BAN quiz 5

betel nut chewing

increases cancer risk by ~9 times, causes submucous fibrosis

66-70Gy

taget dose of radiation for OSCC

max dose to tumor, decreased dose to other structures

what is the benefit of intensity modulated radiation therapy (IMRT)

>55Gy

radiation dose with the highest risk of ORN

stop when they hit tumor, decrease scatter and damage

what is the advantage of PROTON therapy

head and neck CT

first imaging used in OSCC/OPSCC cases

cannot provide definitive diagnosis

what is a disadvantage of adjunctive tests

green

how does normal tissue appear under autofluorescence?

press against tissue, green will return if loss of fluorescence is due to inflammation

how to tell if a tissue is only inflamed when it doesn’t have fluorescence under autofluorescence

predicts likelihood of lymph node involvement

what is the significance of depth of invasion (DOI)

biopsy and imaging

what is needed for TMN staging

next to ulcer (area next to dye uptake)

what site is best for biopsy

extranodular extension

extension of tumor cells beyond node capsule

N3

any extranodal extension is designated what stage

stage IV

ALL N3s are what stage

lungs

most common site of metastasis for OSCC

staging

is staging or grading more PREDICTIVE of PROGNOSIS

monotherapy (one therapy: surgery OR radiation)

what kind of therapy is used to treat stage I and II

multimodal therapy (surgery, radiation, AND chemotherapy)

what kind of therapy is used to treat stage III and IV

metastasis (M1)

what classifies as stage IVc

toluidine blue

a vital stain attracted to dysplastic and malignant cells, used to detect oral precancerous lesions

after 2 weeks

when should mucosal lesions be reassessed after treatment with medication (ex: clobetosol)

time for medication effect, mucosal healing, not too long to cause harm

why should mucosal lesions be reassessed after 2 weeks

false positive possible, stains fibrin and fissured tissue

limitations of toluidine blue

skin, thyroid, hematologic

types of cancer (besides OSCC) that could be identified during routine exam

sun protection/sunscreen

best prevention of SCC of the lip

Asymmetry, Borders, Color, Diameter, Evolution (ABCs)

how are pigmented lesions evaluated for MELANOMA

ultrasound and fine needle aspiration (FNA)

what test could you order if suspicious of thyroid cancer

CBC w/ Diff

what INITIAL test would you order if suspicious of hematologic malignancy

epithelial

what is the tissue of origin of OSCC

floor of mouth

which site of OSCC has the worst prognosis (survival)

p16

marker that is most accurate prognosis for HPV + oropharyngeal squamous cell carcinoma.

atraumatic with primary closure and hyperbaric oxygen for XRT dose larger than 55 Gy

if extraction is necessary what is plan

tongue displacement dental stents

device used to hold tonguee out of way to reduce radiation

radiation dose/location and when treatment starts

critical information for dentist

tooth loss, salivary dysfunction, caries, gingival recession

complications after radiation

bland rinses, topical anesthetics, NSAIDs, Opiods

treeatment of radiation induced mucositis

>30Gy

at what dose of radiation is salivary dysfunction permanent

caries, candidiasis, altered function, discomfort

consequences of dry mouth/salivary dysfunction

25Gy to single or 20Gy to both

recommended dose of radiation to parotid glands to avoid salivary dysfunction

hydration,saline rinse, stimulants (sugar free), topical agents, rx topical sprays

conservative management of salivary dysfunction and dry mouth

pilocarpine (salagen)

sialagogue used for radiation induced dry mouth

50 Gy

above what level of radiation is there a high risk of Osteoradionecrosis (ORN)

OSCC/OPSCC

type of cancer that requires the most radiation

injury, surgery, EXT, infection

risk factors of osteoradionecrosis

hyperbaric oxygen

therapy used to enhance healing and reduce the risk of osteoradionecrosis by increasing oxygen supply to tissues.

