Head and Neck Cancer Flashcards
the role f the dentist and the dental team
- Early detection of soft tissue lesions
- Soft tissue screen on every pt at every appointment
- Pre-treatment assessment and dental care
- Minimal role during treatment unless special interest
- Maintenance of oral and dental health post-treatment
- Palliative care
dental team needs to ensure oral cancer
≠ Dental Disease
pt journey who has cancer in relation to dental care
screening and referral
investigations
dental pre-assessment
support through treatment
- Try to avoid invasive treatment whilst they are undergoing tx
restoration
maintenance and post tx management
head and neck referral guide
emergency referral
- emergency referral - stridor
head and neck cancer dental referral guidelines
Scottish Cancer Refferal Guide - head and neck
- NICE: Improving Outcomes in Head and Neck Cancers
- BAHNO/ Multidisciplinary Management Guidelines
- The Royal College of Surgeons of England/ The British Society for Disability and Oral Health
- Restorative Dentistry: Predicting and Managing Oral and Dental Complications of Surgical and Non-Surgical Treatment for Head and Neck Cancer
head and neck cancer
urgent suspcision of cancer referral for head and neck
- persistent unexplained head and neck lumps for >3 weeks
- ulceration or unexplained swelling of the oral mucosa persisting for >3 weeks
- all red or mized red and white patches of the oral mucosa persisting for >3 weeks
- persistent hoarseness lasting for >3weeks (request chest X-ray as well)
- dysphagia or odynophagia (pain on swallowing) lasting for >3weeks
- persistent pain in the throart lasting for >3weeks
thyroid cancer
urgent suspcision of cancer referral for thyroid cancer
- solitary nodule increasing in size
- thyroid swelling in pre-pubertal pt
- thyroid swelling in 1 or more of the following risk factors:
- neck irradiation
- family history of endocrine tumour
- unexplained hoarseness
- cervical lymphadenopathy
aim of West of Scotland head and neck cancer managed clinical network
equitable management of pts across the West of Scotland to ensure that every pt will be dentally screened prior to entering tx
have dentist check of pt before pt with head and neck cancer tx begins
2013 – Scotland try to ensure that every pt be dentally rescreened prior to entering tx course
- Pt can refuse
impacts of oral cancer
- airway
- upper GI tract
- major senses
- visible cancer - can be difficult to hide
parts of pre-assessment and treatment dentally for cancer pt
- history taking - medical, dental social
- oral and dental assessment prior to start cancer therapy
- any necessary tx carried out
- pre-tx dental scaling by hygienist and OHI
- impressions for fluoride trays
- potentially make a soft splint for lowers - in case of severe ulceration - aid protection of soft tissues
why is pre-assessment history taking important
medical dental and social
need to find out as much as possible
what will be done as part of oral and dental assessment prior to cancer therapy
Radiographs (OPT/ Periapicals)
- Ensures don’t miss anything
- Bone levels, impacted 8s etc
why is any necessary dental tx carried out before cancer therapy begins
Dentally fit prior to oncological care
- Don’t want anything that is a potential source of infection
- Can be radical – RCT not allowed – risk fail
Availability of immediate treatment
- Need to see them timely – so cancer tx can be started ASAP
role of fluoride trays
aid in fluoride therapy for dentate cancer pts
3 pre tx dental assessment priorties
oral hygiene and fluoride
reduce tx complications
reduce post tx complications
why is oral hygiene and F instruction and maintenance important in pre tx dental assessment
won’t prevent mucositis happening but will shorten its duration
what complications are pre tx dental assessment trying to reduce
- Avoid unscheduled interruption of chemotherapy regimen
- Avoid exacerbation of mucositis
- Remove potential sources of infection
what post tx complications is the pre tx dental assessment trying to reduce
- Remove teeth of dubious prognosis – forward planning
- Institute preventive regime
- Plan rehabilitation
- E.g. bridge, denture (CoCr/Acrylic), implants
effect of radiotherapy on
skin and mucosa
erythema
ulceration
mucositis
effect of radiotherapy on
muscle and connective tissue
fibrosis of deeper layers -> trismus
if mouth opening less than 35mm it is very difficult to carry out any Tx
effect of radiotherapy
on saliva glands
dry mouth
effect of radiotherapy
teeth and supporting tissues
dental caries and sequelae
effect of radiotherapy
on bone
endarteritis obliterans O.R.N
little BV in bone close off - no blood flow there -> osteoradionecrosis
why is it key to have mouth as clean as possible prior to tx starting
chlorohexidine gel can be rubbed on if sore to brush due to mucositis - only effective on clean teeth at preventing plaque build up
can have a preventative region in place
most common site for squamous cell carcinoma
lateral border of tongue
Need gauze to hold tongue and manipulate to ensure doing soft tissue exam properly
radiotherapy tx of this SCC could result in
first
- Tumour nearly completely gone
- Teeth not in good condition – plaque
- Tongue sore – at erythematous stage
- As progresses through radiotherapy
later
- As progresses through radiotherapy get ulceration on side of tongue and cheek
- Plaque build-up further as so painful to brush
dentistry considerations during oncology tx
Oral ulceration and Oral infection e.g. develop an abscess suddenly
Emergency dental treatment only
-
Never treat pt during their oncology tx without liaison with medical team
- Is it safe to provide dental treatment?
- Pick right time, bloods OK, ensure not make matters worse
- Do we need to delay chemo / radiotherapy?
