Oral rehabilitation of the cancer patient: A formidable challenge

Analysis of Dental Prosthetic Treatment in Patients with Cancer Aged 65 Years and Older after Expanded Health Insurance Coverage: A Retrospective Clinical Study

Background and Objectives: With increases in cancer incidence and the number of cancer survivors, the demand for cancer management is growing. However, studies on dental prosthetic treatment for patients with cancer are rare. We aim to investigate the dental prosthetic treatment in patients with cancer aged ≥65 years after expanded health insurance coverage. Materials and Methods: This retrospective study included patients who were treated with implants and removable dentures at Ulsan University Hospital in South Korea between June 2015 and June 2023. Data on age, sex, cancer location, comorbid systemic diseases, number of remaining teeth, dental prosthetic treatment history, type of dental prosthetic treatment, and insurance coverage status were extracted from patient medical records and panoramic radiographs. The influence of multiple variables on dental prosthetic treatment was analyzed using the Chi-square and Fisher's exact tests. Results: The study included 61 patients with cancer (32 men, 29 women; average age: 70.9 years). Among them, 56 (91.8%) had insurance coverage benefits, and 34 (55.7%) received treatments such as implants, removable partial dentures, or complete dentures for the first time. Treatment types included 37 (60.7%) cases of implant prostheses and 24 (39.3%) conventional removable dentures. No statistical differences were observed in the type of dental prosthetic treatment according to sex, age, cancer location, number of systemic diseases, and dental prosthetic treatment history (p > 0.05). Patients with <10 remaining teeth received treatment with conventional removable dentures, which was statistically significant (p < 0.001). Conclusions: Of the 61 patients, 56 (91.8%) received insurance benefits, and 34 (55.7%) underwent dental prosthetic treatment for the first time. Within the limitations of this retrospective study, the expanded health insurance coverage alleviated the unmet demand for dental prosthetic treatment. As cancer prevalence continues to increase, expanding customized health insurance coverage is crucial to meet this demand.

Guided placement of zygomatic implants in head and neck cancer patients: implant survival and patient outcomes at 1-3 years of follow-up

Zygomatic implants (ZI) are a valuable option for supporting an obturator prosthesis after maxillary resection. This study was performed to assess the clinical outcomes of a digitally validated guided technique for ZI placement, followed by immediate prosthetic obturation. The primary objective was to evaluate implant survival, while the secondary objective was to assess patient-reported quality of life post-rehabilitation. Twelve patients treated for head and neck cancer received a total of 36 ZI after ablative surgery. The mean duration of ZI follow-up was 30.1 months. The survival rate of ZI placed in non-irradiated patients was 100%, while it was 85% in irradiated patients. Patient-reported outcomes were evaluated using the Liverpool Oral Rehabilitation Questionnaire (LORQv3) and the University of Washington Quality of Life Questionnaire (UW-QOL v4). Most patients reported satisfactory outcomes in the oral function domain of the LORQv3 (mean score 17.7 ± 4.5; possible range 12-48, with lower scores indicating better outcomes). Regarding the UW-QOL v4, the swallowing and chewing domains had the highest scores (mean 97.5 ± 8.7 and 95.8 ± 14.4, respectively; maximum possible score of 100). In conclusion, this treatment approach improves function and quality of life after maxillary ablative surgery. However, irradiated patients showed a noticeable trend of higher implant failure, and this was influenced by tumour position and size impacting the radiation dose to the zygomatic bone.

Design and evaluation of a deep learning-based automatic segmentation of maxillary and mandibular substructures using a 3D U-Net

Background

Current segmentation approaches for radiation treatment planning in head and neck cancer patients (HNCP) typically consider the entire mandible as an organ at risk, whereas segmentation of the maxilla remains uncommon. Accurate risk assessment for osteoradionecrosis (ORN) or implant-based dental rehabilitation after radiation therapy may require a nuanced analysis of dose distribution in specific mandibular and maxillary segments. Manual segmentation is time-consuming and inconsistent, and there is no definition of jaw subsections.

Materials and methods

The mandible and maxilla were divided into 12 substructures. The model was developed from 82 computed tomography (CT) scans of HNCP and adopts an encoder-decoder three-dimensional (3D) U-Net structure. The efficiency and accuracy of the automated method were compared against manual segmentation on an additional set of 20 independent CT scans. The evaluation metrics used were the Dice similarity coefficient (DSC), 95% Hausdorff distance (HD95), and surface DSC (sDSC).

Results

Automated segmentations were performed in a median of 86 s, compared to manual segmentations, which took a median of 53.5 min. The median DSC per substructure ranged from 0.81 to 0.91, and the median HD95 ranged from 1.61 to 4.22. The number of artifacts did not affect these scores. The maxillary substructures showed lower metrics than the mandibular substructures.

Conclusions

The jaw substructure segmentation demonstrated high accuracy, time efficiency, and promising results in CT scans with and without metal artifacts. This novel model could provide further investigation into dose relationships with ORN or dental implant failure in normal tissue complication prediction models.

Rehabilitation of mandibular resected patients using fixed immediately loaded corticobasal implant -supported prostheses. A case series

INTRODUCTION AND IMPORTANCE

Aliments such as congenital conditions, pathological, and iatrogenic circumstances may result in mandibular defects that can severely disturb the patients' oral health, functions (mastication, speech), aesthetics, and quality of life and present a rehabilitating challenge.

