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Questions and Answers

Which dental professional on a multidisciplinary oncology team specializes in restoring teeth affected by tumor or treatment?

  • Radiologist
  • Maxillofacial surgeon
  • Restorative dentist (correct)
  • General dentist

What is the MINIMUM recommended waiting period after extracting teeth associated with a tumor before starting radiotherapy?

  • 10 days (correct)
  • 3 days
  • 3 weeks
  • 5 days

During radiotherapy for head and neck cancer, which mouthwash is recommended for routine supportive care?

  • Chlorhexidine (CHX) mouthwash (correct)
  • Hydrogen peroxide mouthwash
  • Essential oil mouthwash
  • Fluoride mouthwash

Which healthcare professional on the multidisciplinary team is primarily responsible for addressing swallowing difficulties and reducing the risk of aspiration in head and neck cancer patients?

<p>Speech and Language therapist (A)</p> Signup and view all the answers

What is the PRIMARY role of an oncologist in the multidisciplinary management of head and neck cancer?

<p>Administering radiotherapy and chemotherapy (C)</p> Signup and view all the answers

In the context of chemotherapy for oral squamous cell carcinoma, which statement is MOST accurate?

<p>Chemotherapy is rarely used as a treatment modality. (C)</p> Signup and view all the answers

Which of the following is LEAST likely to be recommended as part of dental care DURING radiotherapy?

<p>Extraction of symptomatic teeth by a general dentist (B)</p> Signup and view all the answers

A patient undergoing radiotherapy for head and neck cancer develops a fungal infection in the oral cavity. Which of the following antifungal medications is MOST likely to be prescribed?

<p>Nystatin or Miconazole (B)</p> Signup and view all the answers

Considering the dental management protocol for patients undergoing radiotherapy, what is the rationale behind recommending extraction of teeth associated with the tumor, followed by a waiting period before radiotherapy?

<p>To prevent osteoradionecrosis (ORN) by allowing socket healing before radiation exposure. (C)</p> Signup and view all the answers

A patient is scheduled to begin radiotherapy for nasopharyngeal carcinoma in 5 days. During dental assessment, a lower molar with a large periapical lesion and grade 2 mobility is identified within the planned radiation field. Which of the following represents the MOST appropriate immediate management strategy?

<p>Extract the tooth atraumatically in secondary care within the next 24-48 hours and proceed with radiotherapy as planned. (D)</p> Signup and view all the answers

Which acute toxicity of chemotherapy is often the dose-limiting factor, necessitating careful monitoring of blood cell counts?

<p>Bone marrow toxicity (D)</p> Signup and view all the answers

A patient undergoing chemotherapy is experiencing nausea and vomiting. Which physiological mechanism is primarily responsible for this side effect?

<p>Stimulation of the chemoreceptor trigger zone (A)</p> Signup and view all the answers

Methotrexate-induced mucositis may be potentially alleviated by supplementation with which of the following?

<p>Folic acid (C)</p> Signup and view all the answers

Approximately how long after the first chemotherapy injection does hair loss (alopecia) typically begin, if it is going to occur?

<p>18-21 days (B)</p> Signup and view all the answers

Long-term use of alkylating agents in chemotherapy is most significantly associated with an increased risk of developing which secondary malignancy?

<p>Acute leukaemia (C)</p> Signup and view all the answers

Oral mucositis, a common complication of chemotherapy, typically develops within what timeframe after the initiation of treatment?

<p>7-14 days (B)</p> Signup and view all the answers

Why is maintaining excellent oral hygiene particularly critical for patients undergoing chemotherapy?

<p>To minimize the risk of bacteraemia (A)</p> Signup and view all the answers

Sucking on ice cubes or cold water during the infusion of which chemotherapeutic agent is particularly recommended to help prevent stomatitis?

<p>5-Fluorouracil (5-FU) (B)</p> Signup and view all the answers

A patient receiving methotrexate requires a muscle relaxant. Which commonly used muscle relaxant is known to have potentially increased toxicity in patients on methotrexate?

<p>Suxamethonium (B)</p> Signup and view all the answers

For a chemotherapy patient, what is the minimum platelet count (per litre) generally considered acceptable for routine management without requiring immediate platelet transfusion?

<blockquote> <p>50x10^9 (C)</p> </blockquote> Signup and view all the answers

During which phases of the cell cycle are chemotherapy drugs generally most effective?

