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Prof Lee > Week 10- Oral Health and Cancer Therapy > Flashcards

Week 10- Oral Health and Cancer Therapy Flashcards

1
Q

How does chemoradiotherapy affect salivary glands?

A
  • More than just dry mouth
  • Cell death and fibrosis
  • Loss of functional architecture of glands
  • Serous acini more affected
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2
Q

What are the oral issues associated with chemoradiotherapy?

A 
Salivary gland dysfunction
Dysgeusia
Radiation caries
Radiation damage to teeth
Periodontitis
Trismus
ORN
Mucositis
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3
Q

How much radiation reduces salivary flow within 24 hours?

A

2.2Gy

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4
Q

How much radiation causes permanent hyposalivation?

A

40Gy

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5
Q

How does saliva appear in patients with salivary gland dysfunction?

A

Thick, ropey or aerated

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6
Q

What are the functions of saliva?

A 
Lubrication
Cleansing
Antimicrobial
Remin
Buffering
Mucosal integrity 
Digestion & taste
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7
Q

How does radiation cause dysgeusia?

A

Caused by hyposalivation and radiation injury to taste buds

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8
Q

When do taste buds recover following radiation?

A

Partial restoration of taste 20-60 days post RT.
Full restoration after 2-4 months.
Some report long term changes.

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9
Q

What is graft vs host disease?

A

Donor T cells react against pt tissues directly or through exaggerated inflammatory responses following HCT.

Acute and chronic forms.

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10
Q

What primary organs/structures are involved in graft vs host disease?

A

Skin
Liver
GIT
Oral mucosa

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11
Q

What are the oral manifestations and symptoms of graft vs host disease?

A 
Pseudomembranous ulceration
Erythema and atrophy (acute)
Lichenoid hyperkeratotic changes (chronic)
Dysgeusia 
Salivary gland dysfunction
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12
Q

Why does radiation caries occur?

A 
Shift to cariogenic flora
Reduced salivary antimicrobials
Loss of bioavailable calcium phosphate
Weakens dentine-enamel bonds
Alters prismatic enamel structure
Denatures collagen in dentine
MMPs hydrolyse dentine bonding agents
Can alter pulp vascularity & capacity to repair
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13
Q

Is graft vs host disease a consequence of chemoradiotherapy?

A

No

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14
Q

Where does radiation caries occur?

A

Different locations than common dental decay.

  • Labial surfaces
  • Incisal/cuspal tips
  • Proximal surfaces of lower anteriors
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15
Q

Why is radiation caries common in lower anteriors

A

Usually lower anteriors are bathed in saliva so they aren’t susceptible to caries. However, with salivary gland dysfunction, caries can occur frequently here. Distance between proximal surface and pulp is small for md anteriors.

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16
Q

What are prevention strategies for radiation caries?

A 
Tooth mousse plus
Bicarb mouth rinses
Immaculate OH
High F toothpaste low in SLS
Dietary advice
Regular recalls- 3 monthly
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17
Q

What toothpaste is recommended for patients at risk of radiation caries?

A

neutrofluor sensitive (low in SLS) as it is less irritant to mouth.

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18
Q

Why is GIC used in patients with radiation caries despite its high chance of crazing and getting lost in dry environment?

A

Potential to release fluoride so it’s unlikely to get recurrent caries.
Also, better to loose resto than get recurrent caries. Not always bad to lose the filling as the pt keeps coming back.

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19
Q

What are issues with amalgam in patients with radiation caries?

A

Amalgams cause backscatter and subsequent local mucositis

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20
Q

What are issues with composite in patients with radiation caries?

A

High rates of loss and recurrent caries.

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21
Q

What are issues with full coronal restorations in patients with radiation caries?

A

Margins vulnerable to recurrent caries.

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22
Q

If pt develops caries around crown margins how can it be treated?

A

Place AgF instead of replacing crowns. Can also place GIC

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23
Q

What are the ideal properties of RM-GIC in relation to radiation caries?

A

Similar recurrent caries rates to GIC.

More resistant to acid and crazing.

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24
Q

Why are dentures contraindicated in patients undergoing chemo-radiotherapy?

A

Can compromise plaque control and increase risk of ORN. Avoid in partial dentate unless essential aesthetics and function.

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25
Q

What are issues with performing endo in patients undergoing chemoradiotherapy?

A

Trismus complicates endo- rubber dam, access cavity, instrumentation. Access cavities through incisal or labial aspect or decoronating tooth may improve access.

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26
Q

If teeth are deemed unrestorable in pts undergoing chemoradiotherapy, how should they be treated?

A

Root fill and seal to control symptoms and infection rather than do exo.