hyperbaric oxygen

BEFORE EXT what treatment is NOT recommended

2 Gy 5 days/week for 7 weeks

typical course of radiation for OSCC

refer to oral surgery, prophylactic pentoxifylline and tocopherol

what should be done when EXT is unavoidable in pt with osteoradionecrosis risk

mylohyoid ridge on lingual side of mandible

most common site of osteoradionecrosis

acute iritis, narrow angle glaucoma, uncontrolled asthma

contraindications to sialagogues

clotimazole and nystatin

topical antifungals

caries (high sugar content)

risk of antifungals

osteoradionecrosis (ORN)

exposed and irritated bone as a result of vascular damage from radiation

2 weeks

healing time AFTER EXT BEFORE radiation

root fracture, severe bone loss, endo infection w/ questionable prognosis

teeth in what condition requires EXT prior to radiation

fewer teeth, salivary dysfunction, bad oral hygiene, prior untreated caries, probing ≥5-6mm

risk factors for tooth loss due to radiation therapy

mucositis, salivary dysfunction, mucosal infection, pain, taste dysfunction

ACUTE oral complications of radiation therapy

salivary dysfunction, osteoradionecrosis, neuropathic pain, periodontal disease, fibrosis/trismus

chronic oral complications of radiation therapy

until therapy is complete and tissue regenerates

how long does mucositis caused by radiation persist

fanconi anemia

inherited AR disorder that affects bone marrow, leading to decreased production of blood cells and increased cancer risk by 500-700x

decreasing, decreased tobacco use

what is the current trend of SMOKING RELATED oral squamous cell carcinoma prevalence and why?

HPV

cause of majority of OROPHARYNGEAL TUMORS

painful ulcer, loose teeth, ill-fitting dentures, bleeding gums

clinical presentation of oral cancer

based on tumor, nodes and metastases (TMN)

how are oral cancers staged

oral squamous cell carcinoma

the term “oral cancer” usually reefers to what type of cancer

ventrolateral tongue

most common location for OSCC (oral squamous cell carcinoma)

persistent ulcers, rolled borders, hardness, irregular shape

what clinical findings would raise concern for OSCC/OPSCC

root resorption, irregular radiolucency, punch out radiolucencies, bony expansion, numbness

clinical findings that would raise concern for bony cancers

leukemic gingivitis, bleeding, aphthous, lymphadenopathy

clinical findings that would raise concern for hematologic cancers

tobacco, alcohol, betel/areca nut

major common MODIFIABLE risk factors for oral cancer

age, immunosuppression, genetic disorders

non-modifiable risk factors for cancer

HPV induced oropharyngeal squamous cell carcinoma (OPSCC)

most rapidly increasing cancer diagnosis in men

tonsillar crypts and base of tongue

location of HPV OPSCC

HPV OPSCC has better survival

how does survival of HPV OPSCC compare to tobacco induced OSCCs

most oral manifestations are not malignant

important thing to remember about HPV

HPV 16

Which HPV has highest risk of developing into OPSCC?

NO

does a positive HPV-16 salivary screening mean that the patient will develop OPSCC

vaccination

prevention of HPV OPSCC

dysphagia, odynophagia (pain when swallowing), unilateral ear pain, neck mass

signs and symptoms of OPSCC

any lymph node involvement is at least stage III

how does lymph node involvement affect staging of OSCC

biopsy

required to make a diagnosis of oral cancer

proliferative leukoplakia, erythroplakia, non-homogenous (mixed coloration) leukoplakia, leukoplakia, oral lichen planus

Rank oral pre-malignant lesions (OPML) from highest to lowest risk for transformation to OSCC

leukoplakia

most common OPML (oral premalignant lesion)

ventrolateral tongue and floor of mouth

high risk sites of leukoplakia

erythroplakia

a red patch that cannot be classified as another condition, associated with a higher risk of malignant transformation than leukoplakia

proliferative verrucous leukoplakia (PVL)

much higher malignancy risk than both erythroplakia and localized leukoplakia (malignant transformation 70-100%)

agressive and frequent surgical interventions, monitor for recurrence

treatment of proliferative verrucous leukoplakia (PVL)

premalignant abnormal growth

what does oral epithelial dysplasia mean on biopsy report

NO

does a negative biopsy mean that the lesion will always be benign

excision/surgery

primary (best) therapy for stage I and II OSCCs