<p>G2 and Mitosis (A)</p> Signup and view all the answers

What term describes chemotherapy that is administered after surgery or radiotherapy?

<p>Adjuvant (A)</p> Signup and view all the answers

In the context of widespread metastatic disease, what is the primary goal of induction chemotherapy?

<p>Primary treatment for systemic disease (C)</p> Signup and view all the answers

Which of the following best describes the mechanism of action of alkylating agents in chemotherapy?

<p>Damaging DNA to prevent replication (B)</p> Signup and view all the answers

What is the key difference between phase-dependent and non-phase dependent chemotherapy drugs in terms of their mechanism?

<p>Non-phase dependent drugs kill cells exponentially with increasing dose, while phase-dependent drugs have a plateau effect. (C)</p> Signup and view all the answers

Methotrexate inhibits purine and pyrimidine synthesis. Considering its classification as a phase-dependent drug, during which phase of the cell cycle would it exert its most significant impact?

<p>S phase (DNA synthesis) (B)</p> Signup and view all the answers

The text mentions that selectively targeting tumor cells while sparing normal tissues with chemotherapy is 'quite hard in principle'. What is the fundamental reason for this challenge?

<p>Both normal and tumor cells utilize similar fundamental processes targeted by chemotherapy. (A)</p> Signup and view all the answers

A novel drug is developed to specifically disrupt microtubule formation, a process critical for chromosome segregation during cell division. Based on the provided chemotherapy classifications, this drug would most likely be categorized as a(n):

<p>Vinca Alkaloid (B)</p> Signup and view all the answers

For long-term chemotherapy administration via a central line, where is the distal tip of the catheter typically positioned?

<p>Right Atrium (B)</p> Signup and view all the answers

Both 'Vinca alkaloids' and 'antimitotic antibiotics' are described as stopping mitosis. Based solely on the provided text, what is the most reasonable inference about the key distinction between these two classes?

<p>The text provides insufficient information to infer a clear distinction beyond their shared antimitotic effect. (B)</p> Signup and view all the answers

What is the typical minimum waiting period recommended between extracting teeth associated with a tumor and starting radiotherapy?

<p>3 weeks (A)</p> Signup and view all the answers

Which of the following mouthwash ingredients is typically recommended for routine supportive care during radiotherapy?

<p>Chlorhexidine (CHX) (A)</p> Signup and view all the answers

What is the MOST important aspect of oral hygiene for a patient undergoing radiotherapy?

<p>Maintaining excellent oral hygiene (D)</p> Signup and view all the answers

Which of the following professionals is typically responsible for helping head and neck cancer patients minimize the risk of aspiration?

<p>Speech and Language therapist (D)</p> Signup and view all the answers

What is the role of an oncologist in the multidisciplinary management of head and neck cancer?

<p>Administering chemotherapy and radiotherapy (D)</p> Signup and view all the answers

Which intervention is LEAST likely to be a routine recommendation as part of dental care DURING radiotherapy?

<p>Restoration of carious lesions with amalgam (B)</p> Signup and view all the answers

If a patient undergoing radiotherapy develops a fungal infection in their oral cavity, which topical medication is MOST likely to be prescribed?

<p>Nystatin or Miconazole (D)</p> Signup and view all the answers

Why is extraction of teeth associated with the tumor recommended prior to radiotherapy?

<p>To minimize the risk of osteoradionecrosis post-radiotherapy (B)</p> Signup and view all the answers

In the context of chemotherapy, under what circumstances is it MOST often utilized for Oral Squamous Cell Carcinoma?

<p>Rarely used. (A)</p> Signup and view all the answers

What is the MOST significant risk associated with the long-term use of alkylating agents in chemotherapy?

<p>Development of acute leukaemia. (C)</p> Signup and view all the answers

Which of the following BEST describes the difference between curative and palliative chemotherapy?

<p>Curative chemotherapy aims to eradicate the cancer, while palliative chemotherapy aims to relieve symptoms and improve quality of life. (C)</p> Signup and view all the answers

Approximately how long after chemotherapy initiation does oral mucositis typically develop?

<p>7-14 days. (B)</p> Signup and view all the answers

Sucking on ice cubes during the infusion of which chemotherapeutic agent is particularly recommended to help prevent stomatitis?

