The role of the general dental practitioner in managing the oral care of head and neck oncology patients

Does irradiation of the tooth structure interfere with oxygen saturation measured by pulse oximetry?-An ex vivo laboratorial study

The effect of tooth structure subjected to ionising radiation on oxygen saturation levels (SpO2 ) measured by pulse oximetry was investigated. Fifty-four extracted human third molars were sectioned mesiodistally. Pulse oximeter diodes were placed in prefabricated silicone moulds, secured on a vise with tooth surfaces placed between the diodes and the participant's finger, and SpO2 levels were measured. After that, the tooth surfaces were subjected to ionising radiation in fractionated doses of up to 70 Gy, and SpO2 was measured according to the protocol described. The Kolmogorov-Smirnov test was used for the analysis of normality of the quantitative variables, and Student's t-test compared mean SpO2 levels before and after irradiation. Mean SpO2 after irradiation was 94.6 ± 0.9%, without a statistically significant difference from SpO2 before irradiation, which was 94.7 ± 0.6%. Irradiation of the tooth structure did not interfere with SpO2 levels measured by pulse oximetry.

Dental considerations for head and neck cancer: A clinical review

Introduction

Radiotherapy is one of the treatment modalities for the treatment of head and neck cancer (HNC). However, it leads to the development of chronic and acute side effects. These side effects impact negatively on the patient's quality of life and oral functioning. This clinical review aims to provide basic information about HNC, understand the impact of radiotherapy on oral health, and explain the role of dental care providers for HNC patients during the pre-and post-radiotherapy time.

Materials and Methods

Electronic databases (i.e., PubMed, Scopus, and Google Scholar) were searched using defined keywords. The main inclusion criteria were any studies describing "dental management of patients with head and neck cancer" and "dental management of patients treated with radiotherapy."

Results

Thematic analysis was used to summaries the findings of the included studies (n = 102) into main headings and subheadings. All studies were published between 1970 and 2023.

Conclusion

The number of HNC patients is increasing. This necessitates the need for raising the awareness of dental care providers to the side-effects of HNC therapy which includes treatment with radiotherapy, chemotherapy, and/or surgery. Dental care providers should understand the common side-effects and their treatments besides their role in the pre- (i.e., dental extraction of teeth with poor prognosis and maintaining good oral hygiene) and post- (i.e., oral rehabilitation and post-HNC dental care) radiotherapy dental care.

Dentists' perspectives on denture provision after radiotherapy for head and neck cancer: an exploratory study using the theoretical domains framework

Introduction Patients are often keen to replace their missing teeth after radiotherapy for head and neck cancer (HNC), yet such replacement does not always take place.Aims This study aimed to investigate the influences on dentists' provision of dentures for patients treated with radiotherapy for HNC, including whether risk of osteoradionecrosis (ORN) is a factor influencing intention to provide dentures.Methods An online cross-sectional survey including a case scenario, self-reported behaviour and measures of factors (selected using the theoretical domains framework) that may affect dentists' decisions was completed by general dental practitioners (n = 150) and HNC multidisciplinary team dentists (n = 25) in England.Results Dentists' reluctance to provide dentures for HNC patients post-radiotherapy was often due to concerns about dry mouth and radiation caries rather than risk of ORN. Knowledge of guidelines and beliefs about consequences were independently associated with dentists' intention to replace missing teeth with dentures.Conclusion The likelihood of replacing missing teeth with dentures increased with awareness of clinical guidance on the use of dentures in HNC and that denture provision would have positive consequences that outweigh the costs.

The role of exercise therapy in managing post-radiotherapy trismus in head and neck cancer

Trismus is a post-radiotherapy complication that affects survivors of head and neck cancers. It is described as the reduction of mouth opening to less than 35 mm. The condition is a progressive process; hence early intervention is crucial to prevent further damage and weakness to the elevator muscles of the mandible. Here, we report a 40-year-old woman with known squamous cell carcinoma of the maxillary sinus in stage T3N0M0 who had undergone upper right partial maxillectomy with subsequent 33 fractions of radiotherapy (66 Gy; intensity-modulating radiotherapy). Five months post-radiotherapy, the patient showed interest in replacing her missing teeth to restore her oral functions and facial appearance. At her post-radiotherapy visit in the dental assessment clinic, she showed a mouth opening of 12 mm. The TheraBite® Jaw Motion Rehabilitation System™ and wooden tongue depressors were alternatively used for 6 weeks (4-5 stretches/day; each stretch held for 15 s). Mouth opening gradually increased to 20 mm. Consequently, a definitive obturator prosthesis was fabricated using computer-aided design and computer-aided manufacturing technologies with the 3Shape D900 model scanner. These were challenging and time-consuming steps, but acceptable facial appearance and mouth opening were restored for the patient. This case suggests that Therabite® Jaw Motion Rehabilitation SystemTM and wooden tongue depressors help to increase mouth opening significantly if used together and alternatively.