CASE PRESENTATION

we present a multidisciplinary treatment approach for three cases presented with mandibular resection as a consequence of cystic, benign, and malignant tumour eradication that were rehabilitated with immediately loaded fixed corticobasal implant-supported prostheses and a follow-up period of 5,5 and 4 years. The reported cases present with excellent implant survival, along with healthy peri-implant tissues, stable prostheses, enhanced speech, chewing ability, aesthetics, superior patient satisfaction, and improved overall self-esteem.

CLINICAL DISCUSSION

A multidisciplinary oral and maxillofacial team is mandatory for the successful rehabilitation of patients with mandibular resection and to restore soft and hard tissue loss. The reported treatment modality offers the patient immediate fixed implant-supported prostheses omitting the need for a bone grafting procedure, with optimum peri-implant tissue health, excellent biomechanical and prosthetic results, and significant improvement in function and satisfaction.

CONCLUSION

Corticobasal fixed implant-supported prostheses can be a reliable treatment modality for mandibular resection, resulting in notable enhancements in the patients' oral health, appearance, mastication, speech, and self-esteem.

Long-Term Outcomes of Dental Rehabilitation and Quality of Life after Microvascular Alveolar Ridge Reconstruction in Patients with Head and Neck Cancer

Background/Objectives: Dental rehabilitation after extended tumour resection and jaw reconstruction is challenging. The present study aimed to report the prosthetic outcome and quality of life (QoL) in patients with head and neck cancer (HNC) after microvascular alveolar ridge reconstruction. Methods: The prosthetic outcomes of all consecutive patients with HNC who underwent microvascular alveolar ridge reconstruction at the University Hospital Salzburg between 2011 and 2018 were investigated. Oral health-related QoL (OHrQoL) and overall QoL were assessed using the validated Oral Health Impact Profile-49 (OHIP-49) and Short Form-36 questionnaires. Results: During the study period, 115 consecutive patients with head and neck cancer underwent microvascular jaw reconstruction. Among them, 23.3% and 27.4% received conventional tissue-borne prostheses and implant-supported prostheses, respectively, while 48.7% did not undergo dental rehabilitation. The prosthetic outcome was not associated with tumour stage (p = 0.32). Oral health-related quality of life (OHrQoL) was best in patients with implant-supported dental rehabilitation (OHIP-49 median score = 7) and worst in those with conventional removable dentures (OHIP-49 median score = 54). The corresponding OHIP-49 median score for patients who could not undergo dental rehabilitation was 30.5. All Short Form-36 subscale scores were equal to or higher than the malignancy norm scores. Conclusions: After microvascular jaw reconstruction, approximately one-third of the HNC patients received adequate implant-supported dental rehabilitation. However, the risk of dental rehabilitation failure was 50%. The different prosthetic outcomes affected OHrQoL, but not overall QoL.

Treatment Complications of Head and Neck Cancers and Rehabilitation Measures: A Narrative Review

Head and neck cancers (HNCs) are malignant tumors mainly from squamous cells in the head and neck tissues. Treatment involves a multidisciplinary approach with surgery, radiotherapy, and chemotherapy. However, the long-term prognosis for patients with advanced-stage tumors is guarded, with a median survival time of approximately 24 months. HNC patients have very high rates of depression and anxiety and the highest suicide rate among all cancers due to the intense and challenging nature of the treatment, underscoring the importance of our collective efforts. Rehabilitation success depends on various factors, including tumor, patient, and treatment-related factors. Patients may require post-treatment oral rehabilitation measures, including implants, obturators, and flexible dentures. These measures are crucial, but they often need to be more utilized. Patients may face challenges in maintaining oral hygiene and managing mucositis. Additionally, it is essential to address other intricacies such as trismus, xerostomia, gustatory dysfunctions, neuropathy, speech impairments, and psychological disturbances. Unfortunately, there is little literature on post-treatment rehabilitative measures. Despite its crucial role in improving patients' quality of life, rehabilitation often receives inadequate attention compared to treatment. Our narrative review, which covers various factors that affect rehabilitation, including oral rehabilitation measures and post-treatment complications, is anticipated to deliver practical insights to professionals and inspire positive changes in their regular practice.

Mechanical properties of tissue adhesives used for retaining extraoral silicone prostheses in maxillofacial defects: A systematic review

STATEMENT OF PROBLEM

Different tissue adhesives are available for retaining extraoral silicone prostheses in maxillofacial defects. Comparative assessment of their mechanical properties will help the clinician select the right product for a specific clinical situation, but a systematic review is lacking.

PURPOSE

The purpose of this systematic review was to analyze the existing data in the literature regarding 5 mechanical properties of tissue adhesives for extraoral silicone prostheses: peel strength, tensile strength, shear strength, torsional strength, and tack.

MATERIAL AND METHODS

A manual and electronic search was performed in appropriate databases to identify relevant publications with specific inclusion and exclusion criteria. The retrieved studies were screened for eligibility using the title, abstract, and published full texts. To evaluate the risk of bias, a methodological quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklists for Randomized Controlled Trials. A custom data extraction template was used, and the results pooled using descriptive methods.

RESULTS

After screening, 15 articles, 5 in vitro studies, and 10 clinical studies were eligible for data extraction. In vitro studies assessed tack and peel bond strength. In contrast, clinical studies assessed peel strength, tensile strength, shear strength, and torsional strength through direct comparisons and in diverse settings.

