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BDS4 SCD > Oral cancer symposium > Flashcards

Oral cancer symposium Flashcards

1
Q

What are biopsy specimens fixed in prior to arriving in pathology

A

formaldehyde for at least 24h

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2
Q

What are the aims of assessment pre-radiotherapy

A
  • decide on which teeth need extraction - try and keep important teeth
  • obtain primary closure for XLA
  • reduce tori to ensure dental tolerance
  • prevention - 5000ppm, jaw opening exercises etc
  • baseline records
  • planning for optimal rehab
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3
Q

What are oral side effects of cancer tx

A
  • mucositis
  • taste
  • xerostomia
  • tooth structure changes - changes in pulp space (reducing chances of RCT)
  • trismus
  • ORN
  • soft tissue changes
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4
Q

What is ORN

A
  • serious complication after radio/chemotherapy
  • most common in OP cancer px especially tonsillar/retromolar region
  • 5% incidence
  • mandibular molar area most affected site
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5
Q

What are prosthodontic options for rehabilitating HN cancer patients

A
  • dentures - precision attachments
  • implants
  • bridges
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6
Q

How should we maintain HN cancer px

A
  • ensure absence of bleeding upon probing
  • no excessive pocket depths
  • success rate varies with bone quality, loading dynamics etc
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7
Q

What are the uses of obturators in dentate px

A
  • restore partition between oral and nasal cavities
  • restore palatal contour
  • replace needed dentition
  • provide retention, stability, support for partial denture
  • create partial denture designs that do not stress abutment teeth beyond their physiological tolerance
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8
Q

What is the use of an obturator in a edentate patient

A
  • restore partition between nasal and oral cavity
  • resotre palatal contours
  • replace necessary dentition
  • provide retention, stability and support for the complete denture - obturator prosthesis
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9
Q

What is an interim obturator

A

enables speech and swallowing during immediate post-op and healing periods

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10
Q

What are primary dental implants

A

placed same time as tumour resection
prosthetic obturation of significant maxillary defects where retention of obturator likely to be compromised

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11
Q

What are the advantages of placing implants at time of surgery

A
  • implant surgery in radiotherapy compromised area is avoided, reduced risk of ORN
  • initial implant healing takes place before irradiation
  • px can benefit from support of implants at earlier stage of tx
  • px saved from another surgical intervention
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12
Q

What are disadvantages of primary implant placement

A
  • delay or interfere with oncological therapy
  • development of post tx complications
  • lack of use of installed implants due to early tumour recurrence
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13
Q

When can an OPT be useful in diagnosing oral cavity cancer

A

can show bone involvement

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14
Q

If a neck lump is present, what is the initial imaging of choice

A

ultrasound
ultrasound guided biopsy

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15
Q

When looking at an OPT, what features make us concerned in regards to cancer

A
  • moth eaten bone
  • pathological fractures
  • nonhealing sockets
  • floating teeth
  • unusual periodonta bone loss
  • spiculated periosteal reaction
  • widening of PDL space
  • loss of bony outlines for anatomical features
  • thinning of cortico-endosteal margins
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16
Q

When taking an ultrasound for neck lumps, what are we looking for

A
  • rounded/enlarged lymph nodes - should be rugby ball shaped in normal person
  • necrosis of nodes
  • increased vascularity
  • loss of hilum
  • internal calcification
  • extracapsular spread
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17
Q

What type of biopsy is used in ultrasound guided biopsy

A

core biopsy is better
FNA only provides cells
avoid cystic fluid and areas of necrosis

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18
Q

What is staging based on

A

TNM

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19
Q

What does TNM stand for

A

tumour
nodes
metastasis

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20
Q

How do we look for distant metastasis

A

need imaging in 3d with large field of view - ct or mri
want to image brain chest abdomen and pelvis

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21
Q

What are the advantages of using CT for staging

A

quick
good for soft tissue and bone
iodinated contrast must be given to enhance tumour

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22
Q

What are the disadvantages of CT for staging

A

requires testing to ensure kidney function for the iodine contrast
involves radiation

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23
Q

What are the advantages of MRI for staging

A
  • no ionising radiation
  • good for soft tissue/bone marrow involvement
  • better for perineural spread
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24
Q

What is done when the primary tumour cant be detected

A

PET/CT scan is imaging of choice
PET looks for metabolically active tissues
false positives can occur due to active uscles or infection

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25
Q

Who is part of the MDT

A
  • surgeons
  • radiologists
  • clinical oncologists
  • SLT
  • dietician
  • restorative dentists
  • clinical support nurses
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26
Q