<p>5-Fluorouracil (5-FU) (B)</p> Signup and view all the answers

A patient receiving methotrexate requires a muscle relaxant. Which muscle relaxant is known to have potentially increased toxicity in patients on methotrexate?

<p>Suxamethonium (C)</p> Signup and view all the answers

What platelet count (per litre) is generally considered acceptable for routine dental management of a chemotherapy patient?

<blockquote> <p>50x10^9^/litre (B)</p> </blockquote> Signup and view all the answers

A patient undergoing chemotherapy presents with oral ulceration specifically caused by methotrexate. Which of the following topical treatments is MOST appropriate?

<p>Topical folinic acid (C)</p> Signup and view all the answers

Which of the following strategies is LEAST likely to help reduce alopecia associated with chemotherapy?

<p>Corticosteroid cream application to the scalp (C)</p> Signup and view all the answers

Why might a dental professional recommend taste modification strategies (e.g., increased seasoning) for a patient undergoing chemotherapy?

<p>To improve appetite and nutritional intake despite taste alterations. (A)</p> Signup and view all the answers

Which phase of the cell cycle is characterized by DNA synthesis?

<p>S phase (B)</p> Signup and view all the answers

A chemotherapy patient who is prone to stomatitis is prescribed benzydamine hydrochloride for established mucositis. What is the MOST likely rationale for this prescription?

<p>Benzydamine hydrochloride is a local anaesthetic and anti-inflammatory agent. (C)</p> Signup and view all the answers

What is the primary mechanism of action of alkylating agents in chemotherapy?

<p>Damaging DNA to prevent cell reproduction (B)</p> Signup and view all the answers

In the context of cancer treatment, what does the term 'adjuvant chemotherapy' refer to?

<p>Chemotherapy administered after surgery or radiotherapy (B)</p> Signup and view all the answers

What is the MOST likely placement site for a long-term chemotherapy catheter?

<p>Right atrium (B)</p> Signup and view all the answers

Which of the following describes 'induction chemotherapy'?

<p>The initial treatment for widespread metastatic disease (A)</p> Signup and view all the answers

Methotrexate and 5-FU are examples of what?

<p>Anti-Metabolites (D)</p> Signup and view all the answers

What is the role of 'neoadjuvant chemotherapy' in cancer treatment?

<p>Using chemotherapy as the primary treatment for local control of the tumor (C)</p> Signup and view all the answers

Which of the following chemotherapeutic agents directly prevents cell division by inhibiting mitosis?

<p>Vinca alkaloids (B)</p> Signup and view all the answers

A researcher is evaluating a new chemotherapy drug and observes that it kills cancer cells effectively, regardless of their position in the cell cycle. Furthermore, the rate of cell death increases exponentially with increasing drug doses. How would this drug be classified?

<p>Non-cell cycle specific (C)</p> Signup and view all the answers

Considering the mechanisms through which chemotherapeutic drugs exert cytotoxicity, which of the following represents the MOST significant obstacle to achieving selective eradication of tumor cells while preserving normal tissue function?

<p>The inherent similarities in biochemical pathways and proliferative capacity between cancerous and healthy cells, making it difficult to target tumor-specific vulnerabilities. (B)</p> Signup and view all the answers

Flashcards

Maxillofacial Surgeon

Surgeon specializing in procedures involving the jaws and face.

ENT Surgeon

Surgeon specializing in ear, nose, and throat conditions.

Plastic/Reconstruction Surgeon

Surgeon specializing in reconstruction and repair of body tissues.

Oncologist

Physician specializing in cancer treatment using radiotherapy, chemotherapy, and targeted therapy.

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Speech and Language Therapist

Prevents aspiration (food/liquid entering lungs).

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Pre-RT Extractions

Sputum/teeth associated with tumor should removed minimum 10 days before RT.

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Smoking & Alcohol During RT

Discourage these habits during radiotherapy.

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Supportive Care During RT

CHX, Saline mouthwashes and lidocaine gel.

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Treat Fungal Infections

Nystatin/miconazole treatment

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Chemotherapy

Anti-cancer drugs to treat cancer.

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Chemotherapy Drugs

Drugs that target the G2 and Mitosis stages to kill tumour cells, while sparing normal tissues.

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Adjuvant Chemotherapy

Chemotherapy given after surgery or radiotherapy to eliminate remaining cancer cells.

