Developing a Clinical Auditing Tool for the Post- Operative Dental Care for Oral Cancer

Review Article

Austin Dent Sci. 2019; 4(1): 1024.

Developing a Clinical Auditing Tool for the Post- Operative Dental Care for Oral Cancer

Al Shamrany M*

Department of Surgery, Dental & Maxillofacial Section, King Fahad Specialist Hospital-Dammam, Saudi Arabia

*Corresponding author: Al Shamrany M, Department of Surgery, Dental & Maxillofacial Section, King Fahad Specialist Hospital-Dammam, P.O. Box 15215, MBC 031, 31444 Dammam, Saudi Arabia

Received: September 20, 2019; Accepted: October 16, 2019; Published: October 23, 2019

Abstract

Oral cancer incidence is on the rise. Dentistry is a part of the multidisciplinary service provided to patients with oral cancer before, during and after cancer treatment. Clinical audit is a great tool to improve dental care to patients with oral cancer. The aim of this review is to develop a clinical audit tool to evaluate the post-surgery and radiotherapy dental management for oral cancer based on available evidence.

Keywords: Clinical Audit; Oral Cancer; Dental Care

Introduction

In the United States, it is estimated that approximately 37,000 new cases are diagnosed every year [1]. Oral cancer incidence in the UK has risen by more than 30% since the early 1990s [2]. Dentistry is a part of the multidisciplinary service provided to patients with oral cancer before, during and after cancer treatment. Clinical audit is a great tool that have been used to improve dental care of cancer in general. No clinical audit specific to oral cancer have been published.

The aim of this review is to develop a clinical audit tool to evaluate the post-surgery and radiotherapy dental management for oral cancer based on available evidence.

Methodology

Audit standards were drawn from available evidence sources using PubMed database and Cochrane reviews as well as existing standards, guidelines and policies, and consensus until July 2019.

Next, evidence was reviewed and classified based on the level of strength outlined in table1 and subsequently, each standard was given a grade of recommendation [3]. In some standards, the same standard was given different grades of rating due to the varying strength of evidence.

The Audit Standards:

The audit standards, Table 1,2, were grouped based on the following objectives:

Table 1: Hierarchy of evidence and recommendations grading schem.





  

    
Level 

    
Type of    evidence 

    
Grade 

    
Evidence 

  

  

    
1++ 

    
High quality    meta-analyses, systematic reviews of randomised controlled trials (RCTs), or    RCTS with a very low risk of bias 

    
A 

    
At least one meta-analysis, systematic review of RCTs, or RCT rated as    1++ and directly applicable to the target population; or 

  

  

    
1+ 

    
Well    conducted meta-analyses, systematic reviews of RCTS, or RCTs with a low risk    of bias 

    
A body of evidence consisting principally of studies rated as 1+,    directly applicable to the target population and demonstrating overall    consistency of results 

  

  

    
1- 

    
Meta-analyses,    systematic reviews of RCTs or RCTs with a high risk of bias 

    
    
  

  

    
2++ 

    
High    quality systematic reviews of case control or cohort studies High quality    case control or cohort studies with a very low risk of confounding or bias    and a high probability that the relationship is causal 

    
B 

    
A body of evidence including studies rated as 2++, directly applicable    to the target 

  

  

    
population and demonstrating overall consistency of results; or 

  

  

    
Extrapolated evidence from studies rated as 1++ or 1+ 

  

  

    
2+ 

    
Well conducted    case control or cohort studies with a low risk of confounding or bias and a    moderate probability that the relationship is causal 

    
C 

    
A body of evidence including studies rated as 2+, directly applicable    to the target population and demonstrating overall consistency of results; or 

  

  

    
Extrapolated evidence from studies rated as 2++ 

  

  

    
2- 

    
Case    control or cohort studies with a high risk of confounding or bias and a    significant risk 

    
    
  

  

    
that    the relationship is not causal 

  

  

    
3 

    
Non-analytic    studies, e.g. case reports, case series 

    
D 

    
Evidence level 3 or 4; or 

  

  

    
4 

    
Expert    opinion 

    
Extrapolated evidence from studies rated as 2+ 

  

  

    
    
    
GPP* 

    
Recommended best-practice based on the clinical experience of the    guideline development group 

  

  

    
GPP: Good Practice Point. 

