Dental help

[Grubbe-a-dub-dub]

I wanted to get some input regarding others' experiences with community dentists. Right now I have 3-4 patients waiting to be cleared or have extractions, some waiting on the order of months. I just had one patient's dentist make sure to let us know he is NOT cleared and that he needs 3 more scalings done before he can start radiation (bizarre).

Could just be the area I work in (I work in a rural setting), but it's like pulling teeth to get dentists and oral surgeons to do their jobs.

Has anyone had success with outreach and developing programs to get H&N patients the dental care they need?

At what point do you just take the risks of ORN and dental complications to avoid the risk of progression of the disease?

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[Ray D. Ayshun]

I wanted to get some input regarding others' experiences with community dentists. Right now I have 3-4 patients waiting to be cleared or have extractions, some waiting on the order of months. I just had one patient's dentist make sure to let us know he is NOT cleared and that he needs 3 more scalings done before he can start radiation (bizarre).

Could just be the area I work in (I work in a rural setting), but it's like pulling teeth to get dentists and oral surgeons to do their jobs.

Has anyone had success with outreach and developing programs to get H&N patients the dental care they need?

At what point do you just take the risks of ORN and dental complications to avoid the risk of progression of the disease?

The answer to last last question is: constantly.

 

[TheWallnerus]

I haven’t sent for extractions for HNSCC RT in many many many years. Maybe before the previous decade. With good salivary gland sparing (5mm or smaller PTVs help, don’t go wild with CTV margins, etc), sequential and midtx replanning, encouraged dental followup at all times post treatment, I just have not had a single ORN case in practice. So my theory is you really have to “try” to give them the ORN and have a patient with super infaust protoplasm. I like to mentally pat myself on the back at these times and think sequential IMRT vs SIB (and not going up above 2 Gy per fraction to any cells, and BID boosting gross dz at 1.5 per fraction … less late effects… past 50 Gy to quasi replicate concomitant boost fractionation) must have helped.

 

[OTN]

I haven’t sent for extractions for HNSCC RT in many many many years. Maybe before the previous decade. With good salivary gland sparing (5mm or smaller PTVs help, don’t go wild with CTV margins, etc), sequential and midtx replanning, encouraged dental followup at all times post treatment, I just have not had a single ORN case in practice. So my theory is you really have to “try” to give them the ORN and have a patient with super infaust protoplasm. I like to mentally pat myself on the back at these times and think sequential IMRT vs SIB (and not going up above 2 Gy per fraction to any cells, and BID boosting gross dz at 1.5 per fraction … less late effects… past 50 Gy to quasi replicate concomitant boost fractionation) must have helped.

With protons you don't even have to try to get ORN, it just happens all by itself 10% of the time

 

[sirspamalot]

With protons you don't even have to try to get ORN, it just happens all by itself 10% of the time

Runner up: Dentists..its like pulling teeth...


Ah ha ha!

 

[BobbyHeenan]

I send first but if big delays then I just start treatment.

I have a county health dep with a good indigent dental care team...but if extractions are too complex for them and I have to get oral surgery involved....then I just put on my big boy pants and make the call.

Knock on wood over past decade I've only had 1 mandible necrosis case, and the dude was literally smoking crack and meth after his xrt so i'm not taking full credit, just partial credit.

 

[metallica81788]

Does anybody think it could be worthwhile when starting a new position in smaller town/city to vet local dentists and maybe work out an arrangement for these HN cases? Couldn't hurt. Had to wait a month for a guy to get 3 teeth pulled recently, it's so aggravating.

A few years ago when dentists were mostly closed, it was give them fluoride let it rip and hope for the best. Simpler times.

 

[sirspamalot]

Legend:

 

[A_DeMichele]

Always always send patients for extractions before comprehensive H&N irradiation. If someone is telling you it’s not necessary, they are probably not practicing RadOncs

 

[medgator]

I wanted to get some input regarding others' experiences with community dentists. Right now I have 3-4 patients waiting to be cleared or have extractions, some waiting on the order of months. I just had one patient's dentist make sure to let us know he is NOT cleared and that he needs 3 more scalings done before he can start radiation (bizarre).

Could just be the area I work in (I work in a rural setting), but it's like pulling teeth to get dentists and oral surgeons to do their jobs.

Has anyone had success with outreach and developing programs to get H&N patients the dental care they need?

At what point do you just take the risks of ORN and dental complications to avoid the risk of progression of the disease?

