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Oncology, pharmacology, anaesthetics (IHD DEN303) > Dental implications of managing oncology patients > Flashcards

Dental implications of managing oncology patients Flashcards

1
Q

Oncology statistics

A

300,000 new cases per year
7500 new cases of oral cancer per year
Males (421) > females (376/100,000)
1200 cases of childhood oncology per year

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2
Q

Oral cancer types

A 
90% squamous cell carcinoma
Adenocarcinoma
Teratoma
Melanomas
Rare lesions
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3
Q

Types of oropharyngeal oncology

A

Squamous cell carcinoma

  • HPV positive
  • HPV negative
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4
Q

Types of nasopharyngeal oncology

A

East Asia and Africa
-squamous cell carcinoma
-lymphoepithelioma
Both can be from Epstein-Barr virus

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5
Q

Types of salivary gland tumours oncology

A

Adenocarcinoma

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6
Q

Types of nasal and sinus cancers oncology

A

60% squamous cell carcinoma
10% adenocarcinoma
Lymphomas, plasmacytomas, melanoma

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7
Q

Head and neck oncology epidemiology

A 
Low Socio-economic groups
Smokers
Increased Alcohol Consumption
Poor users of Medical Services
Increased rates of dental disease
Poor dental attendance
Dental phobia
Virus
Hormones 
Genetics
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8
Q

Oral implications of head and neck oncology

A

Direct as a result of the malignancy
Unwanted side effects of cancer therapy
90% Paediatric Oncology cases have oral complications
Survival rate continually improving
-implications for future dental treatment: longevity of the individual, QoL issues

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9
Q

Cancer therapy oral complications

A 
Chemotherapy
Radiotherapy to head and neck region
Bone Marrow Transplantation (BMT)/Haemopoetic Stem Cell Transplantation (HSCT)
-chemotherapy
-total body irradiation
Bisphosphonate Therapy
Monoclonal Antibody Therapy
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10
Q

Oral care pathway

A

RCS England/ BSDH guidelines
Aim to minimise oral complications
90% H&N cancer pts have dental disease
Pre-treatment assessment, dental care in acute phase of cancer therapy, dental care post cancer therapy

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11
Q

Aims of pre-treatment assessment

A

Avoidance of unscheduled interruptions to 1. tx as result of dental problems
Pre-prosthetic planning/ treatment e.g., planning for primary implants/ imps for obturator
Planning for XLA for doubtful prognosis or at risk of dental disease in future and in an area at risk of osteoradionecrosis
XLA as early as possible in pt journey, at least 10 days prior to radiotherapy.
Planning for restoration of remaining teeth as required.
Preventive advice and treatment.
Assess potential for post treatment access difficulties e.g., trismus, microstomia

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12
Q

Oral Care Pathway - prevention

A 
OHI & Dietary Advice ( +Smoking cessation)
High dose fluoride toothpaste
Saliva supplementation
Regular scaling & polishing
Topical Fluoride
Mucositis
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13
Q

Dental Care in acute phase of cancer therapy

A 
Avoided wherever possible
-limit any dental treatment to emergency care only
OH support
Anti-fungals
Denture care
Mucositis
-diet modifications
-2% lidocaine mouthwash
-treatment: Difflam (Benzydamine hydrochloride 15%), allopurinol
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14
Q

OH support in acute phase of cancer therapy

A
  • professional hygienist support
  • brushing, flossing, interdental cleaning
  • alcohol free chlorhexidine
  • anti viral therapy for children with HSCT
  • maintain high dose F- toothpaste & saliva supplementation
  • fluoride mouthrinses (0.05% NaF)
  • topical Fluoride (2.2%)
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15
Q

Anti-fungals in acute phase of cancer therapy

A

Nystatin 100,000 units/ml, 7 days + 48 hours post resolution
Miconazole oral gel 24mg/ml – 10ml QDS
Fluconazole 50mg OD 7-14 days (Oropharyngeal candida)
( Azoles contraindicated with warfarin & statins )

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16
Q

Dental Care in acute phase of cancer therapy - radiotherapy

A

Dress

Extirpate pulps and dress

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17
Q

Dental Care in acute phase of cancer therapy - chemotherapy

A

Low platelet and white cell counts and anaemia
Plan care at optimum point in cycle
Monthly cycles
Dental Tx as close to start of next cycle as possible

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18
Q

Dental care post cancer therapy

A

Risk of uncontrolled dental disease following cancer therapy can continue for at least 12 months following Chemo, radiotherapy, total body irradiation and HSCT
> susceptibility to dental disease can be life long
Growth and development of facial structures and dentition should be closely monitored in children