  










Table 1: Hierarchy of evidence and recommendations grading schem.

Table 2: Audit standards for the dental management of patients who had surgery and radiotherapy oral cancer.





  

    
Standards (Rating) 

    
Target 

    
Exception 

    
Definitions/ instructions 

    
questions on data collection sheet 

  

  

    
Pathway of care 

  

  

    
1. Patients with stable oral health are    seen at least biannually during the period of monitoring by the oncology    team; and those with unstable oral health require more frequent monitoring. (GPP) [3-5]. 

    
100% 

    
None 

    
Period of monitoring by the oncology team:    Within the first three years post-treatment. 

    
1a,1b 

  

  

    
2. Designated specialist/consultant    restorative dentist is responsible to coordinate care including extractions    after discharge to the primary dentist. (GPP) [3-7]. 

    
100% of discharged patients. 

    
None 

    
    
2 

  

  

    
3. Patients with implant-supported or    complex conventional prostheses have long-term follow-up by prosthodontics/    restorative specialist/consultant. (GPP) [5,6].

    
100% of complex cases. 

    
None 

    
Complex case: implant-supported or complex    conventional prostheses 

    
3 

  

  

    
Preventive care 

  

  

    
4. Fluoride and/or re-mineralizing agents    are available to all dentate patients. (A) [4,8]; (B) [9-11]. 

    
100% of dentate patients. 

    
None 

    
Daily topical fluoride application (5000 ppm    fluoride) in custom-made trays or brush-on. 

    
4 

  

  
 

  

    
5. Oral hygiene and caries prevention are    re-introduced as mucositis subsides. (GPP) [5]. 

    
100% 

    
None 

    
    
5 

  

  

    
6. Oral care for patients fed via gastrostomy tube is to be    maintained throughout the pathway. (GPP) [5]. 

    
100 % of patients who had gastrosto-my tube 

    
    
    
6 

  

  

    
Management of complications 

  

  

    
7. Trismus prevention measures are implemented and patients    with established trismus are managed appropriately.

    
100% 

    
None 

    
Trismus: tonic contraction of the masticatory    muscles; and results in a limited mouth opening. 

    
7 

  

  

    
  

  

    
Exercises with a specific device. (B) [10,12]; (C) [5,13,14].

  

  

    
Stacking and taping together tongue spatulas. (B) [4,12]

  

  

    
Trigger point injections, analgesics, and muscle relaxants. (B) [4,15].

  

  

    
Pentoxifylline. (C) [12]

  

  

    
8. Xerostomia is managed appropriately. 

    
100% 

    
None 

    
Salivary gland hypo-function: a decrease in    salivary secretion, with pathological low saliva secretion as = 0.1 ml/min    for unstimulated whole salivary flow and = 0.5 ml/min for stimulated whole    salivary flow. Xerostomia: the subjective complaint of dry mouth. 

    
8 

  

  

    
  

  

    
Pilocarpine in patients with evidence of some    intact salivary function, proving there are no medical contraindications. (A) [3,5,6,16]; (B) [4,10,12,14,17,19] 

  

  

    
Cevimeline. (A) [16,19]; (B) [12] 

  

  

    
Sipping water and sugarless fluids frequently. (C) [4] 

  

  

    
Chewing sugarless gum or lozenges. (B) [4,12,17,19] 

  

  

    
Saliva substitute (mouthwash or gel). (B) [10,19]; (C) [4,5,11,12] 

  

  

    
9. Dental extractions and implants placement    should be carried out by specialists with a working knowledge of principles    of radiotherapy and surgery, e.g. oral and maxillofacial surgeon and    periodontist, under appropriate precautions. (C) [3], (D) [6]. 

    
100% 

    
None 

    
    
9 

  

  

    
Atraumatic approach. (B) [4,20]; (D) [6] 

  

  

    
Pre-extraction antibiotic prophylaxis (Co amoxiclav/    amoxicillin (metronidazole in those allergic to penicillins) are generally    the drugs of choice. (B) [4] 

  

  

    
Hyperbaric Oxygen (HBO) before and after tooth    removal or implant placement. (B) [4,5]; (C) [21,22] 

  

  

    
A minimum of 24 months between the end of    radiotherapy and implant insertion. (D) [8] 

  

  

    
10. Provision of dentures should be delayed    for 12 months or more after completion of radiation to minimize the risk of Osteoradionecrosis    (ORN) of the jaws. (C) [22-26]. 