CONCLUSIONS

The assessed studies showed considerable methodological heterogeneity. When silicone-based tissue adhesives (Secure2 Medical Adhesive; Factor II, Hollister Colostomy Adhesive; Hollister Inc, Dow Corning 355 Medical adhesives; Dow Corning Europe Inc) were compared with water-based adhesives (Pros-Aide Adhesive; ADM Tronics Inc, PSA 1; Cosmedica Ltd, Daro adhesive; Factor II, Epithane-3; Daro Products), the silicone-based adhesives showed a higher peel bond strength (PBS), while double-sided medical adhesive tapes showed lower PBS. A few studies evaluated variations in the PBS as being affected by the addition of stone wool fibers, immersion in water, application of skin protective dressings and adhesive removers, application of multiple layers of adhesive, and usage of urethane liner.

Shikonin enhances chemosensitivity of oral cancer through β-catenin pathway

OBJECTIVES

This study concentrates on exploring the synergistic effect of shikonin on cisplatin against oral cancer.

METHODS

To analyze the IC50 value of shikonin, gradient concentrations of shikonin were added to the oral cancer cell culture medium. After the cisplatin-resistant cell line was established, the effects of cisplatin and shikonin on the survival rate, proliferation, apoptosis and related pathway protein expression of common/drug-resistant oral cancer cells were compared through MTT, clone formation, flow cytometry, and Western blot experiments. β-catenin, which had the most significant expression changes, was overexpressed and silenced, and used to design a reverse validation.

RESULTS

Shikonin inhibited the viability of oral cancer cells. Although cisplatin killed some cancer cells, its effect on drug-resistant cancer cells was significantly reduced. The addition of shikonin enhanced the sensitivity of drug-resistant cells to cisplatin. Shikonin regulated key proteins in cell proliferation and apoptosis-related pathways. Among them, shikonin generated the most evident inhibitory effect on β-catenin. Therefore, β-catenin overexpression plasmid/siβ-catenin was transfected into the cells. Silenced β-catenin was found to reinforce the damaging effect of cisplatin on cancer cells, and overexpressed β-catenin reversed the effect of shikonin.

CONCLUSION

By down-regulating β-catenin expression, shikonin improves the sensitivity of drug-resistant oral cancer cells to cisplatin.

Peri-implant health after microvascular head and neck reconstruction-A retrospective analysis

INTRODUCTION

Prosthodontic rehabilitation after reconstruction with microvascular revascularized free flaps following ablative tumor surgery is challenging due to the altered anatomical and functional conditions. The aim of this retrospective study was to determine whether the type of graft and the type of peri-implant tissue have an effect on peri-implant inflammatory parameters and implant survival.

MATERIALS AND METHODS

Patients who received a free flap reconstruction with subsequent implant-prosthetic rehabilitation between 2010 and 2022 were retrospectively included. The primary outcome variable was the probing depth (PPD) at a minimum of 1 year after completion of prosthetic restoration. Predictive variables were type of free flap, emergence profile, and history of radiation.

RESULTS

Seventy-one patients after free flap reconstruction were included in the analysis. At a minimum of 24 months after implant insertion the primary outcome, PPD showed no clinically relevant differences between the types of free flaps used. The emergence profile through a skin island resulted in an increase in BOP compared to native mucosa in the descriptive analysis (p-value > .05). The analysis showed a 5-year implant survival of 96.2% (95% CI: 0.929-0.996) in cases without irradiation and 87.6% (95% CI: 0.810-0.948) with irradiation of the region evaluated (p-value .034).

CONCLUSION

Flap and associated soft tissue type had no significant effect on 5-year implant survival or peri-implant inflammatory parameters. However, the large heterogeneity of the patient population indicates that further prolonged studies are required for a more differentiated assessment of the long-term success.

p75NTR antibody-conjugated microspheres: an approach to guided tissue regeneration by selective recruitment of endogenous periodontal ligament cells

Repairing defects in alveolar bone is essential for regenerating periodontal tissue, but it is a formidable challenge. One promising therapeutic approach involves using a strategy that specifically recruits periodontal ligament cells (PDLCs) with high regenerative potential to achieve in situ regeneration of alveolar bone. In this study, we have created a new type of microsphere conjugated with an antibody to target p75 neurotrophin receptor (p75NTR), which is made of nano-hydroxyapatite (nHA) and chitosan (CS). The goal of this design is to attract p75NTR+hPDLCs selectively and promote osteogenesis. In vitro experiments demonstrated that the antibody-conjugated microspheres attracted significantly more PDLCs compared to non-conjugated microspheres. Incorporating nHA not only enhances cell adhesion and proliferation on the surface of the microsphere but also augments its osteoinductive properties. Microspheres effectively recruited p75NTR+ cells at bone defect sites in SD rats, as observed through immunofluorescent staining of p75NTR antibodies. This p75NTR antibody-conjugated nHA/CS microsphere presents a promising approach for selectively recruiting cells and repairing bone defects.

Mandibular guiding flange prosthesis to guide mandibular deviation following partial mandibulectomy and partial maxillectomy for squamous cell carcinoma: A case report

ABSTRACT

Squamous cell carcinoma is one of the most prevalent cancers affecting the oral cavity. Rehabilitation following surgical treatment requires a multidisciplinary approach and care. Multiple disabilities such as dysarthria, dysphagia, unesthetic appearance, and psychosocial disorders following the surgery for carcinoma can greatly impact the quality of life of such patients, thereby necessitating multidisciplinary intervention. The clinician has to wait for the healing of the lesion and the effects of radiotherapy to be dwindled in case a secondary osseous grafting is planned. During this time lag until a more definitive prosthesis is planned, an interim prosthesis is must to correct the mandibular deviation due to the unilateral muscular pull. This case presentation describes the utilization of guiding flange prosthesis (GFP) as an interim modality for the establishment of a stable and functional maxillomandibular relationship following combined ipsilateral partial mandibulectomy and maxillectomy.