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19
Q

Dental care post cancer therapy

Prevention and monitoring: children

A
  • should be seen by specialist paediatric dentist and ortho to monitor development every 6 months
  • routine care and preventive dentistry within GDS/ CDS (DBOH, monitor OH, topical fluoride, early intervention with caries)
  • ortho 12 months after all clear
20
Q

Dental care post cancer therapy

Prevention and monitoring: adults

A 
Supervision for 12/12 by named clinician
3/12 Recall interval for at least 12 months
-OH Reinforcement
Topical Fluoride
-application of chlorhexidine gel
Prevention
-caries
-periodontal disease
-mucositis
-trismus
21
Q

Dental care post cancer therapy

General considerations

A 
Uncontrolled perio
-culture - atypical pathogens
Herpes 
-topical acyclovir
Managing caries
-keep simple
-atraumatic 
-stepwise approach
Prosthodontics
Extractions
22
Q

Dental care post cancer therapy

General considerations - prosthodontics

A
  • avoid dentures
  • duplication techniques
  • consider fixed
23
Q

Dental care post cancer therapy

General considerations - extractions

A

Avoid in irradiated pt –> ORN

  • general incidence 7%
  • hyperbaric oxygen (HBOT) incidence 4%
  • antibiotic cover, incidence 6%
24
Q

Risk factors for ORN

A 
Total radiation dose exceeds 60Gy
Dose fraction large + high number fractions
Excess trauma
Immunodeficiency
Malnourished
25
Q

What to do if faced with potential need to extract?

A 
Antibiotic cover
Amoxicillin/Coamoxiclav
Metronidazole (if penicillin allergy)
0.2% chlorhexidine pre-rinse
Adrenaline free LA
Atraumatic
Root canal treatment
De-coronate & RCT
HBOT - specialist care (rest you can do at GDS)
26
Q

Dental care post cancer therapy

Requirements for denture wearers

A 
Leave out at night – except for obturators in first 6 months
Salivary substitutes
> risk of oral candidiasis
-Miconazole gel
-Modified soft liners/tissue conditioners (Nystatin 500,000-1,000,000 units in Viscogel©, Tea tree oil in Coe Comfort©)
-Fluconazole for persistent infections
Replace poor dentures
Tooth borne appliances
27
Q

Dental care post cancer therapy

Management of ORN: staging

A

0: Mucosal defect
I: Radiological evidence of necrotic bone, mucosa intact
II: Radiographic findings + denuded bone visible
III: Exposed necrotic bone with infection + skin fistulas

28
Q

Dental care post cancer therapy

Management of ORN

A 
Referral to oral surgery/ special care dentistry, but maintain shared care
Meticulous oral hygiene
-brushing lesion
-chlorhexidine gel
Soft diet
Gentle scaling/debridement of lesions
Removal of dentures
Monitor lesion by specialist
-surgical intervention
-high dose antibiotic regimes
-HBOT
29
Q

Dental care post cancer therapy

Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): types

A

BRONJ – Bisphosphonate related ONJ

ARONJ –Anti-resorptive Agent-induced ONJ

30
Q

Dental care post cancer therapy

Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): bisphosphonates (including risks)

A 
Oral or IV (Zoledronic Acid)
Bone Metastatic Spread
Risks
-oral    <    IV
1/10,000-1/100,000         1/10 – 1/100
-length of therapy
-extractions
-oral surgery
-intra oral trauma eg poor fitting dentures
31
Q

Dental care post cancer therapy

Prevention and/ or management of medication related osteonecrosis of the jaws (MRONJ): monoclonal antibodies (Mabs)

A

Derived from a single B Cell Lymphocyte clone
No batch to batch variance, therefore effect is more predictable
-Denosumab < Oc differentiation, activity and survival; inhibits bone resorption; SC injection 6 monthly

32
Q

Dental care post cancer therapy

Prevention of medication related osteonecrosis of the jaws (MRONJ)

A 
Meticulous oral hygiene
RCT vs Extractions
Removal/modification of dentures
No periodontal surgery
No implants
33
Q

Management of medication related osteonecrosis of the jaws (MRONJ) if extractions unavoidable

A

Refer for specialist care

  • atraumatic extractions
  • achieve primary closure
  • regular follow-up
34
Q

Management of medication related osteonecrosis of the jaws (MRONJ): refer for specialist care, but maintain shared care

