1 Introduction
2 Facilities
3 Protocols
3.1 Pre-treatment Assessment
3.2 Preventive Care
3.3 Pre- and Post-Treatment Dental Extractions
3.4 Oral Mucositis/Oral Infections
3.5 Prosthetic Care and Rehabilitation
3.6 Maintenance and Monitoring
3.7 Finance
4 Information Resources

1 Introduction

Oral cancer is relatively rare in the United Kingdom. Currently, about 4000 people will be diagnosed and treated for oral, pharyngeal, lip, or salivary gland tumours. The status of the oral cavity in the cancer patient is no different from that found in the general population: poorly maintained dentition, moderate to advanced periodontal disease, ill-fitting denture prostheses, and related soft tissue pathologies associated with tobacco and alcohol use and nutritional and/or general hygiene neglect. Reference

Many of these patients will be treated with radiation therapy to the head and neck area. A substantial number will be subject to clinically significant short and long-term oral adverse effects. Severe problems in the mouth can occur after radiation therapy for head and neck cancer. Most patients being treated for head and neck cancer and many patients with other cancers also experience oral complications from chemotherapy.

These oral problems may make it difficult for a patient to receive all of his or her cancer treatment. Sometimes treatment must be stopped completely. The most important risk factors of oral complications of cancer therapy are oral or dental disease that already exists, poor oral care during cancer therapy, and any factor that affects the mouth tissues. Oral problems that already exist, such as periodontitis, caries, failing restorative work (such as crowns, or fillings), and dentures may increase the risk of infection. Areas where the gums or tissues are irritated can lead to ulceration in the mouth. These patients require urgent dental care before and after cancer treatment.

By starting preventive measures before and during early cancer therapy, it is possible to reduce the occurrence and the problems associated with our patients’ cancer treatment. If this is done it can significantly improve oral physiologic and social functioning. Prevention of oral sequela is much preferred to repair, both on a social and an economic basis. The patient’s oral care and function is an important contributor to post treatment social adaptation and life quality. The Calman report on cancer care emphasised the need to focus treatment and management regimens on both longevity and quality of life. Reference

The larger cancer treatment centres have a head and neck cancer team that usually consists of a radiation oncologist, a head and neck surgeon, a hospital dentist and a medical oncologist who evaluate the patient and recommend the most appropriate treatment plan. Ideally, comprehensive dental care for these patients should be available. The clinical guidelines published by the Royal Colleges of Surgeons of England state that a clear pathway of care is necessary to prevent or minimise oral complications. Reference

The clinical guidelines recommend that every relevant oncology protocol include an early pre-treatment oral assessment with a permanent member of the oncology team responsible for arranging the oral assessment and organising oral care, arranging or carrying out any active dental treatment required. However, this is an exception rather than the rule. In many instances cancer patients receive no dental assessment or preventive treatment to minimise or avert the known and common oral complications of radiation therapy. This is due, in part, to the lack of resources and recognised local standards of dental care for cancer patients undergoing head and neck radiation.

At present, the services provided by the Consultant in Restorative Dentistry for cancer patients go largely unrecognised and hence does not feature in departmental budgets of hospitals. To formalise this service provided, a Restorative Dentistry Oncology Clinic has been set up. To improve the current situation, a campaign to educate general dental practitioners about the role they could play, in conjunction with the hospital cancer service, in managing to reduce the complications of oral cancer treatment is urgently required.

In most circumstances the treatment plan can be carried out the patient’s dentist under the NHS, or privately, under advice from a Restorative Dentistry Oncology Clinic. After the extractions required are completed, urgent care such as placement of restorations, adjustment of prostheses and elimination of oral discomfort are undertaken by the patient’s dentist. All dental care should usually be completed within two weeks of referral of the patient if adequate clinical facilities are available and arrangements made. When possible, dental extractions should have a healing time of seven to ten days prior to commencement of radiation therapy. This window of opportunity for dental treatment and the capacity for rapid delivery of dental care can only be achieved if the patient is given priority both within the hospital’s departments and by the patient’s general dental practitioner. General dental practitioners need to urgently carry out the advised dental treatment plan for these patients to avoid any delay of cancer treatment.