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27
Q

What doses of radiation often cause trismus? When can it start to occur?

A

> 60Gy

May begin at the end of radiotherapy or anytime in the subsequent 24 months

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28
Q

What happens if TMJ or muscles of mastication are in field of radiation?

A

Fibrosis and damage

abnormal proliferation of fibroblasts, scar tissue and nerve damage

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29
Q

What are oral issues with trismus?

A 
Eating
Speaking
Removable dental prostheses
Dental exam & tx
OH
30
Q

How can trismus be managed?

A 
Early tx can prevent/minimise effects
Stacking wooden tongue depressors together 3-4x/day (add more over time)
Therabite device or Dynasplint Trismus system
Trigger point injections
Analgesics
Muscle relaxants
Botulinum toxin
Heat pack
31
Q

What is mucositis?

A

Mucosal damage secondary to cancer therapy occurring in the oral cavity, pharyngeal, laryngeal, esophageal and GI regions

32
Q

What does mucositis cause?

A 
Pain
Ulceration
Painful swallowing
Dysgeusia
Dehydration
Malnutrition
33
Q

What is the pathogenesis of mucositis?

A

Direct mucosal injury by radiation/chemotherapy interferes with oral epithelial turnover time and induces apoptosis.

34
Q

What are the phases of mucositis?

A

1st: Inflammatory/vascular (initiation)
2nd: epithelial (messaging, signalling and amplification)
3rd: ulcerative/bacteriological (pseudomembranous)
4th: healing

35
Q

What is involved in the 1st phase of mucositis (inflammatory/vascular)?

A

Tissue injury induces release of reactive oxygen species, proteins and cytokines, causing more damage.

36
Q

What is involved in the 2nd phase of mucositis (epithelial)?

A

4-5 days after cytotoxic tx.

Upregulation of pro-inflammatory cytokines, tissue injury and cell death.

37
Q

What is involved in 3rd phase of mucositis (ulcerative/bacteriological)

A

Epithelial breakdown 1 week after start of tx.
Colonisation of gram -ve mircrobes and yeast.
Release of inflammatory mediators

38
Q

What is involved in the 4th phase of mucositis (healing)?

A

From day 12-16

Restore integrity of epithelium.

39
Q

What is the degree and duration of radiotherapy induced mucositis related to?

A 
Radiation source
Cumulative dose
Dose intensity
Volume of irradiated mucosa
Smoking & alcohol consumption
Salivary hypofunction
Infection
40
Q

How does saliva contribute to mucositis?

A

Decreased production
Reduced buffering capacity
Increase in viscosity & acidity
Reduced oral IgA favoring growth of highly cariogenic and infectious oral flora.

41
Q

What are the earliest signs and symptoms of mucositis?

A

Erythema
Oedema
Burning sensation
Inc sensitivity to hot/spicy food

42
Q

What do erythematous areas (associated with mucositis) develop into?

A

White desquamative patches and then painful ulcers (high risk of secondary infection)

43
Q

What are the most vulnerable areas for mucositis?

A 
Movable non-keratinised mucosa of soft palate
Cheeks
Lips
Ventral surface of tongue
FOM
44
Q

Does mucositis scar?

A

Often no scarring unless complicated by serious infection or xerostomia

45
Q

What are the 4 grades of mucositis?

A

Grade 0: none
Grade 1: mild (sore mouth)
Grade 2: moderate (ulcers)
Grade 3: severe (can only swallow liquids)
Grade 4: life threatening (can’t eat or drink)

46
Q

What is the impact of oral mucositis on QoL?

A 
Pain
Poss oral bleeding
Impact on communication, speech and expression
Difficultly with denture use, OH, dysgeusia, bad breath, dysphagia. 
Poor nutrition and hydration 
Oral medication difficult to take
Portal for systemic infection
Hospitalisation
Increased cost of care
47
Q

What are the 3 management objectives for mucositis?

A

Prevent/reduce mucositis
Alleviate symptoms
Avoid secondary complications (dehydration, infection, poor nutrition)

48
Q

What factors may worsen mucositis?

A

Poor oral care
Ill fitting prosthesis
Ortho appliances
Defective restos

49
Q

Can dentures be used in patients commencing chemoradiotherapy?

A

May be able to use dentures to maintain nutrition but may need to leave out if mucositis worsens. Can cause trauma, hang onto plaque and increase risk of bacteria getting into sores.

50
Q

What should you do prior to pt commencing chemoradiotherapy?

A

Thorough assessment
Dental procedures performed at least 3 weeks before therapy
Good oral care

51
Q

What is the typical mucositis and caries management for pts undergoing chemoradiotherapy?