Use of dentures, receipt of information, quality of life, and oral function following radiotherapy for head and neck cancer

BACKGROUND

Teeth with a poor prognosis are often extracted prior to radiotherapy for head and neck cancer (HNC) in order to help prevent the need for dental treatment after radiotherapy that might in turn lead to the development of osteoradionecrosis. However, the details and impact of replacing missing teeth after radiotherapy for HNC have received little attention, especially from the patients' perspective.

AIMS

This study aimed to assess the use, satisfaction, and impact of denture use following radiotherapy for HNC. The study also sought to determine patients' satisfaction with information about replacing their missing teeth postradiotherapy. Finally, this study also aimed to assess interest in replacing missing teeth for those who had not done so.

METHODS

A structured, validated, and reliable questionnaire was sent to HNC patients who had received radiotherapy and had missing teeth at the time of discharge. In addition to demographic details and self-reported oral hygiene, the questionnaire included questions on use of (or interest in) dentures, satisfaction with dentures, satisfaction with information about replacing missing teeth, QoL as measured by two questions from the short version of WHOQoL-BREF, and oral functioning as measured by BCSQ-H&N. Demographic details and clinical details were extracted from the hospital records.

RESULTS

N = 80 (24%) returned a completed questionnaire. Participants had an average of 12 missing teeth (SD = 8.05). Most (n = 60, 75%) had not replaced their missing teeth. Of these, 35 (58%) were very or extremely interested in doing so. For HNC survivors who wore dentures, there was variable satisfaction and a number of side-effects of wearing dentures. Satisfaction with information about replacing missing teeth was low. There was no statistical difference in QoL or oral functioning between participants who wore dentures and participants who did not wear dentures. However, those with dentures reported fewer problems with carrying out daily routines as measured by the oral functioning tool.

CONCLUSIONS

QoL and oral functioning were similar regardless of denture use, highlighting reduced oral function in both those with and without dentures. In those who had not replaced their missing teeth, there was substantial interest in doing so and thus may be an unmet need. The dental team could offer HNC survivors more support after radiotherapy and following denture provision to improve information about denture use and increase satisfaction with dentures.

Denture use and dental risk factors associated developing osteoradionecrosis after head and neck radiotherapy: A retrospective analysis of hospital records

OBJECTIVES

This study aimed to assess the association between denture use and occurrence of osteoradionecrosis (ORN) following radiotherapy for head and neck cancer (HNC).

MATERIALS AND METHODS

Medical records of 439 HNC patients treated with radiotherapy at Guy's & St Thomas' NHS Foundation Trust (London, UK) (2014-2019) who had missing teeth at the time of discharge were reviewed. Descriptive statistics were used to summarise the participant characteristics and outcome measures. Logistic regression analysis was used to identify factors associated with occurrence of ORN.

RESULTS

Patients had an average of 14 missing teeth and 39 % wore dentures. Twenty-two (5 %) developed ORN. Out of 22 who developed ORN, 11 (50 %) wore dentures. Of these, 5 patients developed ORN in areas contacted by dentures. Denture use was not significantly associated with the occurrence of ORN (OR = 1.94; 95%CI = 0.79-4.81; p-value = 0.150). Longer duration of radiotherapy (OR =1.03; 95%CI = 1.00-1.06; p-value= 0.048) and more missing teeth in the lower anterior area (OR = 1.11; 95%CI = 1.01-1.22; p-value = 0.024) were significantly associated with the development of ORN.

CONCLUSIONS

Within the limitations of this single-centre study in which few patients developed ORN, denture use may not be a risk factor for ORN following radiotherapy for HNC. This is likely to be the case if dentures are well-fitting and not causing sores or irritation.