If the preceding procedures have been completed, most patients will not need oral care during the course of their radiation therapy. However, continuing evaluation and supportive reinforcement is critical for these patients who will need to be seen in the Restorative Dentistry Oncology Clinic for dental evaluation and prosthodontic treatment if required, for management or amelioration and control of oral problems such as xerostomia, mucositis, opportunistic infection, nutritional difficulty.

Radiation patients with head and neck cancer are at lifelong risk for oral disease as a result of their treatment. The possibility of tumour recurrence or persistence is significant, especially in those who continue to abuse alcohol and tobacco. Dental caries and periodontal disease are common in xerostomic patients and osteoradionecrosis is a serious potential sequela to radiation treatment. Patients are therefore scheduled for oral follow-up care appointments to coincide, wherever possible, with their appointments for review by their oncologist in the Head & Neck clinic.

Occasionally patients may request, by reason of geography or convenience, to see their own dentist. In such cases it is still prudent for them to be seen by the dental oncologist at least annually for the first few years. Thereafter the patient should be seen on a tapering regime with transfer, when desirable, to the general dental practitioner. Keeping the patient’s dentist informed of the treatment delivered and the means of continuing care upon referral back to the dentist is analogous to the manner in which cancer centres seek to involve the primary general medical practitioner into the management of the patient’s medical care plan.

Due to the need for rapid dental treatment planning and care delivery, it is mandatory for a dental assessment and initial dental treatment plan to be at the Restorative Dentistry Oncology Clinic. Ideally, head and neck cancer patients should be referred to a well-staffed specialist dental oncology unit for their appropriate care and treatment planning. However, the lack of manpower means that comprehensive total dental care will be unavailable. It is unfortunate that this has occurred. It is hoped that funding for well staffed dental oncology clinics at cancer centres or host hospitals will be planned for.

Until then, the present service will need to depend upon follow-up care delivered by the general dental practitioner in collaboration with the consultant at the Restorative Dentistry Oncology Clinic. To be successful, a campaign to educate general dental practitioners about the role they could play in managing to reduce the complications of oral cancer treatment is urgently required.


2 Facilities

The Restorative Dentistry Oncology Clinic at St Luke’s Hospital is currently staffed by a part-time consultant in restorative dentistry, who provides the specialist maxillo-facial prosthodontic and periodontic support, and a part-time dental hygienist and certified dental assistant. The patient’s general dentist provides routine restorative dental care of a non-specialized nature under advice from the consultant. A maxillo-facial laboratory provides prostheses for facial and other reconstructions of missing structures. The clinic will be held on the first and third Tuesdays of the month in the week following the Head & Neck cancer clinic held at the Bradford Royal Infirmary. The clinic will also be held on the fifth Tuesday of the month when applicable. This service formally commenced at St Luke’s Hospital in May 2001.


3 Protocols

3.1 Pre-treatment Assessment

Ideally, a pre-treatment dental consultation is offered to all Bradford Health Authority registered patients identified as being "at risk" of dental breakdown or infection resulting from the primary disease or its treatment. The main patient groups "at risk" are those who will experience immunosuppression, prolonged xerostomia, oral mucositis, radiation of oral structures including the salivary glands and jawbone, and those who will undergo surgery involving the oral cavity. The Consultant in Clinical Oncology will refer patients for dental assessment using the referral form appended.
Following the examination, a treatment plan is developed to meet the disease or therapy-related needs. The plan is discussed with the patient, the oncologist, and if appropriate, with the patient's general dental practitioner. The extraction of teeth situated in the radiation treatment volume is performed by oral and maxillofacial surgeons who are members of the consulting staff at the Maxillo-Facial Unit at St Luke’s Hospital. While routine restorative work may be undertaken at the Restorative Dentistry Oncology Clinic, it is preferably done by the patient's dentist.


3.2 Preventive Care

Preventive care is extremely important in reducing cancer therapy sequela. The need for scrupulous attention to oral hygiene procedures is reinforced, and arrangements are made with the patient's dentist to continue oral hygiene measures. Custom gel carriers (similar to athletic mouthguards) are provided to all patients who may experience xerostomia as a result of cancer therapy. The application of a fluoride gel, a remineralizing gel, or a chlorhexidine gel using these carriers may be indicated. Dietary advice to avoid caries is given. These simple measures are capable of eliminating the occurrence of new tooth decay.