A

MUCOSITIS MANAGMENT: Start difflam oral rinse at commencement of chemoradiotherapy (delays mucositis onset)
If they get mucositis, switch to 0.12% Curasept (helps keep mouth clean).

CARIES RISK MANAGMENT: Get them to use CCP and high fluoride toothpaste

52
Q

What is the typical prevention regime for patients undergoing chemoradiotherapy?

A

Topical fluoride followed by CPP-ACP, starting 1 week before radiotherapy & continued
Foam brushes and rinses to reduce risk of microtrauma.
Avoid removable prosthesis (except while eating)
Refrain from smoking and food/drink that can cause irritation.
Saliva substitutes
Bicarb rinse after eating
Difflam, curasept
Natural yoghurt
Xylocaine gel

53
Q

How should candidosis be treated?

A

Miconazole

54
Q

Why is nystatin rubbish at treating candidosis?

A

Full of sugar so feeds the candida as well

55
Q

Why are amphotericin b lozenges ineffective at treating candidosis in chemoradiotherapy patients?

A

They need saliva to dissolve them.

56
Q

How can pain relief be provided for patients with mucositis?

A 
Topical anaesthetics
Difflam (anti-inflamm)
Bicarb/salt rinse
Systemic analgesics
Crytherapy
57
Q

Why is cryotherapy effective in reducing severity of oral mucositis?

A

Causes vasoconstriction so may reduce amount of chemotoxic agent being delivered to oral mucosa.

58
Q

What mouth rinse should be used prior to development of ulceration and what should be used following?

A

Prior: Difflam
Following: 0.12% Curasept

59
Q

What is osteoradionecrosis?

A

Exposed and necrotic bone associated with ulcerated or necrotic soft tissue which persists for >3months in an area that has been previously irradiated

60
Q

What are the 3 classes of ORN?

A

Notani I: confined to dentoalveolar bone
Notani II: ORN limited to dentoalveolar bone &/or mandible above the inferior dental canal
Notani III: ORN involving the md below the inferior dental canal or pathological fracture or skin fistula.

61
Q

What are the effects of ORN?

A 
Pain
Infection
Loss of function
Malodour
Pathological md fracture
Disfigurement
Social isolation
62
Q

What is the triad in pathophysiology of ORN?

A

Radiation
Trauma
Infection

63
Q

Where is bacteria present in ORN?

A

Only present on surface of bone and not in the necrotic area.

64
Q

What is theory of pathogenesis 2 for ORN?

A

Major driving force behind pathogenesis was hypoxia resulting in the hypoxic-hypocellular-hypovascular theory (hyperbaric oxygen is used to treat ORN)

65
Q

What is radiation induced fibroatrophic theory for ORN?

A

Activation & deregulation of fibroblastic activity.
Imbalance between between tissue synthesis and degradation.
Results in fragile healed tissues.

66
Q

Why is the buccal cortex of the mandible the most common place of ORN?

A

Dense bone and higher mineral content absorb a higher radiation dose.

67
Q

What are risk factors for ORN?

A 
Location (tongue, FOM, alveolar ridge, retromolar pad, tonsil)
Stage of cancer 
Dose of radiation (>60Gy)
Prior surgery for tumour in jaw
Having teeth
Poor OH
Smoking & alcohol
Poor nutrition
68
Q

How can you prevent ORN post radiotherapy?

A 
Dental exam prior to radiotherapy
Perform exos 2-3 weeks prior to tx
Management of OH and preventative strategies
Dietary advice
Regular dental recalls
69
Q

What the are the guidelines for management of patients who require dento-alveolar surgery and have previously had radiotherapy or been diagnosed with ORN? (tx planning, preop, peri-op, post op).

A

Tx planning: informed consent, place on operating list with senior staff.
Pre-op: rinse with mouthwash containing CHX, prophylactic AB.
Peri-op: Conservative surgical technique, primary closure of soft tissues where poss.
Post-op: CHX rinse for 2 weeks, post op antibiotics for 5 days.

70
Q

How should ORN be managed conservatively?

A

Systemic AB saved for episodes of acute infection.
Gentle removal of sequestra.
Reduction of local irritants (smoking, alcohol)

71
Q

How does Pentoxfiylline-Tocopherol-Clodronate (Pentoclo) work?

A

Vasodilation
Inhibits inflammatory reactions
Vit E scavenges for reactive oxygen species
Inhibits osteoclastic destruction and osteolysis

72
Q

How can ORN be managed surgically in advanced cases?

A

Radical resection and reconstructive surgery.

Prof Lee (2 decks)

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