- Try hard to avoid
what can be a good management startegy for sore ulceration in oncology pt
Get impression for soft splint when taking F tray impression easier to do then so ready if needed
mucositis causes ulceration
Inflammation and ulceration
- Severe pain
- Analgesia required
- Paracetamol may not be enough go onto opioid based analgesia to gain degree of comfort
Chemo- and radiotherapy - both look similar
Impact on
- Eating
- NG nasogastric tube
- PEG tube
- RIG – radiologically inserted gastrostomy tube
- OH
Exacerbating factors
impact of mucositis
Eating
- NG nasogastric tube
- PEG tube
- RIG – radiologically inserted gastrostomy tube
OH
due to severe pain
oral candidosis
‘disease of the diseased’
- Oral carriage of yeasts common among cancer patients (47-87%).
- Oral candidosis a frequent clinical problem (8-94%).
thrush - extremely uncomfortable
viral infections in oncology tx
Reactivation of Herpes Simplex
- Often intra-oral and clinically atypical – all different
Painful oral ulceration of sudden onset.
More extensive, slow healing & aggressive
High index of clinical suspicion
- Often with prodromal pain comes before ulcers
- Treat as quick as possible with antiviral agents
dry mouth tx options for children
Tooth mousse
- decrease sensitivity, neutralise pH*
- Contains casein (milk protein), calcium and phosphate*
why does xerostomia occur in oncology tx
Salivary flow dec
- 50 – 60% in first week
- Further 20% in next 5 – 6 weeks
Saliva consistency and character
- Viscosity inc
- pH dec
- bad for highly mineralized enamel
dental effects of xerostomia
dental erosion
caries
- less saliva buffering
- change in diet/taste - supplements?
- swallowing impaired
- OH can be poorer as pain due to lack of saliva
radiation induced caries
Very prevalent
- Smooth surface cervical caries
Hard to restore
- Location
- Restorations dry out and fall out
- Continuing battle
- Cervical decay becomes circumferential and teeth snap off
periodontal disease in oncology care
difficult to maintain OH cancer pts
- tired,
- in pain,
- last thing on their mind
= result in bad oral health
see pt regularly (before and after chemo/radiotherapy, not during) to try and maintain periodontium
osteoradionecrosis effects
more common in mandible than maxilla
Know field of radiotherapy tx – help plan what will be affected
image
- Right mandible damage to bone
- Patient had radiotherapy for oropharyngeal tumour
- Went to own dentist and had tooth extracted
osteoradionecrosis prevention
- Remove teeth of doubtful prognosis in the radiotherapy field
- Can be hard for pt to accept as can be radical
- Esp if as trismus can mean hard to treat later on
- Can be hard for pt to accept as can be radical
- Prevention
- Extractions completed at least 10days prior to radiotherapy
- Chance of healing
- Try to do as much as possible to encourage healing – suture etc
- Liaise with oncologist
how to prevent osteoradionecrosis post radiotherapy
Any other treatment option other than extraction?
- decoronate?
Liaise with oncologist – field and dose
Prevention: Pentoxyfylline/Vitamin E ?
- 4-6 weeks post radiotherapy 400mg Pentoxyfylline and 1000 international units of Vitamin E daily
- Hopefully push some BV back into life – resurrect and encourage healing
issue here
long term (5 years) osteoradionecrosis
- Lost several teeth
- Mandible is completely destroyed on both sides (worse on right)
- Still retains some functional upper teeth
infected osteoradionecrosis
Evident inside mouth with fistula to outside of mouth
- Never healed – epithelium lined tract
- Food through PET tube to stomach
IORN between 4-35%.
- Improved detection methods for Actinomyces*
- e.g. group devised a nested PCR approach and found evidence of Actinomyces 20/31 (64.5%).
dental implants and oncology pts
- Revolutionising rehabilitation
- Reduced success of implants in irradiated bone
- Need careful assessment and lots of pre-planning
- Maintenance – crucial to keep implants as clean as possible
- Self care
- Professional support
Risk of implant placement in irradiated bone is similar to risk of ORN if extracting teeth
palliative care role of dental team
Tongue cancer here – unresponsive to all Tx
- Tumour is fungating, smelling, bleeding, friable, unpleasant
- Role for dental team to manage to keep mouth clean
- Need to know how to manage tissues and aspirators
- Role for dental team to manage to keep mouth clean
Go into hospices to aid
discuss
diagnosed later
- Remaining dentition in poor condition*
- OH poor*
- Large tumour*
- Enlarged tongue*
- Ulceration*
- Need to extract lower teeth – hard as he couldn’t move tongue – down with LA*
discuss this pt
6-12 months radiotherapy attending GDP for denture
- Large ulcerations still on tongue – dorsum, lateral borders and down back*
- What causing ulceration on the heavily keratinised surface of tongue?
- Uncomfortable, hard to clean, eating hard*
Recent pt, male, 64 years
- T2 N0 SCC uvula and tonsil
- Hypertensive controlled 162/97
- Type 2 diabetic & osteoarthritis
- Radical DXT
- GORD, hiatus hernia, angina, IHD
- BMI = 45
- Atrial fibrillation – warfarin range 1.9 – 6.8
- Under care 5 GG&C hospitals
- taxi driver and carer for wife
discuss before and after
before
- Teeth stained
- Plaque
- Calculus
- Caries
- Few lower teeth
after
- Lower denture in situ
- Upper teeth – scaled and managed
- OHI regime in place
- Saw regularly – maintained for a while, but eventually lost all
- Work in conjunction with QEUH Maxo facial department*
-
Looks like reasonably full complement of lower teeth
- Reality had no teeth on left side at all
- Soft splint made so he can speak better
- Cover teeth on RHS and made to look like teeth on LHS