    
100% of patients receiving dentures. 

    
None 

    
    
10 

  










Table 2: Audit standards for the dental management of patients who had surgery and radiotherapy oral cancer.

• To assess the pathway of care (immediate follow-up, discharge and long term care).

• To assess preventive care.

• To assess the management of complications.

Table 3 displays a proposed questionnaire to collect audit data.

Table 3: Data Collection Sheet.





  

    
    
Questions: 

  

  

    
Answers 

  

  

    
Pathway of    care 

    
1a.    Patient with stable oral health: Was he/she seen at least biannually during    the period of monitoring by the oncology team? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
1b.    Patient with unstable oral health: Did he/she receive more frequent    monitoring? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
2. Was    there a designated specialist/consultant restorative dentist responsible for    coordinating care including extractions after discharge to the primary    dentist? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
3. Did    the patient with implant-supported or complex conventional prostheses have    long-term follow-up by prosthodontics/restorative specialist/consultant? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
PREVENTIVE    CARE 

    
4. Was    fluoride and/or re-mineralizing agents available to the dentate patient? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
5. Were    oral hygiene and caries prevention re-introduced as mucositis subsided? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
6. Was    oral care for patients fed via gastrostomy tube maintained throughout the pathway?

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
MANAGEMENT    OF COMPLICATIONS 

    
7. Was the patient with    established trismus managed appropriately?

  

  

    
(Exercises with tongue    depressors, Exercises with a specific device, Trigger point injections,    Pentoxifylline, None, NA, Exception)

  

  

    
8. Was the    patient with Xerostomia managed appropriately? 

  

  

    
(Pilocarpine,    Cevimeline, Sipping water and sugarless fluids, Chewing gum, Saliva    substitute, None, NA, Exception) 

  

  

    
9. Was    dental extraction and/or implant placement carried out under appropriate    precautions? 

  

  

    
(Atraumatic    approach, Antibiotic, HBO, No HBO facility, None, NA, Exception) 

  

  

    
10. Was    denture provision delayed 1 year or more after completion of radiation? 

  

  

    
(Yes, No,    NA, Exception) 

  

  

    
Note: Statistical    analysis guide: a therapy will be stratified as “Yes, met standard”. 

  










Table 3: Data Collection Sheet.

Discussion

Overall, evidence related to fluoride therapy and re-mineralizing agents was the strongest. Pilocarpine and Cevimeline also were supported with evidence of a higher level of strength for the management of xerostomia.

One Cochrane review reported insufficient evidence supporting the HBO role in ORN prevention during implant placement [27], however other reviews supported it even with moderate strength of evidence. Another Cochrane review reported insufficient evidence on the benefit of acupuncture and electrostimulation devices for xerostomia [28], therefore they were not included in the standards.

Timing of the placement of the denture after completion of radiotherapy is controversial. The recommended period ranged from 4-6 weeks [29,30], to no longer than 6 months [7,31], to 1 year or more being the majority [22,26]. It has been suggested that patients who never had dentures before radiation or had been dentulous prior to therapy and had either intra- or postradiation extractions seem to be at a higher risk of developing ORN [24,31,32]. Oral cancer places the entire mouth at a radiation dose greater than 5000 cGy, which was reported as a risk factor for ORN in denture users [32]. Therefore, it is best that the provision of dentures should only commence after 1 year following radiotherapy based on weighing risk and benefit.

Conclusion

Clinical audit is a proven quality improvement method that must be part of the practice organizationally to learn and improve performance. Comparing care delivery to standards drawn from high-quality evidence is the core of any clinical audit. There is a lack of strong evidence that supports audit standards related to postsurgery and radiotherapy dental management for oral cancer or head a neck cancer in general. However, audit standards can be developed currently from the highest level of evidence available until stronger evidence emerges.

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Citation:Al Shamrany M. Developing a Clinical Auditing Tool for the Post-Operative Dental Care for Oral Cancer. Austin Dent Sci. 2019; 4(1): 1024.