Scalings aren't a reason to not clear. If he doesn't need extractions, get it going

 

[kimplera]

Scalings aren't a reason to not clear. If he doesn't need extractions, get it going

totally agree with this

also heard that medicare is/will soon be covering medical-related dental work (i.e. radiation and chemotherapy). Hopefully that will help. If we run into problems - just march ahead with the curative treatment

 

[OTN]

I'm fortunate enough that I was able to find a great dentist that gets all my patients in right away, knows exactly what to do, doesn't overcharge them, and even gives them a 30% discount off list price if they come from me. I'm dreading the day he retires.

 

[seper]

I also encourage cavity fillings and, especially, root canals to be done prior to starting XRT... This can get tricky with underserved patients, greedy dentists, but the effort is worth it IMHO

 

[medgator]

I also encourage cavity fillings and, especially, root canals to be done prior to starting XRT... This can get tricky with underserved patients, greedy dentists, but the effort is worth it IMHO

Sure, still shouldn't hold up xrt if it can't done though

 

[RickyScott]

Always always send patients for extractions before comprehensive H&N irradiation. If someone is telling you it’s not necessary, they are probably not practicing RadOncs

Plenty of hpv neg pts can’t afford dental care. I have certainly had cases where pt couldn’t see a dentist.

 

[communitydoc13]

You can leverage the dentists. If you are rural enough, everybody knows everybody (and the dentists are much richer than you). Call them directly.

Months wait is never appropriate and in many cases weeks is not either. (Gotta love those T4 laryngeal or OC cases that show up for consultation with teeth 6+ weeks after surgery). These patients are often poor, often have major barriers to getting extractions, and I often radiate without them without extractions after detailing risks vs risks of delaying XRT.

I never wait for scalings, root canals or anything other than extractions (if they can do it within days, then fine). I would actively call dentists that are delaying cancer care for scalings.

It is hard to get the poor dental care period. I have a go to 90+ minutes away, but nobody local does it. Finding a resource for these folks is very valuable.

 

[TheWallnerus]

Always always send patients for extractions before comprehensive H&N irradiation. If someone is telling you it’s not necessary, they are probably not practicing RadOncs

Rad oncs can’t decide who needs extractions. Dentists don’t have thorough training in “needs this tooth extracted prior to RT” care; it’s all pretty subjective. ORN is very, very rare in modern rad onc. Delaying patient care to get a dental evaluation is common. What’s the evidence for “always send patients for extractions”… from the IMRT era.

 

[seper]

Sure, still shouldn't hold up xrt if it can't done though

For root canal infection and curable head and neck Ca, I hold XRT

 

[RickyScott]

Btw: a lot of dentristry like nutrition is pseudoscience. Supposedly the evidence for scaling, brushing , flossing when it comes to preventing cavities is very poor.

 

[TheWallnerus]

Btw: a lot of dentristry like nutrition is pseudoscience.

Exactly
*ducks to avoid getting punched by a dentist*

 

[temujim]

Exactly
*ducks to avoid getting punched by a dentist*

The likelihood of getting a dentist to quote phase 3 data supporting any procedure they perform asymptotically approaches zero.

 

[RickyScott]

Surprisingly Little Evidence for the Accepted Wisdom About Teeth (Published 2016)

Many of the things we’re told to do for our dental health aren’t supported by systematic reviews.

www.nytimes.com

 

[TheWallnerus]

Damn. I literally have never searched for this. Til now. Maybe this is why I never see ORN… I never send for extractions!

 

[communitydoc13]

Damn. I literally have never searched for this. Til now. Maybe this is why I never see ORN… I never send for extractions!

View attachment 366259

Oh fer crying out loud. This paper tells you nothing. Says absolutely nothing about importance of pre-RT dental extractions either way.

 

[BobbyHeenan]

Btw: a lot of dentristry like nutrition is pseudoscience. Supposedly the evidence for scaling, brushing , flossing when it comes to preventing cavities is very poor.

Some of my best freinds are dentists. It's amazing how so very little of their guidelines/standard of care are not backed by randomized, controlled trials.

Lot's of case series (this place did it this way and had good outcomes, so this is the "best") it seems.

 

[Grubbe-a-dub-dub]

Scalings aren't a reason to not clear. If he doesn't need extractions, get it going

I 100% agree, but the office faxed back our dental letter and wrote "NOT CLEARED" for radiation. The letter is usually just a courtesy that was ask the patient to give to his dentist - but this one went out of the way to tell us to wait to start radiation. They tied my hands...very strange and bizare and I've been trying to get the dentist on the phone to ask WTF is going on.

 

[RickyScott]

I have never asked a dentist to “clear” a pt for radiation. I reccomende my patients see a dentist, and if they don’t, consent them on the slight risk. A dentist has in no way the authority to clear a pt.