CLINICAL SIGNIFICANCE

Replacement of the missing teeth with dentures in HNC patients post-radiotherapy may be a suitable choice for many HNC survivors. However, a powered study in a large cohort that includes clinical evaluation of dentures and the quality of fit alongside denture wearing experience would be useful to further assess the impact of denture use on the development of ORN.

Acoustic diagnosis of elastic properties of human tooth by 320 MHz scanning acoustic microscopy after radiotherapy treatment for head and neck cancer

BACKGROUND

On the elastic profiles of human teeth after radiotherapy for head and neck cancers, generation of dental complications, which may bring several side effects preventing the quality of life, has not well clarified. Thus, we aimed to show the applicability of using 320 MHz Scanning Acoustic Microscopy (SAM) in the evaluation of the tooth damage acoustically at the micrometer level following radiation therapy, and also in the determination of the safe dose limits to impede severe dental damage.

METHODS

This prospective study was performed by SAM employed at 320 MHz by an azimuthal resolution of 4.7 μm resolving enamel and dentin. A total of 45 sound human third molar teeth collected between September 2018 and May 2019 were used for the acoustic impedance measurements pre- and post irradiation. Nine samples for each group (control, 2 Gy, 8 Gy, 20 Gy, 30 Gy and 60 Gy) were evaluated to acquire the acoustic images and perform a qualitative analysis. Scanning Electron Microscopy (SEM) images were obtained to establish a relationship between micromechanical and morphological characteristics of the teeth. Statistical analysis was conducted using the Student t-test succeded by Mann-Whitney U investigation (p < .05), while SEM images were assessed qualitatively.

RESULTS

The analysis included 45 sound teeth collected from men and women 18 to 50 years old. Post irradiation micromechanical variations of human teeth were significant only in the radiation groups of 30 Gy and 60 Gy compared to pre-irradiation group for enamel (7.24 ± 0.18 MRayl and 6.49 ± 028 MRayl; p < 0.05, respectively). Besides, the teeth subjected to radiation doses of 20, 30 and 60 Gy represented significantly lower acoustic impedance values relative to non-irradiated group for dentin (6.52 ± 0.43 MRayl, 5.71 ± 0.66 MRayl and 4.82 ± 0.53 MRayl p < 0.05), respectively.

CONCLUSIONS

These results are evidence for a safe acoustic examination device which may be a useful tool to visualize and follow the safe dose limits to impede severe dental damage through the radiation therapy treatment for head and neck cancers.

Denture use and osteoradionecrosis following radiotherapy for head and neck cancer: A systematic review

BACKGROUND

It is strongly recommended to extract teeth with poor prognosis in head and neck cancer (HaNC) patients prior starting treatment with radiotherapy to avoid need for extraction post-radiotherapy and prevent development of osteoradionecrosis (ORN). Dental extraction means that patients are often left with insufficient teeth leading to psychological problems and reducing their quality of life post-radiotherapy. Some clinicians do not advocate the use of dentures in HaNC patients claiming that dentures might lead to soft tissue irritation followed by ORN when constructed on irradiated jaws.

AIMS

This systematic review aimed to investigate the existing evidence regarding the impact of denture use on the development of ORN in HaNC patients post-radiotherapy.

METHODS

This systematic review followed the Preferred Reporting Item for Systematic Review and Meta-analyses (PRISMA) guideline. Three database systems were used: Ovid Medline, EMBASE and PsycINFO. PROSPERO was searched for ongoing or recently completed systematic reviews. The https://ClinicalTrials.gov was searched for ongoing or recently completed trials. The Joanna Briggs Institute critical appraisal tools were used to assess quality of studies being reviewed.

RESULTS

Only three retrospective case-control studies were included. Numbers of participants included in the three studies are limited with incomparable types of mucosal dentures. None of the studies described the method of measurement of the exposure (denture use) in a standard, validated and reliable way.

CONCLUSION

The three included studies suggested no link between denture use and development of ORN. However, very little evidence exists and the robustness of the studies is questionable. Well-powered studies are needed.

Regular Dental Visits: Influence on Health-Related Quality of Life in 1,607 Patients with Oral Squamous Cell Carcinoma

Background

The incidence of oral squamous cell carcinoma (OSCC) is in the top 10 of all cancer entities. Regular oral examinations by dentists play an important role in oral cancer prevention.