[Accurate tissue flap reconstruction method based on the quadratic surface developability for head and neck soft tissue defects]

Soft tissue defects resulting from head and neck tumor resection seriously impact the physical appearance and psychological well-being of patients. The complex curvature of the human head and neck poses a formidable challenge for maxillofacial surgeons to achieve precise aesthetic and functional restoration after surgery. To this end, a normal head and neck volunteer was selected as the subject of investigation. Employing Gaussian curvature analysis, combined with mechanical constraints and principal curvature analysis methods of soft tissue clinical treatment, a precise developable/non-developable area partition map of the head and neck surface was obtained, and a non-developable surface was constructed. Subsequently, a digital design method was proposed for the repair of head and neck soft tissue defects, and an in vitro simulated surgery experiment was conducted. Clinical verification was performed on a patient with tonsil tumor, and the results demonstrated that digital technology-designed flaps improved the accuracy and aesthetic outcome of head and neck soft tissue defect repair surgery. This study validates the feasibility of digital precision repair technology for soft tissue defects after head and neck tumor resection, which effectively assists surgeons in achieving precise flap transplantation reconstruction and improves patients' postoperative satisfaction.

Prosthetic Oral Rehabilitation with CAD/CAM Suprastructures in Patients with Severe Tissue Deficits: A Case Series

This article presents the outcomes of prosthetic oral rehabilitation using CAD/CAM telescopic bar overdentures in patients with oral cancer (n = 3), severe facial trauma (n = 2), or various syndromes (n = 1), all suffering from severe tissue deficits and requiring complex and comprehensive oral rehabilitation. The aim was to assess the durability and functionality of implant-retained prosthetic structures, ensuring easy oral hygiene and minimizing specialized follow-up needs. The data for this study were sourced from a retrospective cohort at Helsinki University Hospital. The prosthetic reconstruction encompassed the Atlantis 2in1 and the Createch removable telescopic systems. Thus, 40 implants were placed (4 to 7 per patient), with prosthetic structures in the maxilla (n = 4 patients), in the mandible (n = 1), and in both jaws (n = 1). Two patients experienced no complications, two patients had part of the acrylic resin break, and one patient experienced loosening of the bar structure. All complications associated with prosthetic structures were successfully managed, and none of the implants were lost. The follow-up time ranged from 7 to 126 months. This rehabilitation is proved to be an effective solution for patients with complex oral conditions, facilitating both functional restoration and ease of maintenance. These findings underscore the importance of individualized treatment approaches in cases of tissue deficits.

Oral Rehabilitation of Marginal Maxillectomy Patient After Local Flap Reconstruction

The treatment of oral cancer can lead to various oral complications, including oral defects, tissue deformation, and trismus in patients who have undergone oral cancer surgery with resection of any part of the maxillary. Restoring the ability to chew, swallow, and maintain esthetics is essential and a significant challenge. The aim of this study was to report a successful clinical case of preprosthetic surgery and prosthetic rehabilitation of a 65-year-old man who had undergone marginal maxillectomy, resulting in tissue scarring and a significant reduction in maximal mouth opening. The oral rehabilitation was achieved using a conventional removable prosthesis. This case demonstrates that preprosthetic surgery combined with conventional removable prosthesis is an effective strategy for complex rehabilitations providing functional and esthetic improvement in the affected area for patients with marginal maxillectomies resulting from oral cancer.

Backscatter from therapeutic doses of ionizing irradiation does not impair cell migration on titanium implants in vitro

OBJECTIVE

The influence of radiation backscatter from titanium on DNA damage and migration capacity of human osteoblasts (OBs) and mesenchymal stem cells (MSCs) may be critical for the osseointegration of dental implants placed prior to radiotherapy. In order to evaluate effects of radiation backscatter, the immediate DNA damage and migration capacity of OBs and MSCs cultured on titanium or plastic were compared after exposure to ionizing irradiation.

MATERIALS AND METHODS

Human OBs and MSCs were seeded on machined titanium, moderately rough fluoride-modified titanium, or tissue culture polystyrene, and irradiated with nominal doses of 2, 6, 10, or 14 Gy. Comet assay was performed immediately after irradiation, while a scratch wound healing assay was initiated 24 h post-irradiation. Fluorescent live cell imaging documented the migration.

RESULTS

DNA damage increased with higher dose and with backscatter from titanium, and MSCs were significantly more affected than OBs. All doses of radiation accelerated the cell migration on plastic, while only the highest dose of 10 Gy inhibited the migration of both cell types on titanium.

CONCLUSIONS

High doses (10 Gy) of radiation inhibited the migration capacity of both cell types on titanium, whereas lower doses (2 and 6 Gy) did not affect the migration of either OBs or MSCs.

CLINICAL RELEVANCE

Fractionated doses of 2 Gy/day, as distributed in conventional radiotherapy, appear not to cause severe DNA damage or disturb the migration of OBs or MSCs during osseointegration of dental implants.