 

[Grubbe-a-dub-dub]

Yea, I agree. I don't need their "clearance" per se but it's good to have some documentation and communication that the patient has been seen.

I called this particular dentist and he was very standoffish. He was spacing out his visits because he had high blood pressure and was concerned about the anesthesia. I think it's 100% for billing.

Staff was rude, something really wrong with that practice. Rural America is full of crackpots that somehow have licenses to practice.

 

[medgator]

I have never asked a dentist to “clear” a pt for radiation. I reccomende my patients see a dentist, and if they don’t, consent them on the slight risk. A dentist has in no way the authority to clear a pt.

Oral surgeon probably better trained for that purpose, but they absolutely should be cleared for any bad teeth in the high-dose region of the mandible. You're asking for trouble afterwards otherwise

 

[RadOncDoc21]

I indirectly got in good with a head and neck surgeon by playing nice with his oral surgeon. Let’s just say now I’m there rad onc now because I seemed to care more, even though I don’t.

 

[RickyScott]

Oral surgeon probably better trained for that purpose, but they absolutely should be cleared for any bad teeth in the high-dose region of the mandible. You're asking for trouble afterwards otherwise

A lot of pts can’t pay the out of pocket costs. I recommend they see a dentist, but I am not witholding care when they refuse or cant. I just document that there may be an increased risk.

 

[medgator]

A lot of pts can’t pay the out of pocket costs. I recommend they see a dentist, but I am not witholding care when they refuse or cant. I just document that there may be an increased risk.

I've done the same. May improve if CMS starts covering cancer related dental care/extractions in the future

 

[madchemist89]

I send to dentist for dental clearance and I ask for a letter.

 

[grenz]

Clinical practice guidelines for dental management prior to radiation for head and neck cancer - PubMed

Tooth-level clinical practice guidelines were developed using expert consensus via the modified Delphi process. The treatment pathways developed in this study will be prospectively tested to evaluate the outcomes associated with tooth-specific dental treatments.

pubmed.ncbi.nlm.nih.gov

I found that paper helpful for understanding some of what goes into the extraction decision. Doesn’t substitute a dentist’s opinion but makes me more comfortable with charging ahead with RT if the disease status is worrisome enough

 

[sirspamalot]

In other news, I had my dental appointment today - clean bill of health. Scraping your own teeth daily with a dental pick does wonders. Been doing it for 10 years. Can't floss, my teeth are too tight. The results?

I'm in and out of there in under 30 minutes, no pain bleeding or much work for the hygenist really. I only brush once a day, and have had zero cavities (Note: I did have most of my teeth sealed 25 years ago). Mouthwash in the morning. Well, thats more than you wanted to know so.. back to the topic..

I informed the good dentist that upcoming changes to coverage with Medicare will be increasing the business model nicely (coverage for cancer patients dental care).

 

[TheWallnerus]

In other news, I had my dental appointment today - clean bill of health. Scraping your own teeth daily with a dental pick does wonders. Been doing it for 10 years. Can't floss, my teeth are too tight. The results?

I'm in and out of there in under 30 minutes, no pain bleeding or much work for the hygenist really. I only brush once a day, and have had zero cavities (Note: I did have most of my teeth sealed 25 years ago). Mouthwash in the morning. Well, thats more than you wanted to know so.. back to the topic..

I informed the good dentist that upcoming changes to coverage with Medicare will be increasing the business model nicely (coverage for cancer patients dental care).

You’re a regular Oral Roberts

 

[sirspamalot]

 

[Grubbe-a-dub-dub]

Clinical practice guidelines for dental management prior to radiation for head and neck cancer - PubMed

Tooth-level clinical practice guidelines were developed using expert consensus via the modified Delphi process. The treatment pathways developed in this study will be prospectively tested to evaluate the outcomes associated with tooth-specific dental treatments.

pubmed.ncbi.nlm.nih.gov

I found that paper helpful for understanding some of what goes into the extraction decision. Doesn’t substitute a dentist’s opinion but makes me more comfortable with charging ahead with RT if the disease status is worrisome enough

Thank you for actual guidelines and evidence for this. Perhaps ASTRO could collaborate with the ADA or equivalent organization to come up with some consensus guidelines...

 

[grenz]

Thank you for actual guidelines and evidence for this. Perhaps ASTRO could collaborate with the ADA or equivalent organization to come up with some consensus guidelines...

I think that would be very helpful and impactful for both rad oncs and dentists

 

[temujim]

I think that would be very helpful and impactful for both rad oncs and dentists

RTOG 1016 included some secondary dental endpoints. Maybe it will be published some day. That guideline is fine, but just represents opinion in a data free zone.

