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Dental Management of Head and Neck Cancer patients in Northern Ireland: a retrospective analysis Moore, C., McKenna, G., & Killough, S. (2015). Dental Management of Head and Neck Cancer patients in Northern Ireland: a retrospective analysis. Poster session presented at The British Society of Prosthodontics Annual Conference, London, United Kingdom. Queen's University Belfast - Research Portal: Link to publication record in Queen's University Belfast Research Portal Publisher rights © 2015 The Authors General rights Copyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made to ensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in the Research Portal that you believe breaches copyright or violates any law, please contact [email protected]. Download date:09. May. 2017 Dental Management of Head and Neck Cancer patients in Northern Ireland: a retrospective analysis. C. MOORE, G. MCKENNA, S. KILLOUGH. Centre for Dentistry, Royal Victoria Hospital, Belfast Background Results Head and neck cancer principally affects the oral cavity, nasal cavity, sinuses, salivary glands, pharynx and larynx.1 Approximately 300 people are diagnosed with such a malignancy in Northern Ireland every year.2 Management of head and cancer typically entails an extensive multidisciplinary approach combining input from maxillofacial and ENT surgery, oncology, radiology, restorative dentistry, and other specialties.1 96 patients initially were assessed. 41 patients were referred by pro-forma and 55 by email, letter, or telephone. Overall, 51% of tumours were diagnosed within the oral or nasal cavities (figure 2). 21% of patients had initially been referred by their general dental practitioner (GDP). 72% of patients were registered with a GDP. Only 3 patients were dentally assessed within the recommended 7 days postdiagnosis. Objective To determine the oral health outcomes and standard of care provided for Northern Ireland’s (NI) head and neck oncology patients referred for pretreatment dental assessment by the Multidisciplinary Head and Neck Team (MDT), Royal Victoria Hospital, Belfast, and to assess the impact of using a standardised referral pro-forma for dental assessment. Methods A retrospective analysis was undertaken of all head and neck oncology patients referred for pre-treatment dental assessment to the Centre for Dentistry, Queen’s University, Belfast between June 2013 and November 2014. A standardised referral pro-forma was introduced from June 2014 in an attempt to streamline the referral process. Prior to this, patients were referred on an informal ad-hoc basis. Information on the patient’s planned oncology treatment, dental assessment, and dental treatment plan, was determined from their referral letter, their dental notes, and their NI Electronic Care Record. Comparison was made with published guidelines and a review of the relevant literature. Standards were set using guidelines from the Royal College of Surgeons of England, the National Institute for Health and Care Excellence, and the British Association of Head and Neck Oncologists. Figure 2: Pie chart showing distribution of diagnosed tumour site. In terms of dental pathology, 43% were diagnosed with caries, 46% periodontal disease, 10% periapical pathology, and 7% showed evidence of tooth-wear. Ten patients were edentulous (figure 3). Figure 3: Graph showing the percentage of head and neck oncology patients diagnosed with specified dental pathology. Figure 1: Head and Neck Referral Pro-forma for Dental Assessment introduced within the Belfast Health and Social Care Trust/ Queen’s Centre for Dentistry, Belfast, from June 2014. Ninety-one (95%) had planned radiotherapy with 39 (43%) of these patients requiring at least one extraction. Extractions completed within the Centre were carried out on average 11 days prior to the start of radiotherapy. Eight had extractions within the high-osteoradionecrosis-risk 10-day interval period preradiotherapy, whilst 14 had extractions post-radiotherapy. Pro-forma vs. Non pro-forma Literature Review The key messages from the literature were: - All patients should be assessed by a consultant restorative specialist both before and after their cancer treatment.3 The introduction of the referral pro-forma has resulted in a decrease in the mean number of days from MDT-referral to pre-treatment dental assessment (figure 4). Patients requiring pre-XRT extractions and referred by pro-forma also had a longer mean interval time before the commencement of radiotherapy (figure 5). - The assessment should take place within 7 days of diagnosis at the outpatient clinic. It should be undertaken with the same urgency as panendoscopy or exploratory surgery, and with preferential urgency to the first multidisciplinary team meeting (14 days).3 - Studies suggest an incidence of osteoradionecrosis between 5-15% for all head and neck radiotherapy (XRT) patients. The risk following dental extraction is highest immediately prior to, or immediately post radiotherapy (first 4 to 12 months after).4 - The Royal College of Surgeons of England request that teeth of dubious prognosis be extracted at least 3 weeks before XRT, with an absolute minimum interval period of 10 days.5 ENT-UK guidelines echo this minimum 10 day buffer period, however, they also suggest that extractions be carried out at the time of cancer surgery where appropriate.6 -Teeth recommended for extraction include those with deep caries, deep pockets, furcation involvement, non-vitality, retained roots, and unopposed teeth.5,7 Radiograph 1: Orthopantomogram of 51 year old man diagnosed with an unknown primary head and neck cancer, and to receive XRT. Additional risk factors of smoking, poor oral hygiene, xerostomia, epilepsy, alcoholic liver cirrhosis, and pancreatitis. Presented in dental pain with multiple carious lesions, generalised periodontal pocketing. Planned for dental clearance under general anaesthetic. Figures 4 (left) and 5 (right): Graphs comparing those referred by pro-forma and those referred on an informal ad-hoc basis. Table 1: Table showing the percentage of proforma and non pro-forma referrals that definitively indicated whether or not surgery, chemotherapy, and/or radiotherapy were to form part of an oncologic treatment plan. Conclusion Given the high prevalence of pre-existing oral disease amongst head and neck cancer patients, prompt dental assessment and treatment intervention is vital. Efforts aimed at improving the care pathway are on-going within the Restorative Department through the implementation of a mandatory referral pro-forma and a dedicated assessment clinic. References: 1. National Institute for Health and Care Excellence. Guidance on cancer services, improving outcomes in head and neck cancers, the manual. London: NICE, 2004. 2. Belfast Health and Social Care Trust. Head and neck cancer multi-disciplinary team annual report 2013. Belfast: BHSCT, 2013. 3. British Association of Head and Neck Oncologists. BAHNO standards 2009. Online publication available at http://bahno.org.uk/publications/ 4. Scully C, Epstein JB. Oral health care for the cancer patient. Oral Oncol 1996; 32:281-92. 5. The Royal College of Surgeons of England. The oral management of oncology patients requiring radiotherapy, chemotherapy and/or bone marrow transplantation. RCSEng, 2012. Online publication available at http://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines/documents 6. Roland NJ, Paleri V (eds). Head and neck cancer: multidisciplinary management guidelines. 4th edition. London: ENT UK; 2011. 7. Thomson PJ, Greenwood M, Meechan JG. General medicine and surgery for dental practitioners. Part 6 – cancer, radiotherapy and chemotherapy. Br Dent J 2010; 209:65-9.