What are the tx options for HN cancer

A
  • nil (palliative)
  • surgery alone
  • radiotherapy alone
  • chemotherapy
  • dual or triple modality (including immunotherapy)
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27
Q

What is the role of the GDP in screening

A
  • early detection through soft tissue exam
  • photos
  • onward referral
  • pre tx assessment
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28
Q

What are high risk sites for HN cancer

A
  • tongue
  • floor of mouth
  • oropharynx
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29
Q

What is the classic appearance of SCC

A
  • solitary deep ulcer
  • rolled margins on the lateral margin of the tongue
  • palpation of the margin of the ulcer will reveal firm, indurated tissues
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30
Q

What are suspicious mucosal changes

A
  • ulceration
  • swelling
  • erythroplakia
  • speckled leukoplakia
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31
Q

What are potentially malignant conditions

A
  • leukoplakia
  • speckled leukoplakia
  • erythroplakia
  • submucous fibrosis
  • lichen planus
  • keratosis
32
Q

What are the different HN cancer referral guidelines

A
  • scottish referral guidelines for susepcted cancer
  • NICE guidelines
33
Q

What do the scottish referral guidelines say you should refer as urgent suspicion of cancer referral

A
  • Stridor –> emergency referral
  • Persistent unexplained head and neck lumps for >3 weeks
  • Unexplained ulceration or unexplained swelling/induration of the oral mucosa persisting for >3 weeks
  • All unexplained red or mixed red and white patches of the oral mucosa persisting for >3 weeks
  • Persistent (not intermittent) hoarseness lasting for >3 weeks. If other symptoms are present to suggest suspicion of lung cancer, refer via lung cancer guideline
  • Persistent pain in the throat or pain on swallowing lasting for >3 weeks
34
Q

What investigations will a new px on OMFS get when they are suspected of HN cancer

A
  • New px assessment
  • Biopsy to confirm
  • CT scan to investigate extent of tumour
  • Lymph node biopsy
  • CT scan to investigate for metastasis
  • Baseline medical testing - performance score
  • Stage and grade cancer
35
Q

When should the HN team see a patient after referral from the dentist

A

2 weeks

36
Q

When should diagnosis be reached by

A

28 days from referral

37
Q

When should decision to tx be reached by

A

28 days

38
Q

When should definitive tx be started

A

62 days from referral

39
Q

What are aims of the pre-assesment

A
  • identify existing oral disease and potential risk of disease
  • remove infection and potential infection before start of therapy
  • prepare px for expected side effects of cancer therapy
  • establish an adequate standard of OH to meet increasing challenges during cancer therapy
  • develop a plan for maintaing OH, providing preventative care, completing oral rehab and follow up
  • establish necessary multidisciplinary collobration with cancer centre
  • plan post tx prosthetic oral rehab
40
Q

What should a GDP provide in a pre-assessment

A
  • detailed OHI
  • fluoride
  • diet advice
  • PMPR
  • consider CHX
  • restore carious teeth
  • remove trauma
  • impressions for fluoride trays and soft splints
  • denture hygiene instrucions
  • extraction of dubious prognosis teeth
  • AB prophylaxis if neutrophils are low and planning invasive tx
  • orthodontics
  • smoking and alcohol advise
  • restorative tx - study casts for implant planning
41
Q

When is the latest teeth should be extracted prior to cancer tx

A

no later than 10 days

42
Q

What should be checked prior to providing invasive tx

A

neutrophil checks

43
Q

What are the possible cancer tx

A
  • surgical resection with or without reconstruction
  • chemo therapy
  • adjuvant radiothreapy or chemotherapy may be required
44
Q

What is the side effect of surgical tumour resection

A

alterations to normal anatomy
effects function and appearance

45
Q

What is the side effect of radiotherapy

A
  • radiation damage to normal tissues surrounding tumour
  • affecting function of these tissues both in short and long term
46
Q

What is the side effect of chemotherapy

A
  • acute mucosal and haematological toxicity
  • former being accenuated if chemotherapy is delivered concurrently with radiation threapy
47
Q

What is the role of the dentist in cancer therapy

A
  • hygiene support
  • antibacterial mouthwash to aid brushing e.g CHX
  • diet advice
  • fluoride preparation
  • high risk of viral and fungal infections
  • tx of mucositis, xerostomia
  • emergency dental tx could result in delaying cancer tx
48
Q

When does oral mucositis start and end

A
  • starts 1-2 wks after tx begins
  • lasts until 6 wks after tx is complete
49
Q

What are the symptoms of oral mucositis

A
  • may inhibit OH measures
50
Q

What can be used to prevent and manage mucositis

A
  • caphosol
  • sodium hyaluronate gel
  • mucoadhesive oral rinse
  • soluble aspirion
  • difflam
  • zinc supplements
  • alovera
  • cryotherapy
  • manuka honey
51
Q