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Neo-Adjuvant Chemotherapy

Chemotherapy used as the primary treatment for local control of cancer before other treatments.

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Induction Chemotherapy

Chemotherapy used as the primary treatment for widespread (metastatic) disease.

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Non-Phase Dependent Chemotherapy

Kills cells exponentially with increasing doses, equally toxic in any phase of the cell cycle or in the resting phase (G0).

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Phase-Dependent Chemotherapy

Kills cells at a lower dose but reaches a plateau because it's only effective in certain parts of the cell cycle.

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Methotrexate

An anti-metabolite that inhibits purine and pyrimidine synthesis, disrupting DNA production.

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Vinca Alkaloids

Stop cell division by interfering with microtubule function during mitosis.

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5-Fluorouracil (5-FU)

Anti-metabolite that interferes with DNA and RNA growth.

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Alkylating Agents

Damage DNA to stop cell reproduction.

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Local Toxicity (Chemotherapy)

Toxicity affecting tissues directly at the point of contact, potentially causing tissue destruction if the chemotherapy drug leaks outside the vessel.

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Bone Marrow Toxicity (Chemo)

A dose-limiting toxicity where chemotherapy negatively impacts the bone marrow's ability to produce blood cells.

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GI Toxicity (Chemotherapy)

Nausea and vomiting caused by chemotherapy, through stimulation of the CTZ, gut or cerebral cortex.

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Mucositis

Inflammation and ulceration of the mucous membranes lining the digestive tract, common with drugs like methotrexate.

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Alopecia (Chemotherapy)

Hair loss, a common side effect of chemotherapy, often starting 18-21 days after the first injection.

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Carcinogenesis (Chemo)

The potential for chemotherapy, especially long-term alkylating agents, to cause the development of cancer, such as acute leukemia.

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Gonadal Damage (Chemo)

Damage to the reproductive organs, potentially leading to infertility, as a result of chemotherapy treatment.

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Oral Mucositis (Chemo)

Inflammation of the oral mucosa, often developing 7-14 days after starting chemotherapy.

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Infections (Chemo)

Chemotherapy suppresses the immune system, thus increasing the risk of infections.

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Methotrexate Ulceration Tx

Methotrexate-induced ulceration may respond to topical folinic acid

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Dietitian

Ensures patients receive the necessary nutrients, especially important during cancer treatment.

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Restorative Dentist

A dentist who focuses on restoring teeth to full function and health.

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Pre-RT Extractions Timing

Teeth with tumors need to be removed at least 10 days before radiotherapy begins.

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Extractions During Radiotherapy

To minimize complications, extraction is done in specialized setting.

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Oral Hygiene During RT

Continue good oral hygiene practices.

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High Fluoride Supplementation

Using fluoride products to strengthen tooth enamel, reducing risk of decay.

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Nystatin/Miconazole Use

Drugs to treat fungal infections, such as thrush, that can occur during treatment.

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Chemotherapy for OSCC

Anti-cancer drugs are rarely used for treating oral squamous cell carcinoma.

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G0 Phase

Resting phase of the cell cycle where cells are not actively dividing.

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G1 Phase

Phase of the cell cycle involving protein and RNA synthesis, preparing for DNA replication.

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S Phase

Phase of the cell cycle where DNA replication occurs.

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G2 Phase

Phase where RNA synthesis occurs to prepare for mitosis.

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M Phase

Cell division stage; chromosomes separate, forming two identical cells.

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Antimetabolites

Chemotherapy that interferes with DNA and RNA growth by mimicking natural substances.

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Intrathecal Administration

Delivery method around the spinal cord.

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Central Venous Catheters

Long-term chemotherapy administration via catheters placed in the heart.

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Hickman Line

A type of central venous catheter inserted into the internal jugular vein for chemotherapy administration.

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Portacath

A subcutaneous port used for repeated access to the bloodstream, placed under the skin.

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FBC and Chemo

Regular monitoring of blood cell counts is crucial to detect and manage bone marrow toxicity during chemotherapy.

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Chemo and Hair Loss

Hair loss that can occur approximately 18-21 days after the start of chemotherapy treatment.

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Chemotherapy Side Effects

Multiple side effects, including anorexia, fatigue, nausea and oral mucositis, may arise from chemotherapy.

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Chemo-Induced Oral Issues

Inflammation and ulceration are frequent oral complications of chemotherapy, affecting many patients.

