Scottish Cancer Network: Clinical Management Pathways
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Refer patients requiring Restorative Dentistry assessment following a relevant MDT discussion.
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Where surgical resection is likely to result in loss of teeth or impact on the wear of a prosthesis, consider and plan primary dental implants.
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Where surgical resection of the jaws is planned, use digital implant planning software to assess the feasibility and plan primary dental implants. Carry this out in conjunction with the Reconstructive Surgical Team and the Maxillofacial Prosthetic / Reconstructive Scientist Team. If a surgical guide is to be used for fibula resections, consider using this for the placement of primary dental implants.
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Where a maxillectomy is planned, consider primary conventional dental implants +/- zygomatic implants.
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Consider immediate restoration of dental implants.
Restorative dentistry
Warning
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of the Clinical Management Pathway (CMP), taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
- Where deemed appropriate by the surgical team, for patients undergoing surgical resections under general anaesthetic, consider dental extractions at the time of the patient’s surgery.
- For patients undergoing radical (chemo)radiotherapy, consider carrying out dental extractions as early as practical / possible (aiming for >=2 weeks in advance to the planned start date) with an emphasis on avoiding delays to oncology treatment.
- Where invasive dental extractions are required, or where there is a concern over healing, consider a clinical review prior to the commencement of oncology treatment.
- Offer restorative dental treatment at the time of surgery by a collaboration of a Consultant Restorative Dentist (CRD) and the surgical team, with CRD to plan and place dental implants at the time of surgery in conjunction with the surgical team.
- Where dental implants are planned at a secondary surgery, consider establishing an oral rehabilitation plan with the CRD in collaboration with the reconstructive surgical team.
- Offer a CRD/Surgical team joint plan +/- placement of any zygomatic implants for relevant maxillectomy or oral rehabilitation cases.
- Where dental implants are placed at the time of primary surgery, consider a CRD/Surgical team plan for 2nd stage surgery.
- Where immediate surgical obturator prostheses are required, offer planning and any pre-surgical prosthetic work undertaken by a CRD. CRD to attend the surgical procedure for fit of an immediate surgical obturator +/- impressions for interim surgical obturators.
Consider a CRD assessment. This may be relevant in, but is not limited to, clinical cases which require obturators, resections for local control, interim/definitive prostheses.
- Set an appropriate review time point depending on clinical factors, risk assessment, and oral rehabilitation plan.
- Priority should be given to expedited oral rehabilitation of patients where there is a functional or significant aesthetic impairment following head and neck cancer treatment.
- Offer appropriate preventive advice (including oral hygiene instruction, routine maintenance requirements, xerostomia management, and trismus prevention regimens).
- Offer a clear discharge plan with instructions to the general dental practitioner including professionally applied Fluoride supplements and a minimum recall interval of 6 months by the primary dental care practitioner.
- In patients requiring unplanned dental extractions following head and neck cancer treatment, consider re-referral for CRD assessment. Consider referral to an appropriate Oral Maxillofacial Surgery department for dental extractions where there is an increased risk of Osteoradionecrosis (ORN) or surgical complications. Communicate ORN risks associated with dental extractions to patients.
- Consider developing a maintenance/prosthesis replacement plan for patients with complex implant based- or maxillofacial prosthesis.
- Consider advising patients and their general dental practitioners on the appropriate referral pathway or management plan for dental-related complications.
- Consider further referral to and assessment by a CRD in the cases of ORN, particularly when further surgical resection or prosthetic modification is required.