There has been an increase in the numbers of cases of head and neck cancer in the UK with over 12000 new diagnoses last year alone. Early detection and early referral are key to improve outcomes and the role of the dentist in detecting new disease, or monitoring for recurrence, cannot be overestimated.
Once patients have been treated in a Hospital setting, it is expected that their routine dental care is carried out in dental practices. General Dental Practitioners and Dental Care Professionals are considered essential healthcare professionals which should be involved in their care before, during, and after treatment. Patients who have been treated for head and neck cancer can present with altered oral anatomy as result of surgery and reconstructions, and with long term side effects of chemo-radiotherapy including dry mouth, periodontal disease, trismus, and higher incidence of caries. Therefore, preventative and monitoring regimes are of utmost importance.
The key factors to consider are:
Carry out review of the soft tissues at every visit. Make sure that any changes to the soft tissues are documented on the patient’s notes, pictures taken, and an urgent 2-week referral is made if there is a suspicion of recurrence. It is important to document that a soft tissue examination has been carried out, even when the findings are negative. It is important to look for non-healing ulcers, new red or white patches, and indurated areas, especially in smokers. Relieve any factors which may be traumatising the area (sharp teeth, dentures, etc.), document, take pictures, and review at 2 weeks. If the area persist, then make a 2-week urgent referral.
Carry out supportive periodontal therapy which should be more frequent at the start of treatment (at 3-4 monthly intervals). The frequency of recall could be reduced once the patient is shown to comply with oral hygiene measures, prevention, dietary, and fluoride advice, these visits should always include:
Smoking cessation advice/referral if needed,
Oral hygiene review and instructions,
Dietary advice. These patients may be on a highly cariogenic diet to maintain their nutritional status. It is important to consider the challenges they may have in terms of nutrition and do our best to help them reduce the risk of caries by
Prescription of 5000pppm fluoridated toothpaste to be used twice daily for life (unless there is a contra-indication).
Spit after toothbrushing without rinsing.
Use of a fluoridated mouthwash 3-4 daily at other times than toothbrushing.
Alternate use of upper and lower soft guards to be used nightly as fluoride reservoirs.
Basic periodontal examination, and periodontal treatment following BSP guidelines
Restorations and endodontic treatment are not contra-indicated but may be challenging if there is trismus.
Extractions may be contra-indicated if there is a history of radiotherapy and/or bisphosphonate treatment. It is better to refer any patients requiring extractions to a Hospital setting.
Any referrals for a suspected lesion should be made using the centralised 2-week urgent pathways but at CODE we have a range of clinicians who treat patients with head and neck cancer daily. We are always to help with any restorative, prosthodontic, periodontic, endodontic, oral surgery, hygiene or therapy needs for your patients.