head and neck cancer Flashcards
(27 cards)
risk of head and neck cancer
4 times greater in men living in the most deprived area
85% of cases occur in people over the age of 50
pt journey
screening and referral
investigation and dx
MDT - tx plan
dental pre assessment
cancer tx
dental support during tx
end of tx
restoration
maintenance post tx
role of GDP
screening and referral
* Early detection through soft tissue examination
* Photographs
* Onward referral
Pre-tx assessment
guidance for GDPs
Scottish Cancer Referral Guidelines
NICE: Improving outcomes in head and neck cancers
British Association of Head and Neck Oncologists Multidisciplinary management guidelines
The Royal College of Surgeons of England / The British Society for Disability and Oral Health 2018 (now British Society for Special Care Dentistry)
Predicting and Managing Oral and Dental Complications of Surgical and Non-Surgical Treatment for Head and Neck Cancer A Clinical Guideline: RD-UK Consultant and Specialist Group Nov 2016
ENT UK
referrals for head and neck cancer
when there is:
7
Stridor – emergency referral required! (inspiration breath)
Persistent unexplained head and neck lumps >3weeks
Ulceration or unexplained swelling of the oral mucosa persisting for >3weeks
All red or mixed red and white patches of the oral mucosa persisting for >3weeks
Persistent hoarseness lasting for >3weeks (request a chest x-ray at the same time)
Dysphagia or odynophagia (pain on swallowing) lasting for >3weeks
Persistent pain in the throat lasting for >3weeks
special 2week urgent suspected cancer referral
investigations needed for cancer dx
New patient assessment within OMFS
Biopsy to confirm diagnosis
CT Scan to investigate extent of tumour
Lymph node biopsy
CT Scan to investigate for metastasis
Baseline medical testing – Performance Score determine tx mode best for individual pt
Stage and grade cancer
aims of dental pre-assessment to cancer tx
Identify existing oral disease and potential risk of disease – want to avoid unscheduled interruptions to primary treatment as a result of dental problems
Remove infection and potential infection before the start of cancer therapy.
Prepare the patient for expected side effects of cancer therapy.
Establish an adequate standard of oral hygiene to meet the increasing challenges during cancer therapy.
Develop a plan for maintaining oral hygiene, providing preventive care, completing oral rehabilitation and follow-up.
* Expectation that it will get harder (F)
Establish the necessary multidisciplinary collaboration within the cancer centre
To plan post-treatment prosthetic oral rehabilitation
what to provide in dental pre-assessment
Detailed oral hygiene – OHI, interdental cleaning
Fluoride: topical application - duraphat, mouthwash (0.05% alcohol free), fluoride toothpaste (5000ppm)
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)
10ml should be rinsed round the mouth for 1 minute then spat out, twice daily.
0.2% CHX may be diluted 1:1 with water if it causes mucosal discomfort
30 minutes should be allowed between use of chlorhexidine and toothbrushing
Definitively restore carious teeth
Removal of trauma: adjust sharp edges on teeth/dentures
Impressions: construct fluoride trays, soft splints
Sharp bits of teeth can be sore if mucositis flares up so prevent further trauma
Another mode of F application
Denture hygiene and instructions to avoid wear during cancer treatment (tender/sore)
Extract teeth with dubious prognosis - should be extracted as soon as possible before radiotherapy and high dose intravenous bisphosphonate treatment; no less than 10 days before starting cancer treatment
* Teeth in direct association with the tumour,
* teeth in the direct path of the radiation beam,
* teeth with doubtful prognosis (deep caries or periodontal pockets, non-vital teeth)
Antibiotic prophylaxis if neutrophils are low and planning invasive treatment – liaise with medics
Orthodontics: discontinue and remove fixed appliances – soft essix retainer if they want to maintain progress
Smoking and Alcohol advice
Restorative: Study casts for implant planning, pre-treatment records, planning for trismus
cancer tx options
4
Surgical resection with or without reconstruction
Radiotherapy
Chemotherapy
Adjuvant radiotherapy or chemoradiotherapy may be required following surgical resection (possible immune modulation)
cacner tx side effects
Surgical tumour resection can produce alterations to the normal anatomy which adversely affect function and outward appearance
Radiotherapy causes unavoidable radiation damage to normal tissues surrounding the tumour, affecting function of these tissues both in the short-term (during and immediately after tx) and long-term (months and years after tx or lifelong)
Chemotherapy causes acute mucosal and haematological toxicity – the former being accentuated if chemotherapy is delivered concurrently with radiation therapy