Targeted inhibition of eIF5Ahpu suppresses tumor growth and polarization of M2-like tumor-associated macrophages in oral cancer

Eukaryotic initiation factor 5A2 (eIF5A2) is overexpressed in many types of cancer, and spermidine-mediated eIF5A hypusination (eIF5Ahpu) appears to be essential to most of eIF5A's biological functions, including its important role in regulating cancer cell proliferation, epithelial-mesenchymal transition (EMT), and cancer stem cell (CSC) properties as well as immune cell functions. Here we investigated the role of eIF5Ahpu in the growth of oral squamous cell carcinoma cells (OSCCs) and OSCC-induced polarization of M2-like tumor-associated macrophages (TAMs). TCGA dataset analysis revealed an overall upregulation in the mRNA expression of eIF5A2 and several key enzymes involved in polyamine (PA) metabolism in HNSCC, which was confirmed by Western blot and IHC studies. Blocking eIF5Ahpu by GC-7 but not the upstream key enzyme activities of PA metabolism, remarkably inhibited cell proliferation and the expression of EMT- and CSC-related genes in OSCC cells. In addition, blocking eIF5Ahpu robustly inhibited OSCC-induced M2-like TAM polarization in vitro. More Importantly, blocking eIF5Ahpu dramatically retarded tumor growth and infiltration/polarization of M2-like TAM in a syngeneic orthotopic murine tongue SCC model. Thus, eIF5Ahpu plays dual functions in regulating tumor cell growth and polarization of M2-TAMs in OSCC.

Towards Optimum Mandibular Reconstruction for Dental Occlusal Rehabilitation: From Preoperative Virtual Surgery to Autogenous Particulate Cancellous Bone and Marrow Graft with Custom-Made Titanium Mesh-A Retrospective Study

The purpose of this retrospective study was to evaluate computer-assisted virtual surgery and the outcomes of mandibular reconstruction using an autogenous particulate cancellous bone and marrow (PCBM) graft combined with a custom-made titanium mesh (TiMesh) using a three-dimensional (3D) printing model. Eighteen consecutive patients were included, and preoperative virtual simulation surgery was performed using digital data. Segmental bone defects showed deviation of the mandible due to displacement of the condyle and segments, unnatural length of the mandibular body, or poorer intermaxillary relationship compared to the marginal bone defect caused by previous operations. These mandibular disharmonies could be simulated, and virtual surgery was performed on a computer with adjustment of displaced mandibular segments, length of the mandibular body, and dental arch with digital bone augmentation. TiMesh was manually pre-bent using a 3D printing model, and PCBM from the iliac crest was grafted with TiMesh. The short-term clinical results were good; reconstruction of the alveolar crest was prosthetically desirable; and minor complications were observed. In conclusion, virtual reconstruction is crucial for treating complex deviated mandibles. Accurate condylar and dental arch positions with an optimum mandibular length are important for prosthetically satisfactory mandibular reconstruction.

Removable partial prosthesis combined with swallowing training is an efficient clinical solution for oral cancer post-operation patients with palatal defect and dysphagia: a prospective study

OBJECTIVE

Dysphagia is one of the major complications of oral cancer patients, and is disturbing thousands of patients worldwide. Our study aim to evaluate the clinical efficacy of prosthesis combined with swallowing training on palatal defect and dysphagia in post-operative oral cancer patients.

MATERIALS AND METHODS

Sixteen oral cancer patients with palatal defect and dysphagia post-operation were treated with removable prosthesis and individualized swallowing function training. Swallowing function of patients before and after treatment was analyzed and compared by videofluoroscopic swallowing examination. The severity of depression and life quality were evaluated by Depression Scale (SDS) and Functional Assessment of Cancer Therapy-Head and Neck (FACT-H&N) scores, respectively.

RESULTS

Oral transit time (OTT) significantly shortened after treatment (P < 0.01), and Penetration-Aspiration Scale (PAS) scores was significantly higher after treatment (P < 0.001). Different consistency bolus showed different risk of aspiration. Thickened liquids were related to lower PAS scores (P < 0.001). SDS standard score was significantly lower after treatment (P < 0.05). The total score of FACT-H&N after treatment was significantly higher (P < 0.05). No patients came back for regressed swallowing function during the follow-up period (17.06 ± 2.376 months).

CONCLUSION

Removable prosthesis and swallowing training can significantly improve swallowing function, reduce depression degree, and improve quality of life (QOL).

CLINICAL RELEVANCE

Removable prosthesis combined with swallowing training is a cheap and effective method to improve QOL in patients with palate defect and dysphagia after oral cancer.

Mastication in health-related quality of life in patients treated for oral cancer: A systematic review

INTRODUCTION

Treatment for oral cancer can impair oral functions such as mastication, which may negatively affect quality of life (QoL). In this review, an overview is provided of masticatory ability in patients treated for oral cancer.

METHODS

The PubMed (MEDLINE), Embase and Cochrane databases were systematically searched for scientific literature on masticatory ability in relation to QoL in patients treated for oral cancer. Studies were included when oral cancer treatment was provided, and the University of Washington Quality of Life (UW-QoL) questionnaire was used. Risk of bias (MINORS) was independently assessed by two authors.

RESULTS

The PubMed (MEDLINE), Embase and Cochrane search yielded 575 unique records of which 111 were assessed full text, and 27 studies were included. The UW-QoL mastication scores ranged from 31.9 to 97.4. There was a wide variety in methodology, patient groups, tumour site, treatment and assessment moment, to such a degree that outcome scores are difficult to compare.

CONCLUSION

The wide variety in studies exploring health-related QoL in relation to mastication in oral cancer patients prevents the identification of possible relations between treatment, masticatory ability and QoL. Our findings underline the limitations in currently available literature and indicate the necessity for more comparable research.

