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EvidencebasedDecisionMaking

Craniofacialsciences
UConnSDM
AEGD
SteveRuiz

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Clinical Question
What are the dental considerations of the
cancer patient?

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PICOQuestion
Howdoesthetreatmentofacancerpatientdifferfroma
noncancerpatient?

Population:CancerPatients
Intervention:Dentaltreatment
Comparator:Noncancerpatients
Outcome:Reductionincaries.

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AbroadliteraturesearchwasconductedinMEDLINE/PubMedand
EMBASEforpaperspublisheduptoMay2015.
Nolanguagefilterswereapplied.Metaanalysis,systematicreviews,
randomizedcontrolledtrials,clinicalstudiesandcohortstudieswere
consideredassourcesforevidencetoanswertheresearchquestion.

Papersonheadandneckcancerpatientssubjected
topreradiationdentalscreening,(chemo)radiation
andoralfollowupwereincluded.

PubmedSearchStrategy
SearchTermsUsed,includinganylimitsapplied

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HeadandNeckCancer

Numberof
citations
266917

Radiotherapy

284969

DentalPreservation

2311

Fluorideapplications

3086

CervicalRestorations

838

GlassIonomer

7026

Radiationcaries

1548

OralHealth

107128

Cervicaldecay

358

10

Chemotherapy

2609858

Article1

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ArticleTitle
Citation

Evidencesupportingpreradiationeliminationoforalfociofinfection
inheadandneckcancerpatientstopreventoralsequelae.

TypeofStudyand
LevelofEvidence

SystematicReview/High

Brieflydescribethe
studydesign

AbroadliteraturesearchwasconductedinMEDLINE/PubMed,1770
identifiedpapers.Theselectedstudieswereincludedforfulltextanalysisif
headandneckcancerpatientsreceivedexternalbeamradiotherapyand
preradiationdentalscreeninghadbeenperformed

Brieflydescribethe
relevantresults

Thefollowingshouldbeconsidered
asoralfociofinfectionandshouldbeeithereffectively
treatedbeforeonsetofradiotherapyorbeeliminated:Deepcaries,Active
Periodisease,nonrestorableteeth,partiallyorimpactederuptedteeth.

Listweaknessesofthe Mostpaperslackeddetailsonhowdentalscreeningwas
studyifany
Performed,randomizedcontrolledtrialswerenotacceptedinthereview.
Aretheseresults
applicabletoyour
clinicalquestion?
Whyorwhynot?

Theconsensusinthedentalfieldappearstobethatahighlevel
oforalhygieneisimportantduringandafterradiotherapy;oral
hygieneinstructions,removalofdentalcalculusandfluorideapplication.

Article2

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ArticleTitle
Citation

OralSurgeryinPatientsUndergoingChemoradiationTherapy

TypeofStudyand
LevelofEvidence

SystematicReview./High

Brieflydescribethe
studydesign

150multidisciplinarycitationsidentifiedbut48citationsselectedfromPubmed.full
textanalysis.

Brieflydescribethe
relevantresults

Preventionandthoroughpreparationare
vitalbeforethestartofchemotherapyandradiation
therapy.LoweringriskforORN

Listweaknessesofthe Studydesignnotdetailed.
studyifany
Aretheseresults
applicabletoyour
patient?Whyorwhy
not?

TheconcernistheinstigationofORN.ORNinareasexposedtolessthan60Gyis
unlikely.Knowledgeoftheradiationfieldallowsbetteroralcaresoindicated
procedurescanbeperformedforareasthatareexposedtodoseslessthan50Gy.

Article3

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ArticleTitle
Citation

Twoyearclinicalperformanceofglassionomerandresin
compositerestorationsinxerostomicheadandneckirradiatedcancer
patients

TypeofStudyand
LevelofEvidence

RandomizedControlledtrial

Brieflydescribethe
studydesign

35highcariesrisk,postradiation,xerostomic
adultswith3cervicalcariouslesionsinthesamearch.Every
patientreceivedaKetacFil(KF),PhotacFil(PF)andHerculite
XRV(HX)restoration.

Brieflydescribethe
relevantresults

Inthishighriskxerostomicpatientgroupwithradiation
caries,theuseofconventionallysettingglassionomersis
associatedwithprotectionagainstsecondarycaries.

Listweaknessesofthe NonethatIcouldFind.
studyifany
Aretheseresults
applicabletoyour
patient?Whyorwhy
not?

Yes.Itmaybepreferabletopreservetheremains
oftheglassionomerfillingandrestorethetoothwitha
sandwichtechnique

Article4

ArticleTitle

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Citation

Dentalpreservationinpatientsirradiatedforheadandneck
tumours:A10yearexperiencewithtopicalfluorideanda
randomizedtrialbetweentwofluoridationmethods

TypeofStudyand
LevelofEvidence

RandomizedTrial/Mid

Brieflydescribethe
studydesign

Patientsatriskwererandomizedintoonearmusing
thefluoridegelasexplainedaboveorintoonearm
usinga1350ppmFtoothpastefor3min,twice
perdayfollowingmorningandeveningmeals.

Brieflydescribethe
relevantresults

Dentalcariesoccuredin3%ofthepatientsreceiving
thefluoridegelascomparedto11%inthose
usingthetoothpaste

Listweaknessesofthe NoControl
studyifany
Aretheseresults
applicabletoyour
patient?Whyorwhy
not?

25%ofallpatientsirradiatedtotheheadandneckmaybenefitfrom
systematicdentalpreservationwithlowfailurerate(4%dental
caries,1%osteoradionecrosis).Thisresultsinasignificantimprovementin
thepatient'squalityoflife

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Summarize the scientific evidence relevant to this

question:
Theconsensusinthedentalfieldappearstobethatahigh
leveloforalhygieneisimportantduringandafter
radiotherapy;oralhygieneinstructions,removalofdental
calculus;nonrestorableteethandfluorideapplication.

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Summarize your experience and clinical

judgment relevant to this question:
Theuseoffluorideinanyformdecreases
theriskofdecay
Bestresultsachievedbyprescribing
Prevident5000.

Conclusions

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Taking into account the scientific evidence, your experience and

clinical judgment, and the clinical circumstances, what are your
conclusions about this clinical question?
Hospitaldentist,oralandmaxillofacialsurgeon,anda
maxillofacialprosthodontistmustbeinvolvedearlytoprevent
avoidableoralcomplications.
Preventionandthoroughpreparationarevitalbeforethestartof
chemotherapyandradiationtherapy.Oralcomplicationsmust
beaddressedimmediatelyand,evenwiththebestmanagement,
cancausedelaysandinterruptionintreatment,withserious
consequencesfortheoutcomeandprognosis.

DiscussionPoints

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Whatarewecurrentlypracticinginrelationtothistopic?
CompletedentalPreradiationscreeningexam
Shouldwemodifyourclinicalpracticetobemoreconsistentwiththe
evidenceonthistopic?WhyorWhynot?
Yes.Newand/orsimpletreatmentsarestillnotbeingusedenough.
Ifmodificationisneeded,howcanweachieveit?(forexample:informalcommunicationto
providers,changeaclinicalpracticepolicyetc.)
Casepresentationsandinformalcommunication.