Head and Neck Cancer

Question 1

What is the role of a GDP in cancer patients in terms of screening and referral?

Answer 1

• early detection through soft tissue examination
• photographs
• onwards referral
• pre-treatment assessment

Question 2

What guidance can dentists refer to when treating cancer patients?

Answer 2

• scottish cancer referral guilelines
• NICE: improving outcomes in head and neck cancer
• british association of head and neck oncologists multidisciplinary management guidelines

Question 3

What situations would make a dentist refer a patient on with suspected head and neck cancer?

Answer 3

• stridor (emergency referral required)
• persistant unexplained H&N lumps > 3 weeks
• ulceration or unexplained swelling of oral mucosa > 3 weeks
• all red/mixed red & white patches for > 3 weeks
• persistant hoarseness lasting for > 3 weeks
• dysphagia or odynophagia for > 3 weeks
• persistant throat pain > 3 weeks

Question 4

What is stridor?

Answer 4

Noisy/laboured breathing
- requires emergency referral

Question 5

What is odynophagia?

Answer 5

Pain on swallowing

Question 6

What investigations are done on H&N referral patients?

Answer 6

• biopsy to confirm diagnosis
• CT scan to investigate extent of tumour
• lymph node biopsy
• CT scan to investigate metastasis
• baseline medical testing
• stage & grade cancer

Question 7

Who is part of the multidisciplinary team?

Answer 7

• oncologist
• radiologist
• surgeon
• clinical nurse specialist
• SALT (speech & language therapist)
• dietician
• dentist
• physio
• physchologist
• occupational therapist

Question 8

What is the aim of an MDT?

Answer 8

To provide patient with a collaborative, multi-professional environment facilitating effective care

Question 9

What is involved in a cancer patients dental pre-assessment?

Answer 9

• full IN DEPTH examination
• radiographs ESSENTIAL (OPT and periapicals)

Question 10

What are the aims of dental pre-assessment in cancer patients?

Answer 10

• identify existing oral disease & potential risk of disease
• remove infection/potential infection before treatment
• prepare patient for expected side effects of cancer therapy
• establish oral hygiene regime
• plan post-treatment care

Question 11

Why is it essential to identify existing oral disease & potential risk of disease before starting cancer treatment?

Answer 11

to avoid unscheduled interruptions to primary treatment as a result of dental problems

Question 12

What should dentists provide at the cancer pre-assessment?

Answer 12

• detailed oral hygiene
• fluoride (topical, mouthwash, toothpaste 2000ppm)
• GC tooth mousse
• dietary advice
• PMPR to stabilise perio condition
• consider chlorhexidine mouthwash & gel
• restore carious teeth
• removal of trauma
• impressions: construct fluoride trays, soft splints
• extraction of hopeless teeth

Question 13

What side effect can result from surgical cancer treatment?

Answer 13

• alterations to normal anatomy
• function affected
• appearance affected

Question 14

What side effect does cancer radiotherapy treatment have?

Answer 14

Unavoidable damage to normal tissues surrounding tumours
- altered function

Question 15

What side effect does cancer chemotherapy have on the patient?

Answer 15

Acute mucosal and haematological toxicity

Question 16

What side effects can head and neck cancer treatment have on the patient?

Answer 16

Effects on:
- respiration
- mastication
- swallowing
- speech
- taste
- salivary gland function
- mouth opening

Question 17

What is the dentists role during cancer therapy?

Answer 17

• hygienist support
• oral & denture hygiene
• diet advice
• fluoride preparations
• examine for viral & fungal infections
• treatment/symptom relief of mucositis and xerostomia

Question 18

What is oral mucositis?

Answer 18

SEVERE PAIN produced by mucositis
- begins 1-2 weeks after treatment starts (more common in chemotherapy)
- huge impact on OH
- severe impact on eating

Question 19

How can oral mucositis be prevented/managed?

Answer 19

• Caphosol (neutral supersaturated calcium phosphate mouth rinse)
• Gelclair (polyvinyl sodium hyaluronate gel)
• mucoadhesive oral rinse
• soluble aspirin
• benzydamine hydrochloride (Difflam)
• zinc supplements
• aloe vera
• cryotherapy
• manuka honey

Question 20

What symptoms/signs would suggest that a patient has a score of 2 for Mucositis?

Answer 20

• deep or raspy voice
• some pain upon swallowing
• dry or cracked lips
• tongue has a shiney appearance
• thick or ropey saliva
• reddened or coated mucosa WITHOUT ulceration

Question 21

What signs would suggest that a patient has a score of 3 for Mucositis?

Answer 21

• difficult talking or painful speech
• unable to swallow
• ulcerated bleeding lips
• blistered or cracked tongue
• absent saliva
• ulcerated mucosa with or without bleeding

Question 22

What infections are commun during cancer treatment?

Answer 22

Oral Candida Infections

Question 23

What antifungals may be prescribed if a patient is suffering from candidiasis during cancer treatment?

Answer 23

• chlorhexidine mouthwash
• miconazole (topical)
• fluconazole (systemic)
• nystatin

Question 24

What can sometimes become reactivated during cancer treatment?

Answer 24

Herpes Simplex Virus

Question 25

What is the prodromal period during the reactivation of herpes simplex virus during cancer treatment?

Answer 25

pain prior to ulceration that needs urgent treatment with systemic antivirals

Question 26

How is saliva affected in cancer patients?

Answer 26

Saliva consistency and character is affected
- becomes more viscous & acidic

Question 27

What effects may a cancer patient suffering from xerostomia notice?

Answer 27

Difficulty with :
- chewing
- swallowing
- speech
- taste
- quality of life

Question 28

What can be done to help cancer patient suffering with xerostomia?

Answer 28

• fluoride supplementation
• oral gel or lubricants to protect lips and soft tissues
• Pilocarpine HCl can enhance salivary secretions in patients who have dysfunctional salivary glands
• stimulation by sugar free chewing gum
• salivary replacement

Question 29

What adverse effects can occur due to use of Pilocarpine HCl?

Answer 29

• sweating
• headache
• urine frequency

Question 30

What are the causes for post cancer treatment trismus?

Answer 30

• post-surgical inflammation
• fibrosis of those tissues as a result of chemotherapy and radiotherapy

Question 31

Why are caries a common occurrence in patients being treated for cancer?

Answer 31

• indirect effect of non-surgical treatment
• reduced salivary flow/salivary function
• poor OH due to painful mouth

Question 32

What is one of the most severe and debilitating complications that can follow radiation therapy for head and neck cancer?

Answer 32

Ostoradionecrosis (ORN)
- area of exposed bone of at least three months duration in an irradiated site not due to tumour recurrence

Question 33

How can ORN be prevented in cancer patients?

Answer 33

• removal of teeth with doubtful prognosis
• extractions completed at least 10 days prior to radiotherapy
• encourage healing with primary closure/sutures where possible

Question 34

When are patients at an increased risk of ORN?

Answer 34

• total radiation dose exceeded 60Gy
• dose fraction was large with a high number of fractions
• local trauma as a result of tooth extraction, perio disease or ill-fitting prosthesis
• immunodeficiency
• malnourishment

Question 35

what is stage 0 ORN?

Answer 35

mucosal defects only; bone exposed

Question 36

what is stage I ORN?

Answer 36

radiological evidence of necrotic bone; dento-alveolar only

Question 37

what is stage II ORN?

Answer 37

positive radiographic findings above ID canal with denuded bone intra-orally

Question 38

what is stage III ORN?

Answer 38

clinically exposed radionecrotic bone, verified by imaging techniques, along with skin fistulas & infection
- potential or actual pathological fracture