Dental Implant Failure Risk in Post Oncological Patients, a Retrospective Study and Sapienza Head and Neck Unit Decisional Protocol- 7 Years of Follow-Up

(1) Background: Patients with head and neck cancer are treated by ablative surgery, radiotherapy, chemotherapy, or a combination of these. The side effects of cancer therapies can compromise conventional prosthesis rehabilitation; therefore, dental implants can result in a more effective solution. The aim of the study is to explain how to rehabilitate a patient that underwent head and neck cancer therapy. (2) Methods: This retrospective study conducted from 2015 to 2021 included 223 postoncological patients, aged between 32 and 80 years old. Eighteen patients did not proceed with any treatment, and two died. Therefore, 203 patients have been analyzed and rehabilitated following our decisional protocol, with a mean period of follow-up of 4 years. The implant placement was considered successful when a mean bone loss of 1.6 mm for the first year and a mean of 0.13 mm in subsequent years occurred (3) Results: A total of 161 patients were rehabilitated with a conventional prosthesis, 42 patients (F:M ratio 19:23) with an implant-supported prosthesis and a total of 200 implants were placed; 9 implants were lost (4.5% of 200 implants). Conclusions: The results confirmed that by following our protocol it is possible to obtain an acceptable rate of implant survival, considering the delicacy and complexity of post-oncological patients.

Oral Health Management and Rehabilitation for Patients with Oral Cancer: A Narrative Review

Surgery is the current first choice for oral cancer treatment. Intensity-modulated radiation therapy, molecular targeted drugs, and immune checkpoint inhibitors are still used as adjuvant therapy for advanced cancer. In addition, postoperative rehabilitation and multidisciplinary treatment have also been developed in recent years. Multidisciplinary team approaches and supportive care in oral cancer treatment reportedly shorten the time to treatment and improve outcomes. Although there is enough evidence confirming the role of oral and maxillofacial surgeons, dentists, and dental hygienists in supportive care in oral cancer treatment, there are very few systematic studies. In particular, oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment. We provide a narrative review focusing on oral health management from a multidisciplinary and supportive care perspective, applicable in oral cancer treatment.

An Overview of Clinical Oncology and Impact on Oral Health

As the incidence of cancer continues to increase, so too will the use of various forms of cancer therapeutics and their associated oral and dental complications. Although many of the acute and chronic oral toxicities of cancer therapy are largely unavoidable, appropriate and timely management of these complications has the potential to alleviate morbidity and improve outcomes. Undoubtedly, the substantial short- and long-term impacts of cancer therapy on the health of the oral cavity requires increased awareness, prevention, and treatment by multidisciplinary healthcare teams consisting of medical oncologists, dentists, and other oral healthcare specialists. This mini review provides a brief purview of the current state of clinical oncology and its impact on oral health. The topics introduced here will be further investigated throughout the remainder of the "Oral Complications in Cancer Patients" mini-review series.

Oral rehabilitation after squamous cell carcinoma mandibular resection

Introduction: Squamous cell carcinoma of the oral cavity is the most common cause of mandibular defect. The functional and aesthetic impacts of this surgery must be considered. The number of mandibular resections depends on the TNM classification of the tumor. Mandibular reconstruction by a fibula free flap has become the gold standard. Unfortunately, not all mandibular resections are rehabilitated. The purpose of this study is to evaluate oral rehabilitation after mandibular resection in patients with squamous cell carcinoma. Materials and methods: A retrospective study was conducted to evaluate oral rehabilitations according to the type of surgical resection and reconstruction. The secondary evaluation criteria were type of rehabilitation, implant success rate, post-radiotherapy delay, rehabilitation success rate, and causes of non-rehabilitation. Results: The study included 157 patients with mandibular resection. Of the patients, 26.7 percent received oral rehabilitation. All rehabilitation with implants was functional. The main causes of non-rehabilitation were death or recurrences related to the progression of the disease, postoperative anatomical difficulties, and cost of oral rehabilitation. Conclusion: Oral rehabilitation after mandibular resection surgery is insufficient. A rehabilitation unit including a maxillofacial surgeon, oral surgeon, and dentist is essential. Implementation of the unit should be considered as soon as possible. The cost of rehabilitation should not be a limiting factor.

Quality of life in cancer patients with or without medication-related osteonecrosis of the jaw

PURPOSE

Cancer and its therapies can have a significant impact on general and oral health and, therefore, cause a reduction in patients' quality of life (QoL). The study aimed to evaluate the QoL of cancer patients who use antiresorptive and anti-angiogenic medications with or without the development of medication-related osteonecrosis of the jaws (MRONJ).

METHODS

Sixty-two patients diagnosed with cancer under antiresorptive therapy answered three instruments from the European Organization for Cancer Research and Treatment (EORTC). The first questionnaire (QLQ-C30) aimed to measure the overall QoL, the second (QLQ-ELD14) is a complementary module for elderly patients, and the third (QLQ-OH15) aimed to assess oral health related to QoL.

RESULTS

The mean age of the patients was 62.19 years, and 12.9% developed MRONJ. There was no significant difference between sex and MRONJ. Among the QLQ-C30 scales, the item "role functioning (RF2)" presented a significant result (p = 0.019). Those patients without MRONJ had a better function performance both in their daily chores and in their free time. Age was not associated to MRONJ, although some concerns are common to the elderly and cancer patients. QoL related to oral health presented a significant result (p = 0.048) showing that MRONJ has a negative impact on patients' QoL.

CONCLUSION

Our results showed that MRONJ has a significant impact on the general and oral QoL of cancer patients, and therefore prevention and awareness must be a priority.

Retrospective long-term clinical evaluation of implant-prosthetic rehabilitations after head and neck cancer therapy

OBJECTIVE

To assess clinical and patient-reported outcomes of implant-prosthetic rehabilitations in patients with a history of head-neck cancer (HNC), treated with tumor resection without (TR) or with adjuvant radiotherapy (TR/RT). A healthy cohort rehabilitated with the same reconstructive protocols served as control group (C).