Head and neck caner tx can have adverse effects on respiration, mastication, swallowing, speech, taste, salivary gland function, mouth opening and the outward appearance of head and neck region
dental issues during cancer tx
10
- oral mucositis - inflammation and ulceration of mucosa
- candida infections (chronic hyperplastic atrophic candidiasis)
- traumatic ucleration
- reactivation herpes simplex
- xerostomia
- trismus
- dental erosion
- radiation induced caries
- periodontal disease
- ORN
management of oral mucositis
Neutral supersaturated calcium phosphate mouth rinse (Caphosol),
Polyvinyl pyrrolidine/sodium hyaluronate gel (Gelclair),
Mucoadhesive oral rinse (Mugard),
Soluble aspirin,
Benzydamine hydrochloride (Difflam)
* 15ml 4-8xdaily starting before radiotherapy and continuing during and for 2-3 weeks afterwards is recommended (alcohol containing so initially stingy)
oral cooling (ice)
alternative - aloe vera, manuka honey, tea tree oil
management of candidiasis in cancer pt
alert cancer team to prescribe antifungals (miconazole, nystatin or system fluconazole)
management of reactivation of HSV in cancer pt
coldsores
alert cancer team - needs urgent tx with systemic antivirals (acyclovir)
management of traumatic ulceration in cancer pt
soft splint
xerostomia in cancer tx
Reduced salivary flow 50-60% in first week with a further 20% in next 5-6 weeks (happens after tx)
* Recovery may happen over a number of years or not return at all.
* Caused by ionising radiation damage to salivary tissue in the radiotherapy fields
Saliva consistency and character is affected: saliva becomes more viscous and acidic (damage to dentition), clearing effect reduce
F supplements, sips water, oral gel/lubricants
causes of trisumus in cancer tx
3
- post-surgical inflammation
- fibrosis of those tissues as a result of chemotherapy and radiotherapy
- Reduction of mouth opening due to tumour recurrence should be excluded.
Trismus that follows radiotherapy can occur rapidly over the first 9 months after treatment, tends to be progressive and may be irreversible
tx for cancer related trismus
physical therapy modalities e.g. passive and active stretching exercises, and the use of devices for stretching the muscles of mastication e.g. Therabite and and stacked tongue depressors
Starting therapy early and compliance with exercises were important factors in the success of treatment
radiation induced caries
Indirect effect of non-surgical treatment (chemotherapy and radiotherapy)
Result of reduced salivary flow and altered saliva function in combination with the high protein and calorie diet
Very common despite our best efforts
Rapidly developing
Widespread caries can result that is often circumferential around the teeth and
* Cervical margins and smooth surfaces
* May affect incisal edges.
Attempts to restore can be difficult
* Flex at cervical margin of tooth – composite # off easily
osteoradionecrosis
area of exposed bone of at least three months duration in an irradiated site and not due to tumour recurrence.
One of the most severe and debilitating complications following radiation therapy for head and neck cancer
prevention ORN
- Remove teeth of doubtful prognosis in the radiotherapy field – this can be upsetting for the patient after diagnosis. Consider shortened dental arch.
- Prevention (exam at least 6monthly; hygiene visits)
- Extractions completed at least 10days prior to radiotherapy
- Liaise with oncologist
- Encourage healing with primary closure / sutures where possible
Patients are at particular risk of ORN when:
* The total radiation dose exceeded 60Gy
* The dose fraction was large with a high number of fractions
* There is local trauma as the result of a tooth extraction (especially mandibular extractions), uncontrolled periodontal disease or an ill-fitting prosthesis.
* The person is immunodeficient
* The person is malnourished
Where there is a high risk of ORN and where it is clinically feasible, serious consideration to root canal therapy and/or decoronating/SScrowns should be made
management of ORN
High dose antibiotic regimes should be instigated when symptomatic ORN is diagnosed and continued until a definitive treatment outcome or symptom relief is achieved
antibiotic prophylaxis prior to extraction or sequestrectomy should be given and continued until mucosal integrity has occurred
and analgesia advice
reconstruction post cancer
implants - speciliast to plan and place, maintenance and depends on bone quality
dentures - avoid - trauma, candida - but restore functio
obturators (seal between oral cavity and sinus - voice)
OPT signs of cancer
- Moth eaten bone - Also dx for ORN, osteonecrosis and osteomyelitis
- Pathological fractures
- Non-healing socket
- Floating teeth
- Unusual periodontal bone loss
- Spiculated periosteal reaction
- Widening of periodontal ligament space
- Loss of bony outlines for anatomical features e.g. walls of antrum, corticated margins of IDC
- Thinning of cortico-endosteal margin