Methods

Patients with OSCC (n = 1,607) and physicians (n = 1,489) completed questionnaires during the DÖSAK Rehab Study. The psychosocial and functional factors collected in these questionnaires were assessed in the present study. We compared patients who visited their dentist at least once a year (group A) with those who visited their dentist less than once a year (group B).

Results

Patients in group A had significantly better health-related quality of life after tumor treatment than patients in group B. Patients in group A also had a smaller tumor size and less lymph node metastasis and lost fewer teeth during the treatment. This resulted in better prosthetic rehabilitation and better psychological status after tumor treatment.

Conclusions

Dentists play an important role in the early recognition of oral cancer. This study should encourage dentists to take a more active role in oral cancer prevention.

Recent Trends in Oral Cavity Cancer Research Support in the United States

The objectives were to characterize oral cavity cancer (OCC) funding from the National Institutes of Health (NIH) with a secondary aim of comparing NIH support provided to OCC and other malignancies. NIH awards supporting OCC inquiry from 2000 to 2014 were accessed from the NIH RePORTER database. These data were used to evaluate temporal trends and the role of human papilloma virus and to determine the academic training and professional profiles of the principal investigators. Comparison of 2014 funding levels with other malignancies was also performed, controlling for incidence. Overall funding totals decreased considerably after 2009. Funding administered through the National Institute of Dental and Craniofacial Research (NIDCR) was 6.5 times greater than dollars awarded by the National Cancer Institute in 2000. During the period evaluated, NIDCR support decreased in most years, while National Cancer Institute support increased and approached NIDCR funding levels. Funding for human papilloma virus-related projects gradually rose, from 3.4% of dollars in 2000 to 2004 to 6.2% from 2010 to 2014 ( P < 0.05). A majority of principal investigators had a PhD omnia solus (57%), and 13% possessed dual PhD/clinical degrees. Among clinicians with specialty training, otolaryngologists and oral/maxillofacial pathologists garnered the most funding. OCC had a 2014 funding:incidence ratio of $785, much lower than for other malignancies. There has been increased volatility in funding support in recent years possibly due to budget cuts and sequestration. The National Cancer Institute has played an increasingly important role in supporting OCC research, concomitant with decreasing NIDCR support. Our findings suggest that OCC is underfunded relative to other non-oral cavity malignancies, indicating a need to increase the focus on rectifying the disparity.

Characteristics and referral of head and neck cancer patients who report chewing and dental issues on the Patient Concerns Inventory

BACKGROUND

Patients experience considerable dental-related difficulties following head and neck cancer (HNC) treatment including problems with chewing, dry mouth, oral hygiene, appearance and self-esteem. These can go unrecognised in busy follow-up clinics. The Patient Concerns Inventory (PCI) is specifically for HNC patients, enabling them to select topics they wish to discuss and members of the multi-professional team they want to see.

AIM

The study aimed to identify the clinical characteristics of patients raising dental concerns on the PCI and to explore the outcome of onward referral. Assessments included the PCI and the University of Washington Quality of Life Questionnaire (UW-QOL) version 4, with clinic details collated from hospital and cancer databases.

METHOD

PCI data were obtained from 317 HNC patients between 2007 and 2011. Their mean age was 63 years and 60% were male. Most had oral squamous cell carcinoma and underwent surgery. The median (IQR) time from treatment to first PCI was 13 (4-42) months.

RESULTS

Three comparison groups were identified: patients with significant chewing problems, patients without significant chewing problems who wanted to discuss dental-related concerns and patients without significant chewing problems who did not want to discuss such concerns. Fifty-two percent reported either a significant chewing problem on the UW-QOL or a wish to discuss dental-related concerns. A quarter specifically asked to talk to a dental professional. Clinical characteristics significantly associated with dental issues were stage, primary treatment and free flap reconstruction. Clinic letters were copied to only 10% of general dental practitioners (GDPs).

CONCLUSION

Better communication with GDPs is essential.

Checking the cheek bite injury: fabrication of an interim cheek guard appliance

Among the various sequelae associated with the treatment of oral carcinoma (both surgical and radiotherapy), the two conditions that can be of serious concern are reduced mouth opening and mucositis. The limited mouth opening can lead to entrapment of buccal mucosa in between teeth during the chewing cycle, which in turn can lead to further injury of the mucosa. A simple method has been described by the authors to prevent the cheek bite by fabrication of a cheek guard appliance. Favorable results were seen within a few days after insertion of the appliance.