Download Dental Management of Head and Neck Cancer patients in Northern

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.
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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.