Restorative aspects management of head and neck oncology patients

Question 1

How many new patients per year NI?

Answer 1

300

Question 2

Survival of head and neck oncology

Answer 2

78% 1 year
56% at 5 years

Question 3

Side effects of HANC tx

Answer 3

Post surgical defects
salivary gland hypofunction
dental caries
periodontal disease
trismus
mucositis
osteoradionecrosis

Question 4

damaging effects of radiation

Answer 4

salivary gland acinar degeneration and interstitial fibrosis
loss of enamel prism structure, gaps at EDJ, obliteration of dentinal tubules, degeneration of odontoblast processes
avascularity, acellularity, widening of PDL

Question 5

Pre radiotherapy dental extractions

Answer 5

teeth with poor prognosis
2-3 weeks prior to xrt
ORN risk pre-XRT extractions - 4.16%
ORN risk post XRT extractions - 7%

Question 6

during active cancer therapy

Answer 6

leave out dentures as much as possible
manage mucositis
treat acute dental pain
liaise with oncology team RE neutrophil levels
advice from OMFS

Question 7

Post radiotherapy dental assessments

Answer 7

6 months post XRT
Prevention reinforced
Treatment planning

Question 8

Xerostomia

Answer 8

Stimulation - pilocarpine
Substitution

Question 9

Trismus

Answer 9

Mechanical devices
Therabite device
7-7- or 5-5-30 protocol
physiotherapist involved
continue for 6-10 weeks post XRT

Question 10

Osteoradionecrosis

Answer 10

spontaneous cases
denture induced trauma and active periodontitis
triple therapy

Question 11

QOL of patients

Answer 11

generally reduces from diagnosis and 3 months
slow improvement 1 year post tx

Question 12

determinants of poor QOL

Answer 12

Smokers
Problem drinkers
Psychosocial difficulties
maladaptive coping issues

Question 13

Disfigurement

Answer 13

tumour resection
effects of xrt
anxiety
relationship with partner
social isolation
depression

Question 14

Eating and Swallowing

Answer 14

Dysphagia can impact nutritional intake and poorer QOL
PEG/RIG feeding tube
Mucositis
Xerostomia
Taste disturbances
infections
trismus
psychological issues

Question 15

Shoulder dysfunction

Answer 15

Neck dissection
movement limited and painful

Question 16

Pain

Answer 16

25% pts experience pain at 12 and 24 months post TX
Poorer QOL, increase in depression
Analgesics can mask dental pain and thus delay intervention

Question 17

Fatigue

Answer 17

Insomnia
Mood disturbances
Managed with physical exercises, psychotherapy and relaxation

Question 18

Employment issues

Answer 18

up to 50% do not return to work
many require financial support

Question 19

psychological distress

Answer 19

rates of depression 13-52%
younger pts
limited social support
fatigue
suicide risk
requires careful management

Question 20

Benefits of dental implants

Answer 20

improves support and retention of a removal prosthesis
help to raise self esteem
improve overall QOL
psychological crutch

Question 21

bar-retained obturator

Answer 21

implants can dramatically improve the stability and retention of the complete denture with obturator

Question 22

Zygomatic implants

Answer 22

used to retain obturators, an alternative to free flap reconstruction or conventional obturation
2/3 can be used in each quadrant
risk of orbital trauma
v difficult when trismus present.

Question 23

Mandible

Answer 23

More commonly reconstructed with graft than maxilla
Range of donor sites available:
iliac crest
radius
fibula
scapula

Question 24

implants in irradiated jaws

Answer 24

possible but careful case selection required
failure rates higher than in non-irradiated bone
failure rates higher than in maxilla compared to the mandible
Risk of causing ORN
Failures less likely with dose of less than 45Gy

Question 25

Implants for post XRT pts?

Answer 25

where dose is less than 50 Gy, survival likely to be comparable to non-irradiated patients
conflicting evidence on timing of placement
non-smoker

Question 26

failure of implants

Answer 26

implants can be placed into vascularised grafts at primary surgery or secondarily into irradiated or non-irradiated grafts.
There may be an increased risk of implant failure in free flap bone that has been irradiated

Question 27

osteoradionecrosis

Answer 27

usually observed after several years of radiotherapy
related to local trauma with hypovascular, hypocellular, hypoxic tissue
a result of radiation induced endartheritis