MATERIALS AND METHODS

A total of 28 women and 29 men were considered in the present retrospective study. Participants received 322 implants, finally supporting 79 prosthetic reconstructions. Primary outcome was the assessment of implant and prosthetic survival rates. Furthermore peri-implant soft tissue parameters (attached peri-implant mucosa, AM; modified bleeding and plaque indices, mBI/mPI; probing depth, PD) and prosthetic technical complications were documented. Patient-reported outcome measures (PROMs) by means of visual analog scales (VAS) and the Oral Health Impact Profile German 14 form (OHIP G14) were collected. For statistical purposes Chi-square and Mann-Whitney-U-Test were adapted.

RESULTS

After a mean follow-up of 81.2 ± 50.3 months, implant survival rate was 98.1% (HNC-TR), 98.2% (HNC-TR/RT) and 100.0% (C), respectively (four implants failed in the HNC groups). HNC-TR/RT showed significant higher mPI and mBI compared to C. Within HNC-TR/RT, vestibuloplasty significantly reduced mBI and PD values. No failures occurred at the prosthetic level. Overall, higher VAS scores were reported for bar- compared with Locator-retained prostheses. Furthermore, increased OHIP G14 values resulted for HNC-TR/RT.

CONCLUSIONS

High survival rates on implant and prosthetic level were observed. The use of soft tissue grafts resulted in stabilization of the peri-implant mucosa in irradiated patients. In terms of retention and chewing ability, participants preferred bars over Locator attachments.

Oral health-related quality of life in oral cancer patients: systematic review and meta-analysis

Aim: The purpose of this meta-analysis was to evaluate the impact of oral health on quality of life in oral cancer patients (OCPs). Methods: PubMed, Scopus and Web of Science databases were searched for publications on oral health-related quality of life (OHRQoL) in OCP and the information was extracted according to the PRISMA guidelines. A random effect model was used to obtain the pooled standard mean differences of Oral Health Impact Profile (OHIP)-14 questionnaire responses in meta-analysis. Results: total of 12 research papers were analyzed and revealed poor OHRQoL in OCPs (standard mean difference: 2.53; 95% CI: 1.55-3.50; p < 0.00001) compared with healthy individuals due to the effects of oncotherapy. Moreover, OHRQoL deteriorated with combinations of different treatment modalities. Conclusion: Oral health and oncotherapy can affect the quality of life in OCPs.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Frequency and type of digital procedures used for the intraoral prosthetic rehabilitation of patients with head and neck cancer: A systematic review

STATEMENT OF PROBLEM

In spite of a digital workflow playing an important role in the intraoral prosthetic rehabilitation of patients with head and neck cancer, information about how it has been implemented and its clinical implications is sparse.

PURPOSE

The purpose of this systematic review was to evaluate the use of a digital workflow in the intraoral prosthetic rehabilitation of patients with head and neck cancer by analyzing the frequency and type of the digital procedures used.

MATERIAL AND METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The following terms were applied for the search conducted in the MEDLINE-PubMed, Cochrane, and SciELO databases: (prosthesis OR dental OR rehabilitation) AND (digital OR CAD-CAM OR intraoral scanner) AND (Cancer OR head neck). Articles that specified data on intraoral prosthetic treatment and analyzed the use of a digital workflow in the different prosthetic phases such as digital scanning and computer-aided design and computer-aided manufacturing (CAD-CAM) in patients with head and neck cancer were included. Data from the frequency and type of digital procedures were analyzed.

RESULTS

Thirteen articles were included, and all had incorporated CAD-CAM techniques in at least 1 of the prosthetic treatment stages (scanning, design, and/or fabrication). Only 1 patient was rehabilitated by using a completely digital workflow. The most frequent prosthetic treatment was an obturator (82.6%). Regarding the image capture method, the most used method was cone beam computed tomography (CBCT) (60.9%).

CONCLUSIONS

Most reports described the partial use of a digital workflow in the intraoral prosthetic rehabilitation of patients treated for head and neck cancer. A digital workflow is used for specific stages but not for the entire process. More studies are needed to evaluate digital systems, ideally comparing parameters with the conventional method, and to determine whether this technique has more relevant clinical implications.

Survival of Dental Implants in Oncology Patients versus Non-Oncology Patients: A 5-Year Retrospective Study

Patients with a history of cancer are increasingly common in the dental office. Treating cancer patients requires a multidisciplinary team, which should include the dentist, in order to control the complications that occur in the oral cavity and also to recover the patient undergoing treatment in any of its types: surgical, medical, radiotherapeutic, or its possible combinations. Dental implants can be a safe and predictable treatment option for prosthetic rehabilitation. The aim of this paper is to describe in retrospect the success rate of osseointegrated implants in oncology and non-oncology patients placed by the Master of Dentistry in Oncology and Immunocompromised Patients, as well as the Master of Medicine, Surgery and Oral Implantology of the University of Barcelona Dental Hospital, between July 2011 and March 2016. 466 patients were reviewed, with a total of 1405 implants placed, considering the oncological history of the patients and the implant success rate. The total success rate in the concerned period was 96.65%. When comparing cancer patients with healthy ones, the success rate has been 93.02% in the first case, and 97.16% in the latter. According to the literature review, our results encourage implant placement in cancer patients, it is important to recognize that this is an analysis of a complex care pathway with a large number of confounding variables. However, the findings should not be considered as generalizable.