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Oral Hygiene and Chemo

Maintaining excellent oral care is important to prevent bacteremia and infections during chemotherapy.

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Chemotherapy and Taste

Taste changes during treatment can diminish appetite and impact nutritional status, delaying healing.

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Chemotherapy & Nutrition

Chemotherapy can cause taste alteration, which can further affect the nutrition.

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Chemo and Proliferating Mucosa

Due to the rapid rate of renewal of mucosal cells, mucosal cells are affected.

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Study Notes

Evaluation of Disease - Oral Cancer

  • Imaging includes CT and MRI, it is better to show Soft Tissue

Cancer Risk Factors

  • Use of HRT (hormone replacement therapy) increases women's risk for breast Cancer
  • Breast Cancer becomes Cancer when it breaks through the basement membrane

Signs and Symptoms of Cancer

  • Anaemia could be related to gut cancer
  • Anaemia is Hypochromic Microcytic due to Chronic Blood Loss
  • Delayed Pain affects Pancreatic Cancer after some time
  • Delayed Pain affects the Antrum and Ovarium due to lots of room to grow before it is noticed
  • Motor/Sensory Deficits; damage to the VII cranial nerve in Parotid Cancer, Trigeminal (unexplained numbness of face)
  • Blood in Urine/Sputum/Faeces
  • A cough that lasts 3 or more weeks is a symptom
  • Anorexia is also a symptom

Diagnosing and Staging Cancer

  • Any suspicious lesion should be referred to and biopsied

TNM Staging Components

  • T (Tumour): Size of the Tumour; bigger the Number, bigger the Size
  • N (Lymph nodes): Lymph node involvement; bigger the number, more Lymph Nodes involved
  • M (Metastases): Spread to different parts of the body; bigger the number, more spread

TNM Staging - Notes (N)

  • N₁: mobile nodes, <3 cm, ipsilateral (same side)
  • N2: mobile nodes, 3-6 cm, contra (opposite side) or bilateral (both sides)
  • N3: fixed nodes >6 cm

Grading System for Cancer

  • Graded upon the Resemblance of Cancer Cells to the Normal Cells
  • Higher the number, the less it looks like Normal Cells
  • The Worse the Cancer Is with a higher number

 

Why is Radiotherapy Used?

  • Neoadjuvant or Induction Treatment is Given before Surgery to shrink Tumour
  • Adjuvant Treatment is Given after Surgery to destroy any Residual Tumour Cells
  • For Bone Marrow Transplants
  • 49% are cured by surgery, 40% are cured by radiotherapy, and 11% are cured by chemotherapy

Radiosensitivity

  • Highly sensitive includes: Lymphoma, Leukaemia, Seminoma, Ewing's sarcoma, and Many embryonal tumours
  • Moderately sensitive includes: Small-cell lung cancer and Breast cancer
  • Relatively insensitive includes: Squamous carcinomas (including gynaecological, head and neck, and skin tumours), Adenocarcinomas of the bowel, Glioma, Sarcoma of bone and connective tissue, and Melanoma

Side Effects of Radiotherapy

  • Radical External Beam Irradiation often requires a Multi-Field Technique used Employing Three or Four Fields
  • Radiotherapy allows to apply Higher Doses without as much Collateral Damage

Dental Aspects of Radiotherapy

  • Dental Aspects of Radiotherapy DENTAL ASPECTS
  • Prior starting radio/chemotherapy, it is important for the patient to be dentally fit.
  • Patients should maintain good oral hygiene and are on high fluoride supplements (FV, Duraphat etc).

Complications of Radiotherapy

  • Mucositis: Side effect of both Radio and Chemotherapy
  • Oral Erythema, Pain, Ulceration, and Bleeding significantly impairs Quality of Life
  • Excellent Oral Hygiene is essential
  • Low Level Laser Therapy
  • Topical Lidocaine, can purchase from pharmacies
  • Degree of Dry Mouth dependent on the Dose Provided
  • Permanent Reduction in Salivary Gland Function, there may be some recovery
  • Serous Acini more susceptible to damage
  • Infections: Due to Dry Mouth, increased risk of Candidal Infections, Acute/Chronic Sialadenitis
  • Hypogeusia: Loss of Sense Of Taste
  • Taste may begin to recover within 2-4 months
  • Extremely High Doses given, may never recover
  • "Think of eating as a job"
  • If the Patient doesn't eat, they will become Malnourished and this will affect healing

