An Open Letter to Indian Head and Neck Onco-Surgeons from 3 Dental Specialties

There is no doubt that as a head and neck onco surgeon, you are saving thousands of lives every year. But adding quality to this life will make satisfaction among patients much higher. With current advances in surgery, the quality of life can be significantly improved for such patients by surgery alone, but there are certain other associated procedures of dental care which can make a good improvement in the patient’s quality of the life with oral cancer.

The QOL factor

When we talk about quality of life (QOL) for patients with oral cancer, there are three main things that are considered:

1. ability to chew and eat food properly
2. proper speech and
3. social acceptance of facial appearance.

All these three crucial factors which can add quality to the life cannot be achieved without integrating us i.e., the 3 specialists of dentistry. Read on till the end to know which ones! All the patients of oral cancer may or may not require the surgery but almost all the patients will certainly need some form of dental treatment, so it is extremely important to integrate us in providing comprehensive care to the oral cancer patients.

Misconceptions & truth about dentistry

General misconceptions about dentistry some of the head and neck onco surgeons have:

1. Dentistry is mainly about tooth removal, filling of cavities in decayed teeth and giving artificial teeth, which can be done by any dentist and in any phase of the cancer treatment .
2. All the dentists are the same in terms of skills and qualifications.
3. It is quite easy for any and every dentist to treat any dental disease, irrespective of mouth opening status of the patient.

But the truth about “Dentistry” is :

1. It is not just tooth removal, it is a minor surgical procedure called tooth extraction: a dentist makes sure tooth extraction is done without creating any morbidity (jaw necrosis) or mortality (life threatening medical complication in high risk patients) causing minimal trauma to surrounding tissues to aid wound healing . The concerned speciality here is ‘oral and maxillofacial surgery’.
2. It is not just filling the decayed tooth, it is restoring the tooth/teeth where in not only tooth is restored anatomically but is also restored functionally and esthetically, which helps in maintaining proper chewing and proper speech for the patient. Concerned speciality here is ‘conservative dentistry and endodontics’.
3. It is not just articial teeth replacement, it is replacement of missing tooth/teeth and associated structures, where not only the missing teeth, gums and bone are restored for function, esthetics and speech, but also various maxillofacial prosthesis including eye prosthesis, ear prosthesis, jaw prosthesis, obturator and bite guide dentures to restore the form and function of entire face. Concerned speciality here is ‘prosthodontics and maxillofacial implantology’.
4. All dentists are not same as there are 9 different specialities and it takes minimum 8 years to become specialist in dentistry.
5. Head and neck oncosurgeons do procedures under General Anaesthesia, while dentists do almost all our procedures under Local Anaesthesia so please remember that patient`s cooperation and patient`s normal mouth opening are particularly important for them.

Why are we writing this letter to you?

Oral cancer itself does not affect the dental care directly, but it is the treatment of oral cancer surgery and/or radiotherapy which create problems in delivering proper dental care to the patient. For example:

• surgery and radiotherapy causes fibrosis which leads to decrease in mouth opening i.e., TRISMUS
• after radiotherapy the chances of developing osteoradionecrosis of the jaw are very high .

Both these two complications of cancer therapy together turn the most common and simplest procedures of dentistry, into the most difficult ones. Here is the quick reference guide on how to give better quality of life to the patient with oral cancer, by integrating medical and dental fraternity in the most scientifically harmonius way. As we know there are three phases of any cancer treatment A] pretreatment planning phase B] treatment C] post treatment rehabilitation phase Pre-treatment phase In this phase, an onco-surgeon plans how the resection will be and what will be the reconstruction type. Involving three different specialists of dentistry will help you in getting better post operative outcome in terms of quality of life. For example:

1. If patient has preexisting trismus due to oral submucous fibrosis then we, (the 3 specialists of dentistry) will tell you how difficult or easy the dental care would be in post operative phase, so it is better to remove the teeth / involve them in your resection margin rather than leaving it.
2. In case you are not closing it primarily (although rarely), then it is better to consult prosthodontists who will tell you which tooth/teeth he/she wants you to exclude from the resection (obviously only if it is beyond the safe margins) so they can plan the obturator accordingly.

During treatment While doing marginal mandibulectomy or alveolectomy as a part of planned resection, please do not leave broken tooth/teeth inside as it is not always possible to remove the tooth in post operative phase due to trismus or ongoing radiotherapy. It happens more frequently now a days because of the advancement in bone resection equipment which can cut the bone so precisely and artistically to achieve 2cms of safe margins from the lesion margins. But while doing this you cut the part of the tooth/teeth (not whole of the tooth) and if you do not give due importance to the anatomy of the tooth/teeth, then there are chances you may leave roots of the tooth/teeth within the bone (become source of pain and or infection in the later phase). So, to avoid this you need to consult oral and maxillofacial surgeon intraoperatively (who are also trained in various head and neck surgeries) who will help you out in extracting the tooth/teeth properly not only from the primary lesion are but also other decayed/ non-restorable/ 3rd molars /difficult to access posterior molars. Post–operative phase Please do not start the radiotherapy before consulting us (the 3 specialists of the dentistry) We all have different and highly skilled role to play:

1. A) The Oral and maxillofacial surgeons (tooth extractors): They will decide whether the extraction of the decayed tooth/teeth is needed or not. Most likely all the 3rd molars, and sometimes 2nd molars, will be advised to be removed, as these are not so accessible for the patient to maintain oral hygiene and for us to carry out any dental procedures considering the post-surgical and post radiation fibrosis resulting into the trismus.
2. B) the Endodontists (tooth savers): They will decide whether any dental treatment to save the tooth, like restorative or endodontic procedures, is needed or not, again considering the post-surgical and post radiation fibrosis resulting into the trismus.
3. C) The Prosthodontists (bite restorers): They will decide whether patient needs bite guide denture or not. They can provide stable occlusion to the patient which will help in more efficient chewing and better control of jaw movements and better speech.

Concluding message

In case you are confused or unsure about consulting particular dental specialists, then your first point of contact can be oral and maxillofacial surgeons, as they very well understand the nature and course of the head and neck cancer, and at the same time they know when and how to involve the other dental specialists to improve quality of life in patients with oral cancer. Please watch this video to understand how difficult it is to perform tooth extraction in a patient who is treated for oral cancer without involving the dental specialists at the right stages. Link: https://www.youtube.com/watch?v=iZIRhZeYTsI https://www.youtube.com/watch?v=iZIRhZeYTsI

Multidisciplinary cancer care begins with timely recognition and documentation; use this structured oral cancer screening and referral guide.