Chris Butterworth

Systematic review of primary osseointegrated dental implants in head and neck oncology

The aim of this paper is to provide a systematic review of articles concerning primary osseointegrated dental implants in the head and neck oncology setting. We searched MEDLINE (1950 to March 2009) and Embase (1980 to March 2009) using the terms head and neck, oral, maxillofacial, craniofacial, jaws, mandible, maxilla, zygoma, dental implants, osseointegrated implants, implants, tumour, cancer, oncology, immediate, simultaneous, and primary. Two authors independently reviewed the abstracts, and all those written in the English language that referred to the placement of primary dental implants in patients with cancer of the head neck were included. Articles that referred to craniofacial or extraoral implants were excluded. Of 892 abstracts 83 were eligible for further consideration; the full articles were evaluated, and 41 that complied fully with the inclusion criteria are presented as a tabulated summary. There are three case reports, 13 reviews, and 25 clinical studies. Eight of the clinical studies refer solely to the insertion of dental implants at the time of primary oncological resection, and only two were of a prospective design. We have concisely summarised publications concerning primary dental implants, and our findings will help to inform head and neck cancer teams, particularly oncological surgeons, restorative dentists, and maxillofacial prosthodontists of the evidence base surrounding this approach to oral rehabilitation.

Contemporary clinical management of oral squamous cell carcinoma.

Global estimates of the incidence of oral squamous cell carcinoma vary a little between sources, but it appears to be around the eighth commonest site for malignant tumours, with approximately 300,000 cases per year (42). This incidence is increasing in line with carcinogen exposure, and this is highlighted in the developing world, where betel quid and tobacco chewing are of similar importance 1 to smoking and alcohol (43). In the developed world, although smoking is now in decline in many countries, there has not been a corresponding reduction in oral squamous cell carcinoma incidence. This may be related to differing risk factors and an ageing population. As an example, the UK incidence of oral squamous cell carcinoma increased by 23% between 1995 and 2004 (16, 23), and it is now the commonest sub-site of head and neck cancer (36). Similarly, the incidence and mortality for oral squamous cell carcinoma have rapidly increased in Eastern Europe (33). In terms of correlations with risk factors, it appears that any reduction due to the reduced prevalence of smoking (41) has been outpaced by rising alcohol consumption (28–30), ageing or inadequacies of diet (21).The effects of increasing prevalence of mucosal infection from high-risk human papilloma virus 2 (19) are apparently less important in oral than oro-pharyngeal sites. This increasing trend in oral squamous cell carcinoma is more marked in those with highest socio-economic deprivation (22), and the social dimension of this disease should not be ignored. Clearly oral squamous cell carcinoma is an important and far from rare cancer in many populations. Efforts aimed at prevention and lifestyle modification are self-evidently vital to improve this situation. However, the need to improve outcomes for those presenting with established disease remains important. This review summarizes current clinical practice, highlighting areas of controversy or rapid progress in the field.

A Survey of General Dental Practitioners in the North West of England Concerning the Dental Care of Patients Following Head and Neck Radiotherapy

Aims The aim of this survey was to investigate the views of general dental practitioners (GDPs) on their perceived roles and the barriers regarding dental care of patients following head and neck radiotherapy. Methods From a total of 1163 GDPs on the Mersey Postgraduate Dental Deanery mailing list, 369 were selected at random. Questionnaires were sent out in February 2010 followed by reminders a month later. A study-specific questionnaire was piloted prior to the survey. Results One hundred and ninety-eight of the potential 336 respondents returned valid questionnaires, a response rate of 59%. They did not respond to all questions. Of those who responded, 99/188 (53%) were either ‘not at all’ or ‘little’ happy about managing these patients and 118/183 (64%) and 100/173 (58%), respectively, perceived that complex management and the new General Dental Services (nGDS) contract introduced in 2006 were ‘quite a bit’ or ‘very much’ barriers to treatment. The majority of the respondents felt that they were ‘quite a bit’ or ‘very much’ happy to carry out routine fillings (177/195; 90%), periodontal treatment (166/195; 85%), removable dentures (161/195; 83%), crown and bridge work (123/192; 64%), and root canal therapy (114/195; 58%) but only 53/191 (28%) to perform dental extractions. Over half of the respondents felt that they had ‘quite a bit’ or a ‘main role’ in managing radiotherapy caries, xerostomia, detecting recurrence and offering smoking-cessation advice. Conclusion The majority of the GDPs who responded had been involved in the management of patients who had undergone radiotherapy to the head and neck. A substantial number perceived barriers to care, such as the complexity of the treatment and the nGDS contract. These findings need further investigation. Continuing professional development would be helpful to improve GDPs’ confidence in dealing with this group of patients.