More Complications of Radiotherapy

  • Radiation can cause Fibrosis of the Masticatory Muscles
  • Decreases Blood Supply
  • Osteoradionecrosis - Endarteritis Obliterans
  • Bone is 1.8x denser than Soft Tissues, thus more Radiation is absorbed
  • Ionising Radiation causes Vascular Channels in the Bone to Narrow, decreases the Blood Flow to the Bone
  • Bone becomes Hypocellular, Hypo-Vascular and Hypoxic compared with Non-Irradiated Tissues
  • Osteoradionecrosis (ORN): Area of Exposed Devitalised Irradiation Bone that fails to heal over a Period of Three to Six Months in the absence of Local Neoplastic Disease
  • Smoking and alcohol should be discouraged
  • Supportive care
  • FUNGAL INFECTIONS are the primary concern

Chemotherapy

  • Chemotherapy is rarely used for Oral Squamous Cell Carcinoma
  • If given after Surgery/DXT is called ADJUVANT (DXT = Radiotherapy)
  • NEO-ADJUVANT is used as Primary Treatment for Local Control = Chemotherapy
  • Primary treatment in widespread Disease is known as INDUCTION CHEMOTHERAPY
  • Patient with an Oral Melanoma
  • Cannon ball metastases can be seen is an indication for chemo
  • Good example of a patient who would be fit for chemotherapy
  • KINETIC CLASSIFICATION Kills Cells at a Lower Dose but reach a plateau kill at higher doses Alkylating Agents damage DNA to stop reproduction ANTI-METABOLITES which interfere with DNA and RNA growth
  • Vinca Alkaloids stops cell division
  • ANTIMITOTIC ANTIBIOTICS stops mitosis

Routes of ADMINISTRATION

  • Oral, I.M., I.V., Intrathecal (around spinal cord)
  • Long-Term catheters are placed in the Right Atrium.
  • Portcath is better as its all under the skin and so is less susceptible to infection

Complications - Acute Toxicity

  • Local Toxicity - tissue destruction if injected out of vessel
  • Bone Marrow Toxicity - dose-limiting factor
  • GI Toxicity - nausea and vomiting
  • Stimulation of CT zone, Gut and Cerebral Cortex
  • Methotrexate - Mucositis
  • Alopecia
  • Can be reduced by Scalp Cooling
  • Hair Loss starts 18-21 days after first injection
  • Not all Agents cause it

Long-Term Toxicity

  • CARCINOGENESIS - Long-term Alkylating Agents can lead to Acute Leukaemia
  • GONADAL DAMAGE - STERILITY

Side Effects

  • Anorexia
  • Backache
  • Oral mucositis
  • Infections
  • Nausea/vomiting
  • Oedema
  • Fatigue
  • Anaemia
  • Headaches

Dental Aspects of Chemotherapy

  • Loss of Taste:
  • Loss of taste affects Appetite, and Nutrition
  • "Think of Eating as a job"
  • Dental Aspects of Chemotherapy includes: Oral hygiene
  • DURING Chemotherapy: -Ulceration caused by methotrexate - If prone to Stomatitis -ESTABLISHED MUCOSITIS -Liquid form CANDIDIASIS - HERPETIC INFECTIONS BLOOD CONSIDERATIONS: -PLATELETS: -GRANULOCYTES: -AFTER Chemotherapy increases susceptibility to infection and bleeding tendencies

Principles of Oncology:

  • Staging can determine type of treatment
  • Provide Follow-Up -Head and Neck Patients are Transition to palliative care
  • Patient -Palliative Care is now from the beginning -But Patients may need to be Changed to Full Palliative

Biology of Abnormal cancer cells

  • They do not have to Responds to signals for Programmed Cell Death (fingers as an example!)
  • Webbed Fingers happen in the womb, so it will create spaces between Figures
  • They're able to migrate throughout the body
  • Specific Scans can show Metastasis in different-Inject a Radioactive Substance

Progression

  • In progression stage where the Abnormal Cells have continued to grow into a Primary Tumour

Immunotherapy

  • Includes inducing, enhancing or suppressing the Immune Response
  • Active immunotherapy
  • Adoptive immunotherapy includes
  • Tumour Vaccines

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