Questions and Answers
Which of the following are most common side effects of cancer treatment? Select all that apply
Oral mucosa has a high turnover rate. Is this statement true or false?
True
Cytotoxic chemotherapy and radiation can compromise bone development and lead to _______.
osteonecrosis
Match the following with their corresponding clinical manifestations due to myelosuppression:
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What is a systemic sialogogue used for addressing radiation-induced damage?
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Intensity modulated radiation therapy (IMRT) always spares parts of the salivary glands.
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What is the purpose of cryotherapy in the prevention of oral mucositis during chemotherapy?
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What is the goal of aggressive prophylactic dental care in patients undergoing chemotherapy?
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What should be done to optimize radiation delivery to the head and neck during radiation therapy?
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What is the purpose of making the oncology team aware of metal in the oral cavity during radiation therapy?
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What is the benefit of prophylactic placement of a percutaneous endoscopic gastrostomy tube in patients at high risk for mucositis?
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What is the purpose of mucoadhesive hydrogel rinse in the prevention of oral mucositis?
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What is the benefit of zinc supplements in patients undergoing radiation therapy to the head and neck?
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What is a common consequence of radiation therapy induced mucositis in patients with head and neck cancer?
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What is a recommended management strategy for radiation therapy induced mucositis?
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What is a characteristic of salivary gland dysfunction due to radiation therapy?
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At what dosage of radiation therapy has xerostomia been reported?
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What is a complication that can arise due to radiation therapy induced xerostomia?
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What percentage of patients with head and neck cancer who receive radiotherapy are at risk of developing mucositis?
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What is a recommended alteration for patients with radiation therapy induced mucositis?
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What can be a clinical manifestation of myelosuppression in RBCs?
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What is a potential effect of radiation therapy on tooth development?
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At what age are pediatric patients more susceptible to abnormal dental development due to chemotherapy and/or radiation?
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Why is it important to consider the age of pediatric patients when planning cancer treatment?
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What is a potential effect of high doses of chemotherapy on dental development?
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Which of the following is a preventive measure for pediatric cancer patients?
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Which of the following is a common risk factor for opportunistic infections in head and neck cancer patients?
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Which of the following preventive measures can help reduce the risk of radiation-induced xerostomia?
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What is the primary complication of medication-related osteonecrosis of the jaw (MRONJ)?
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What is the primary goal of using artificial saliva in patients with salivary gland dysfunction?
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What is the primary advantage of using intensity modulated radiation therapy (IMRT) in head and neck cancer patients?
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Which of the following patient-related factors increases the risk of mucositis?
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What is a critical step in the healing process of mucositis?
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What is the consequence of ulceration in mucositis?
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What occurs during the primary damage response phase of mucositis?
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What is the result of NF-κB activation during the signal amplification phase of mucositis?
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What can be manifested as a result of myelosuppression? Select all that apply
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Study Notes
Cancer Therapies and Dental Considerations
- The National Cancer Institute (NCI) recommends that dental professionals be part of the cancer care team and that patients see their dentist 4 weeks prior to initiating cancer treatment (if possible) to allow for healing if any dental work is required.
Oral Side Effects of Cancer Treatment
- Can be acute, delayed onset, local, systemic, or functional.
- Examples of functional side effects include dysgeusia (change in taste) and dysphagia (difficulty swallowing).
- Side effects can be direct (e.g., radiation-induced mucositis) or indirect (e.g., bleeding or infections due to cytotoxic therapy).
Common Oral Side Effects of Cancer Treatment
- Mucositis
- Opportunistic infection (viral or fungal)
- Salivary gland dysfunction
- Taste disturbance
- Pain
Mucositis
- Can occur throughout the GI tract, from mouth to anus.
- Symptoms manifest depending on the affected site.
- Patients with mucositis have a 2x risk of developing infections and 4x the risk of death compared with patients who do not develop mucositis.
- Pathogenesis involves initiation, primary damage response, signal amplification, ulceration, and healing.
Risk Factors for Mucositis
- Patient-related: smoking, poor oral hygiene, younger age, female sex, pretreatment nutritional status, and pretreatment neutrophil counts.
- Treatment-related: type of chemotherapy, dose and field of radiation, frequency, and duration.
Prevention and Management of Mucositis
- Preventive measures for chemotherapy: soft tooth brush, gentle flossing, bland mouth rinse, prophylactic dental care, cryotherapy, and mucoadhesive hydrogel rinse.