A 
Meticulous oral hygiene
-brushing lesion
-chlorhexidine gel
Soft diet
Gentle scaling/debridement of lesions
Removal/modification of dentures
Monitor lesion by specialist
-surgical intervention
-high dose antibiotic regimes
-HBOT
35
Q

Head and neck MDT

A 
*Multidisciplinary team*
Anaesthetist with a special interest in head and neck cancer
Gastroenterologists, radiologists, surgeons, and other health professionals with expertise in gastrostomy creation, feeding tube placement and support for patients who require tube feeding
Ophthalmologist
Pain management specialist
Therapeutic radiographer
Maxillofacial/dental technician
Dental therapist/hygienist
Benefits advisor
Clinical psychologist
Physiotherapist
Occupational therapist
Neurosurgeon (for skull base)
Neuro-otologist (for skull base)
Palliative care specialist (doctor or nurse)
GMP
GDP
36
Q

Short term side effects of treatment

A

Mucositis: inflammation and ulceration of the mucosal lining of the oral cavity.
Infection: chemotherapy induced neutropenia makes the patient susceptible to bacterial, viral, and fungal infections. Oral candidal infections are extremely common following chemo or radiotherapy.
Xerostomia: dry mouth resulting from a decrease in the production of saliva as a result of radiotherapy.

37
Q

Long-term treatment side effects

A

Altered anatomy
Rampant dental caries: thought to be result of < salivary flow as well as possible direct radiogenic damage to the ADJ
Trismus: may be caused by surgical scarring or by radiotherapy induced fibrosis of MoM
Mastication difficulties: if significant number of opposing pairs of teeth are lost
Osteoradionecrosis: hypovascularity and necrosis of bone followed by trauma induced or spontaneous mucosal breakdown, leading to a non-healing wound.
Xerostomia

38
Q

Preventative management

A

Maintenance of good oral hygiene by effective tooth brushing; flossing daily.
Dietary Advice with regard to caries prevention.
Daily topical fluoride application (2800ppm or 5000ppm fluoride toothpaste) in custom-made trays or brush-on. Daily fluoride mouthrinse.
Daily use of GC Tooth Mousse TM containing free calcium
Saliva replacement therapy/ use of frequent saline rinses
Jaw exercises to reduce trismus (therabite).

39
Q

Rehab for H&N cancer: soft tissue and mandibular recon

A

Flaps

40
Q

Rehabiliation for head and neck cancer

A

Multidisciplinary decision-making should include the patient, surgeon (often in conjunction with plastics) and dental prosthodontist/restorative specialist.
Prosthetics or reconstructive options
-reconstructive should be considered as the defect becomes larger and more complex

41
Q

Palatal obturator

A

A palatal obturator is a prosthesis that totally occludes an opening such as an oronasal fistula They are similar to dental retainers, but without the front wire

42
Q

Implants for H&N cancer

A 
Wide variation between UK centres
Pre vs Post RXT
Primary vs secondary
First line of care vs care when conventional removable failed
Fixed vs Removable ISPs
43
Q

Maxillofacial prosthesis

A 
Need to have a competent maxillofacial technician
Correct materials
Possible alternate application for “dental” implant
Similar prosthodontically driven tx plan
Often conducted by plastics
Eyes
-can have custom painted iris 
-motorised
Ears
Noses
Cheeks
44
Q

Fabrication - maxillofacial prosthesis

A

The mohs procedure had pulled the nasal septum to the right hand side due to scar tissue formation.
Accepted position and worked to maximise the aesthetics from a face-on and lateral view.
the glasses were also tried on with the wax try in to ensure the prosthesis would not lift away from the nasal base.
A small acrylic plate was made to attach the soft silicone prosthesis to, in the area of the bridge of the nose to allow for a strong attachment to the glasses.

45
Q

maxillofacial prosthesis - fit

A

The prosthesis was constructed separate from the glasses in the lab.
A primary try in was conducted and shades taken for extrinsic staining.
At fit, small adjustments were made to the amount of silicone flaring over the skin of the cheek with a scalpel.
After painting the finishing touches to the extrinsic staining at the chair-side, the glasses were attached to the prosthesis using cold cure PMMA resin, after roughening the frame with an acrylic bur

46
Q

When to put primary implants in

A

Where there is continuity of the mandible
In patients who require the prosthetic obturation of significant maxillary defects
Where retention of the obturator is likely to be compromised
In pts undergoing rhinectomy or orbital exenteration.

Oncology, pharmacology, anaesthetics (IHD DEN303) (6 decks)

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