3.3 Pre- and Post-Treatment Dental Extractions

Pre-radiation extractions should commence as soon as possible after completion of the dental treatment plan. The longer the period allowed for healing, the better, however extractions should not interfere with anti-cancer radiation therapy or with mould room or simulator appointments. If removal of teeth is required prior to radiation, the mould room and radiation oncologist should be notified since it may affect the fit of the mask thereby delaying treatment. Pre-radiation extractions should be done with minimal trauma, possible flap elevation, alveoplasty (to ensure rounded healed contours to better facilitate later prosthodontic treatment) and primary closure with minimal tension. This may or may not require bone recontouring and incision of the periosteum to achieve a tension free closure. Elective extractions in the upper arch and, indeed, any elective oral surgery, should be delayed until after treatment. Pre-radiation extractions should be done for teeth that are hopeless or borderline and are in, or near, the radiation field or surgical site. If more time is available and more extractions are required, they should be done pre-therapeutically.

With respect to post-radiation extractions, the use of hyperbaric oxygen routinely and prophylactically for all dental extractions is not recommended. In cases where extractions are required in the lower jaw, and where the radiation dose exceeds 60 Gy, and the tooth to be extracted is in the field of treatment, as determined by the radiation oncologist, prophylactic hyperbaric oxygen may be beneficial but not mandatory. In almost all maxillary cases, where low doses of radiation are used (50 Gy or less), and in cases where the tooth in question is not in the radiation field, prophylactic hyperbaric oxygen is not recommended nor required. Post-radiation dental extractions should be completed by either an oral and maxillofacial surgeon or an experienced dental oncologist. In either case, minimal trauma to the tissues should be a priority with avoidance of periosteal flaps, minimal bone contouring and closure of the wounds with tension-free sutures. These patients require regular and frequent follow-up examinations to assess for the presence of osteoradionecrosis.

Dental extractions in patients receiving cytotoxic chemotherapy should be done only at cancer centres or host hospitals where the oncologist can be consulted, the blood count values can be reviewed or acquired, and appropriate medical back-up is available for transfusion and supportive care.


3.4 Oral Mucositis/Oral Infections

Oral mucositis is a common complication of head and neck radiotherapy and may occur in patients treated with intensive chemotherapy. Management in order to reduce oral mucositis and to treat mucositis when it occurs is offered to patients. Oropharyngeal infections may develop during therapy. Prevention and treatment of fungal, bacterial and viral infection is provided.


3.5 Prosthetic Care and Rehabilitation

Prior to surgery for the removal of oral structures, a full dental examination should be performed. Radiographs necessary to confirm the status of any remaining natural teeth will be obtained. Impressions are made for study models so that surgical stents can be constructed. These temporary prostheses are inserted and further refined by the prosthodontist or surgeon at the time of surgery. The use of a surgical stent in this manner maintains oral function, enhances appearance, and supports and protects skin grafts in the sites of the surgical defect. This approach significantly reduces the duration of hospitalisation that would otherwise be required. Regular adjustment of such prostheses is required to accommodate changes in the contour and consistency of adjacent tissues.

The prosthetic rehabilitation of patients whose condition has been altered by a cancer or the treatment for that cancer is also undertaken. This may include the replacement of teeth with partial or complete dentures, and the construction and delivery of prostheses to replace intra, and extra-oral structures removed surgically.

The Restorative Dentistry Oncology Clinic collaborates with other disciplines (Maxillo-facial Surgery, ENT, Speech Pathology, Nutrition, Social Work, etc), in order to optimise patient care.

3.6 Maintenance and Monitoring

The Clinic maintains a recall programme in order to ensure that the delivery of care following dental assessment has been appropriate to the needs of individual patients. A database is being developed with which dental care can be analysed.

1. Toth BB et al. Minimizing Oral complications of Cancer Treatment. Oncology, 1995; 9, No 9 (September 1995)
   
   
2. Feber T. Management of mucositis in oral irradiation. Clin Oncol (Royal College of Radiologists) 1996; 8:106-11.
   
   
3. Calman, K., Hine, D. A Policy Framework for Commissioning Cancer Services. Dept. of Health, April 1995.
   
   
4. Clinical Guidelines: The Oral Management of Oncology Patients, Faculty of dental Surgery, Royal College of Surgeons of England.