervical margins of teeth, incisal edges, can be around full neck
-> rapidly progressing
What is the issue with radiation caries?
Difficult to restore- teeth flex more at cervical margins
What causes patient with cancer to get periodontal disease?
Patients have more pressing concerns than oral hygiene during and after treatment
Can be affected by depression and poor self care
What is ORN?
An area of exposed bone of at least three months duration in an irradiated site and not due to tumour recurrence
How is ORN prevented?
- 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
WHat are the risk factors for ORN
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
What are the stages of ORN?
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
What may 2 Small white lines on an OPT be?
Surgical staples used to close blood vessels
What restorative material is preferred in cancer patients?
Resin based
-> avoids excess removal of tooth tissue
SSC
What options are there for rehabilitation in cancer patients?
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
What is an obturator, what is required?
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
What is palliative care and its aims?
For patients who do not respond to cancer treatment
Keep patient comfortable and pain free
May have to attend a hospice
What is done in terms of dental care following cancer treatment?
Discharge to GDP from special care- when initial side effects have stopped
If difficult- shared care, second opinions
Even compliant patients still have risks