- Preventive measures for radiation therapy to head and neck: make oncology team aware of metal in oral cavity, adequate oral care, delivery of radiation optimization, shielding, laser therapy, zinc supplements, and prophylactic placement of a percutaneous endoscopic gastrostomy tube.
Grading of Oral Mucositis
- Various grading systems exist, including the World Health Organization (WHO) scale and the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE).
Management of Chemotherapy-induced Mucositis and Radiation Therapy-induced Mucositis
- Both have similar management strategies, including bland rinses, topical anesthetics, low-level laser therapy, and systemic agents.
Salivary Gland Dysfunction
- Radiation-induced xerostomia has been reported in the first days of radiation therapy, with doses between 2 and 10 Gy.
- Clinical features include decreased salivary secretion, increased salivary viscosity, and a "ropey" or foamy texture.
- Increases risk for secondary infections.
Prevention and Management of Salivary Gland Dysfunction
- Amifostine (Ethyol) is FDA-approved for xerostomia caused by radiation therapy, but its use is controversial due to toxicity, compromised tumor control, and cost.
- Systemic sialogogues such as pilocarpine can be used, and intensity-modulated radiation therapy (IMRT) can spare parts of the salivary glands.
Opportunistic Infections (Viral or Fungal)
- Can occur due to myelosuppression, xerostomia, and damage to the mucosa.
- Caused by viral, bacterial, or fungal infections.
Medication-related Osteonecrosis of the Jaw (MRONJ)
- A complication in patients taking anti-bone resorptive drugs, such as bisphosphonates and monoclonal antibodies like denosumab.
- Prescribed for patients with multiple myeloma, osteoporosis, metastatic carcinoma, and Paget's disease.
- Can cause osteomyelitis of the jaw.
Graft-Versus-Host Disease (GVHD)
- A condition that occurs in patients with a history of previous bone marrow transplantation.
- Can cause oral chronic GVHD.
Prevention of Oral Mucositis
- Preventive measures for chemotherapy: soft toothbrush, gentle flossing, bland mouth rinse (normal saline, sodium bicarbonate) 4 times a day, prophylactic dental care (Rx of caries, extraction of compromised teeth), and cryotherapy (ice chip therapy) to reduce risk by 25%
- Preventive measures for radiation therapy to head and neck: make oncology team aware of metal in oral cavity, adequate oral care, optimized radiation delivery to limit oral exposure, shielding, laser therapy (632.8 nm laser), zinc supplements, and prophylactic placement of a percutaneous endoscopic gastrostomy tube
Grading of Oral Mucositis
- No specific details mentioned in the text
Management of Chemotherapy-Induced Mucositis
- Similar to radiation therapy-induced mucositis management
- Bland rinses (normal saline, salt-and-soda mouthwashes), swish and spit, up to 4 times a day
- Topical anesthetics (2% viscous lidocaine), swish and spit
- Low-level laser therapy
- Systemic agents (opiates)
- Alteration of diet (avoid trauma to mucosa)
Management of Radiation Therapy-Induced Mucositis
- Occurs in up to 91% of patients with head and neck cancer who receive radiotherapy
- Often a dose-limiting toxicity, leading to early discontinuation of radiotherapy and worse outcomes
- Management is fairly similar to chemotherapy-induced mucositis
Salivary Gland Dysfunction
- Radiation-induced xerostomia reported in first days of RT, with doses between 2 and 10 Gy
- Decreased salivary secretion
- Increased salivary viscosity
- Residual saliva becomes "ropey" or foamy
- Examining gloves may stick to dry mucosal surfaces
- Increases risk for secondary infections
Prevention of Salivary Gland Dysfunction
- Amifostine (Ethyol): FDA-approved for xerostomia caused by radiation therapy, protect cells by scavenging oxygen-derived free radicals, but controversial due to toxicity and cost
- Systemic sialogogues (pilocarpine): evidence suggests depletion of secretory granules and decreased radiation-induced damage
- Intensity modulated radiation therapy (IMRT): spares parts of salivary glands, but conflicting results
Opportunistic Infection
- Etiology: viral, bacterial, fungal
- Caused by myelosuppression, xerostomia, damage to mucosa
- Suppression of bone marrow leads to mucositis
MRONJ
- Complication in patients on anti-bone resorptive drugs (bisphosphonate and monoclonal antibodies like denosumab) for multiple myeloma, osteoporosis, metastatic carcinoma, and Paget's disease
- Causes osteomyelitis of the jaw
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