Managing the Oral Health of Cancer Patients During the COVID-19 Pandemic: Perspective of a Dental Clinic in a Cancer Center

The practice of dentistry has been dramatically altered by the coronavirus disease 2019 (COVID-19) pandemic. Given the close person-to-person contact involved in delivering dental care and treatment procedures that produce aerosols, dental healthcare professionals including dentists, dental assistants and dental hygienists are at high risk of exposure. As a dental clinic in a comprehensive cancer center, we have continued to safely provide medically necessary and urgent/emergent dental care to ensure that patients can adhere to their planned cancer treatment. This was accomplished through timely adaptation of clinical workflows and implementation of practice modification measures in compliance with state, national and federal guidelines to ensure that risk of transmission remained low and the health of both immunocompromised cancer patients and clinical staff remained protected. In this narrative review, we share our experience and measures that were implemented in our clinic to ensure that the oral health needs of cancer patients were met in a timely manner and in a safe environment. Given that the pandemic is still on-going, the impact of our modified oral healthcare delivery model in cancer patients warrants continued monitoring and assessment.

Mandibular dental implant placement immediately after teeth removal in head and neck cancer patients

BACKGROUND

Little is known about immediate implant placement in head and neck cancer patients. We studied implant survival and functional outcomes of overdentures fabricated on implants placed immediately after removal of the lower dentition during ablative surgery or preceding primary radiotherapy (RT).

METHODS

Inclusion criteria were primary head and neck cancer, dentate lower jaw, and indication for removal of remaining teeth. Two implants to support a mandibular overdenture were placed immediately after extraction of the dentition during ablative surgery, or prior to starting primary radiotherapy. Standardized questionnaires and clinical assessments were conducted (median follow-up 18.5 months, IQR 13.3).

RESULTS

Fifty-eight implants were placed in 29 patients. Four implants were lost (implant survival rate 93.1%). In 9 patients, no functional overdenture could be made. All patients were satisfied with their dentures.

CONCLUSIONS

Combining dental implant placement with removal of remaining teeth preceding head neck oncology treatment results in a favorable treatment outcome.

What is the optimal timing for implant placement in oral cancer patients? A scoping literature review

BACKGROUND

Oral cancer patients can benefit from dental implant placement. Traditionally, implants are placed after completing oncologic treatment (secondary implant placement). Implant placement during ablative surgery (primary placement) in oral cancer patients seems beneficial in terms of early start of oral rehabilitation and limiting additional surgical interventions. Guidelines on the ideal timing of implant placement in oral cancer patients are missing.

OBJECTIVE

To perform a scoping literature review on studies examining the timing of dental implant placement in oral cancer patients and propose a clinical practice recommendations guideline.

METHODS

A literature search for studies dealing with primary and/or secondary implant placement in MEDLINE was conducted (last search December 27, 2019). The primary outcome was 5-year implant survival.

RESULTS

Sixteen out of 808 studies were considered eligible. Both primary and secondary implant placement showed acceptable overall implant survival ratios with a higher pooled 5-year implant survival rate for primary implant placement 92.8% (95% CI: 87.1%-98.5%) than secondary placed implants (86.4%, 95% CI: 77.0%-95.8%). Primary implant placement is accompanied by earlier prosthetic rehabilitation after tumor surgery.

CONCLUSION

Patients with oral cancer greatly benefit from, preferably primary placed, dental implants in their prosthetic rehabilitation. The combination of tumor surgery with implant placement in native mandibular bone should be provided as standard care.

Postimplantation radiation therapy in head and neck cancer patients: Literature review

There is no recommendation regarding the timing for implant surgery in patients with head and neck cancer (HNC) who require postoperative radiation therapy (RT). This systematic review focused on the literature about the outcomes of implants placed during ablative surgery in patients with HNC who underwent postoperative RT. Implants placed after radiation therapy and implants placed in reconstructed jaws were excluded. Four comparative studies involving 755 native mandible primary implants were analyzed. The survival rate with postimplantation RT was 89.6% vs 98.6% in patients with no additional radiation. The overall success of implant-retained overdenture in patients with RT performed postimplantation was 67.4% vs 93.1% in patients with implant surgery that was carried out 1 year after the completion of radiation therapy. Only five cases of osteoradionecrosis (ORN) of the jaw were reported. The outcomes for implant survival rates appear to be positive for irradiated implants.

Oral Rehabilitation of Patients Sustaining Orofacial Injuries: The UPenn Initiative

Tissue injuries in the oral and maxillofacial structures secondary to trauma, warfare, ablative cancer, and benign tumor surgery result in significant losses of speech, masticatory and swallowing functions, aesthetic deformities, and overall psychological stressors and compromise. Optimal oral rehabilitation remains a formidable challenge and an unmet clinical need due to the influence of multiple factors related to the physiologic limitations of tissue repair, the lack of site and function-specific donor tissues and constructs, and an integrated team of multidisciplinary professionals. The advancements in stem cell biology, biomaterial science, and tissue engineering technologies, particularly the 3-dimensional bioprinting technology, together with digital imaging and computer-aided design and manufacturing technologies, have paved the path for personalized/precision regenerative medicine. At the University of Pennsylvania, we have launched the initiative to integrate multidisciplinary health professionals and translational/clinical scientists in medicine, dentistry, stem cell biology, tissue engineering, and regenerative medicine to develop a comprehensive, patient-centered approach for precision and personalized reconstruction, as well as oral rehabilitation of patients sustaining orofacial tissue injuries and defects, especially oral cancer patients.