How can mucositis be classified

A
52
Q

What antifungal is not effective at preventing candida infections due to cancer tx

A

nystatin

53
Q

What are antifungals that can be prescribed

A
  • CHX
  • miconazole - topical
  • fluconazole - systemic
  • nystatin
54
Q

How can canecr tx result in traumatic ulceration

A
  • teeth rubbing delicate intra oral tissues
55
Q

How does reactivation of herpes simplex virus present in those undergoing cancer tx

A
  • prodromal period - pain prior to ulceration
  • often intraoral and clinically atypical
  • more extensive, slow healing and aggressive
  • high index of clinical suspicion
56
Q

How is saliva effected by cancer tx

A
  • reduced salivary flow
  • saliva becomes more viscious and acidic causing damage to teeth
  • recovery may be slow/not at all
57
Q

What is the impact of xerostomia

A
  • chewing
  • swallowing (dysphagia)
  • speech (dysarthria)
  • taste (dysgeusia)
  • QoL
58
Q

What are the risks of xerostomia

A
  • caries
  • periodontal disease
  • candida
  • sialadenitis
  • prosthodontic difficulties
59
Q

What is the cancer induced xerostomia caused by

A

ionising radiation producing damage to the salivary glands

60
Q

What tx can we give px for xerostomia

A
  • oral gels and lubricants
  • pilocarpine - enhance slaivary secretions
  • sugar free gum
  • salivary replacements
  • avoid glandosane
61
Q

What are the causes of trismus following cancer tx

A
  • post surgical inflammation
  • fibrosis of those tissues as a result of tx
  • reduction in mouth opening due to tumour recurrence should be excluded
62
Q

Why are cancer tx px more prone to caries

A
  • combination of xerostomia, OH, diet, taste etc
63
Q

How does radiation induced caries present

A
  • indirect effect of nonsurgical tx
  • result of reduced salivary flow and altered salivary function in combo with high protein and calorie diet
  • rapidly developing
  • widespread caries that can often be circumferential
  • may effect incisal edge
  • hard to restore
64
Q

What is ORN defined as

A

area of exposed bone of at least 3 months duration in an irradiated site and not due to tumour recurrence
one of the most severe and debilitating complications following radiation therapy for HN cancer

65
Q

How do we prevent ORN

A
  • remove teeth of doubtful prognosis in the radiotherapy field prior to tx
  • prevention
  • extraction completed at least 10 days prior to radiotherapy
  • encourage healing with primary closures and sutures where possible
  • hyperbaric oxygen?
  • antibiotic prophaylxis until completion of healing –> coamoxiclav or amoxycillin
66
Q

When are px at particular risk of ORN

A
  • total radiation dose exceeded 60Gy
  • dose fraction was larger with a higher number of ractions
  • local trauma as a result of tooth extractions, uncontrolled periodontal disease or an ill fitting denture
  • immunodeficient px
  • malnourished px
67
Q

When a px is high risk of ORN, and a tooth is carious, what should you consider

A
  • rct
  • restoration/crown amputation
68
Q

What is stage 0 ORN

A
  • mucosal defects only, bone exposed
69
Q

What is stage I ORN

A
  • radiological evidence of necrotic bone, dento-alveolar only
70
Q

What is stage II ORN

A
  • positive radiographic findings above ID cancl with denuded bone intraorally
71
Q

What is stage III ORN

A
  • clinically exposed radionecrotic bone
  • skin fistulas and infeciton
  • potential or actual pathological fracture
72
Q

What is prevention and tx for px post cancer tx

A
  • regular exams
  • avoid invasive tx that could truamatise bone
  • consider decoronation
  • use atrumatic techniques where possible
  • caries management - try to keep teeth around
  • full or partial coverage crowns when px show good OH
  • avoid routine restorative tx until px in remission
  • antimicrobials for acute condition
73
Q

What prosthesis can px be given for reconstruction

A
  • implants
  • dentures
74
Q

When are implants less likely to succeed in HN cancer px

A
  • reduced success in irradiated bone
  • failure less likely with radiation dose <45Gy
  • requires maintenance - self care and professional support
75
Q

When should dentures be used

A
  • avoid when possible
  • esential they will aid ability to chew, social adaptation etc
  • dneture hygiene essential
76
Q

What advise should px be given regarding obturators

A
  • review regularly
  • do not leave out at night for first 6 months psot tx
  • may be worn at night for comofort and function after 6 months too
  • daily cleaning mandatory

BDS4 SCD (5 decks)

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