Randomised controlled trials in HBO: “A call to arms” for HOPON & DAHANCA-21

On many occasions review articles highlight the inadequaies of published evidence and in their conclusions call for etter quality research or randomised controlled trials. The wo reviews published in BJOMS on the subject of prevenion and treatment of osteoradionecrosis with HBO1,2 do not iffer from the trend in this regard. However, on this occasion OMFS is in the unique posiion of having two perfectly complementing HBO trials in hich to enter their patients. HOPON, opened in late 2008 s a CR-UK sponsored trial addressing the issue of preention of ORN; and DAHANCA21, opened in early 2009 ddresses the treatment of established ORN. Both trials carry he accreditation of the National Cancer Research Network nd as such qualify for NHS funding of treatment costs and he involvement of research network trials practitioners. They ave been developed following widespread consultation and ave successfully overcome the numerous hurdles presented y gaining grant funding, ethics, R&D and MHRA. Recent IGN guidelines & Cochrane reviews have suggested trials nto H&N HBO as a priority. We urge those routinely managing the complications of ead and neck radiotherapy region to consider recruitment f their patients into these complementing trials. There is ow a unique opportunity to contribute to this important and ontroversial field. HOPON: Hyperbaric Oxygen for the Prevention of steoradionecrosis. Via trial co-ordinator: Matt Bickerstaff: OPON@liv.ac.uk. Website: www.lctu.org.uk then “Clinial Trials”, “Open”, “HOPON”. Tel: +44 (0) 151 794 8934; ax: +0151 794 8930.

360° peri-implant, keratinised, soft-tissue grafting with stereolithographic-aided dressing plate

Surgical procedures to improve the quality of peri-implant soft tissue are a routine part of dental implant practice, especially in the edentulous patient with a significant lack of attached keratinised tissue. The use of a dressing plate at the recipient site can be beneficial in supporting free, keratinised, soft-tissue grafts during the early healing phase, especially if grafting is undertaken around all aspects of the implant and not just to the facial section. This paper outlines the use of a dressing plate, constructed on a stereolithographic model, for use at second-stage implant surgery to allow for 360 degrees peri-implant, keratinised, soft-tissue grafting.

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.

Refining the definition of mandibular osteoradionecrosis in clinical trials: The cancer research UK HOPON trial (Hyperbaric Oxygen for the Prevention of Osteoradionecrosis)

INTRODUCTION Mandibular osteoradionecrosis (ORN) is a common and serious complication of head and neck radiotherapy for which there is little reliable evidence for prevention or treatment. The diagnosis and classification of ORN have been inconsistently and imprecisely defined, even in clinical trials. METHODS A systematic review of diagnosis and classifications of ORN with specific focus on clinical trials is presented. The most suitable classification was evaluated for consistency using blinded independent review of outcome data (clinical photographs and radiographs) in the HOPON trial. RESULTS Of 16 ORN classifications found, only one (Notani) appeared suitable as an endpoint in clinical trials. Clinical records of 217 timepoints were analysed amongst 94 randomised patients in the HOPON trial. The only inconsistency in classification arose where minor bone spicules (MBS) were apparent, which occurred in 19% of patients. Some trial investigators judged MBS as clinically unimportant and not reflecting ORN, others classified as ORN based on rigid definitions in common clinical use. When MBS was added as a distinct category to the Notani classification this ambiguity was resolved and agreement between observers was achieved. DISCUSSION Most definitions and clinical classifications are based on retrospective case series and may be unsuitable for prospective interventional trials of ORN prevention or treatment. When ORN is used as a primary or secondary outcome in prospective clinical trials, the use of Notani classification with the additional category of MBS is recommended as it avoids subjectivity and enhances reliability and consistency of reporting.

Restorative dentistry and oral rehabilitation: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK and provides recommendations on the pre-treatment oral and dental assessment, during and after treatment and oral rehabilitation. Restorative dentists are core members of the multidisciplinary team treating head and neck cancer patients, involved from the treatment planning phase through to long-term rehabilitation. Recommendations • Preventative oral care must be delivered to patients whose cancer treatment will affect the oral cavity, jaws, salivary glands and oral accessibility. (G) • Close working and communication between the surgeons, oncologists and restorative dental specialists is important in ensuring optimal oral health outcomes. (G) • Intensity-modulated radiotherapy has been shown to reduce long-term xerostomia and should be offered to all appropriate patients. (R) • If patients are deemed at risk of trismus they should be warned and its progressive and potentially irreversible nature explained. (G) • Where it is known that adjuvant radiotherapy will be given, extractions should take place at primary surgery to maximise the time for healing and minimise the number of surgical events for patients. (G) • Osseointegrated implants should be considered for all patients having resection for head and neck cancer. (G)

A new clinical training scheme for overseas dentists under Tier 5

Since the introduction of the Points Based Immigration System to the UK the opportunities for overseas trained dentists to train in the UK have been limited. This paper describes a new opportunity which has resulted from the Tier 5 Medical Training Initiative.

The zygomatic implant perforated (ZIP) flap: a new technique for combined surgical reconstruction and rapid fixed dental rehabilitation following low-level maxillectomy.

This aim of this report is to describe the development and evolution of a new surgical technique for the immediate surgical reconstruction and rapid post-operative prosthodontic rehabilitation with a fixed dental prosthesis following low-level maxillectomy for malignant disease.The technique involves the use of a zygomatic oncology implant perforated micro-vascular soft tissue flap (ZIP flap) for the primary management of maxillary malignancy with surgical closure of the resultant maxillary defect and the installation of osseointegrated support for a zygomatic implant-supported maxillary fixed dental prosthesis.The use of this technique facilitates extremely rapid oral and dental rehabilitation within a few weeks of resective surgery, providing rapid return to function and restoring appearance following low-level maxillary resection, even in cases where radiotherapy is required as an adjuvant treatment post-operatively. The ZIP flap technique has been adopted as a standard procedure in the unit for the management of low-level maxillary malignancy, and this report provides a detailed step-by-step approach to treatment and discusses modifications developed over the treatment of an initial cohort of patients.