Replacement of missing teeth after radiotherapy for head and neck cancer
Radiotherapy is a standard treatment for head and neck cancer (HNC) patients. However, the significant morbidity and reduced quality of life (QoL) associated with radiotherapy had led the Royal College of Surgeons and the British Society for Disability and Oral Health to provide comprehensive guidelines on how the dental team might help in reducing the short-term and long-term side effects of radiotherapy. This can involve extraction of teeth with poor prognosis; hence many HNC patients have numerous extracted teeth post-radiotherapy. Denture use has been used with caution as trauma that develops from ill-fitting dentures and dry mouth could increase the likelihood of osteoradionecrosis (ORN), which is a serious complication affecting HNC patients post-radiotherapy. However, it is not known if this is evidence-based, including the impact on QoL and oral functioning. Thus, research is required to assess the impact of denture use on ORN, QoL and oral functioning. Moreover, very little research exists that considers the perspective of the patients and healthcare professionals about the use of dentures following radiotherapy. This doctoral research included 5 studies: Study 1: A rapid review that collated and compared the national and international guidelines for denture use following radiotherapy for HNC. This review concluded that there is mixed advice that may not help dentists to makes evidence-based decisions about replacement of missing teeth for HNC patients post-radiotherapy. Study 2: A systematic review of the existing evidence regarding the impact of dentures following radiotherapy for HNC on risk of ORN and QoL. Out of 6 included studies, 3 indicated that ORN might not be associated with denture use. Further, denture use may result in improvement in some domains of QoL, but not all (see publication 1). Study 3: A retrospective study design included reviewing the medical record of 439 HNC patients who had received radiotherapy and had missing teeth at the time of discharge. Using a binary logistic regression, this study indicated that denture use might not be a risk factor for ORN following radiotherapy for HNC (see publication 2). Study 4: A cross-sectional survey using a structured validated, and reliable questionnaire completed by 80 HNC patients who had received radiotherapy and had missing teeth at the time of discharge. Using Mann Whitney and chi-squared tests, this study indicated that QoL and oral functioning were similar regardless of denture use. There was dissatisfaction with information and in those who had not replaced their missing teeth, there was a substantial interest in denture use; this might be an unmet need (see publication 3). Study 5: The final study was an exploratory cross-sectional survey of 150 general dental practitioners (GDPs) and 25 HNC multidisciplinary team (MDT) dentists in England to assess their practices and perspectives on replacing missing teeth after radiotherapy for HNC. The study indicated that GDPs and HNCs MDT dentists had similar views and practices. ORN was not the most common cited reason for why dentists would not to replace missing teeth with dentures. Other key reasons were dry mouth and radiation caries. The likelihood of replacing missing teeth with dentures increased with awareness of clinical guidance on the use of dentures in HNC and that denture provision would have positive consequences that outweighed the costs.