 

[RickyScott]

Time to treatment and overall treatment affect survival in head and neck. Refer the pt to a dentist, but if they can’t go or there is a delay, consent them to the possible risk in this data free zone and go ahead with the treatment. I have had 2 thought leaders tell me over the years that they personally see almost no radio necrosis in the imrt era.

 

[medgator]

Time to treatment and overall treatment affect survival in head and neck. Refer the pt to a dentist, but if they can’t go or there is a delay, consent them to the possible risk in this data free zone and go ahead with the treatment. I have had 2 thought leaders tell me over the years that they personally see almost no radio necrosis in the imrt era.

Probably seen 2 cases in 5 years, in both cases patients continued to smoke heavily and had some underlying microvascular disease as well.

If you want want to go big on your ORN rate, you need protons!

 

[TheWallnerus]

have had 2 thought leaders tell me over the years that they personally see almost no radio necrosis in the imrt era.

There’s actually data speaking to that

 

[madchemist89]

I have seen orn in imrt patients. It's rare, but it does occur. I would say <5%.

 

[evilbooyaa]

I also encourage cavity fillings and, especially, root canals to be done prior to starting XRT... This can get tricky with underserved patients, greedy dentists, but the effort is worth it IMHO

But why would you hold RT for a cavity filling?? If the patient needs a root canal prior to RT they probably need an extraction instead.

Always always send patients for extractions before comprehensive H&N irradiation. If someone is telling you it’s not necessary, they are probably not practicing RadOncs

You mean evaluation by a dentist to see if extractions are necessary, or do you mean extract all the teeth in all patients prior to comprehensive H&N RT?

I had a poor T3N0 vocal cord SCC patient who got his borderline teeth yanked by over-zealous dentistry....

Lots of dogmatic voodoo about H&N RT and teeth. Some folks would NEVER do a dental procedure on someone who had H&N RT as per twitter... looking for the thread but can't find it now...

 

[mheat3]

I think that would be very helpful and impactful for both rad oncs and dentists

Which means ASTRO won't do it

 

[communitydoc13]

I had a poor T3N0 vocal cord SCC patient who got his borderline teeth yanked by over-zealous dentistry....

Lots of dogmatic voodoo about H&N RT and teeth. Some folks would NEVER do a dental procedure on someone who had H&N RT as per twitter... looking for the thread but can't find it now...

Too bad on the T3 Larynx. You were probably getting pretty low doses to tooth bearing bone anyway with this diagnosis.

Long term outcomes are dicey though with post-XRT extractions. I'm not opposed to the dentist pulling out sick teeth prior to XRT.

Recently had patient almost 10 years out from OP XRT, now on VEGF inhibitor for RCC and got extraction in ipsilateral posterior jaw!! Was fine before extractions and now with pretty significant ORN. Really would have preferred more aggressive dentistry before XRT or less aggressive now.

 

[Middle Age DDS]

Residency trained dentist here.

I enjoy the jokes, and some are not far off. Like all professions, it just depends on experience and training.
I have to do this every so often. Bottom line, get rid of a tooth/teeth that potentially needs to come out while undergoing RT. Otherwise, clear for treatment. Fabricate some Flouride trays, rx flouride rinses if they lose some salivary function. I'm all about teeth are secondary to saving someone's life.

I love what you guys do. I have a kid in med school, and I wouldn't mind them looking at Radiation Oncology. I wish I could hear the job outlook isn't as dire as it seems.

My experience is awesome with Radiation Oncology. A lot of my family has Dupuytren's including a brother. I noticed a little tightening in my palm. This would really screw up my career. I had to do some research as RT for Dupuytren's doesn't appear to be common in the states (at least currently). As an example, two hand surgeon friends never heard of it being done. I think there are actual clinics in Europe.

I was able to reach out to a fantastic Radiation Oncologist who was sort of excited to try this. I'm not sure if he ever did it before. Anyway 18 treatments and 3-4 years later I am great. We will never know if it would progress, but I was willing to deal with the long-term ramification if any. I am very grateful. I will admit getting on the table when you are "healthy" sure gets your attention.........lol.

My hand hasn't been an issue for me I haven't really thought about this in 3-4 years. Maybe some of you treat Dupuytren's? What an amazing gift and I am sure it would be a nice adjunct to what you normally do.

 

[taserlaser]

Residency trained dentist here.

I enjoy the jokes, and some are not far off. Like all professions, it just depends on experience and training.
I have to do this every so often. Bottom line, get rid of a tooth/teeth that potentially needs to come out while undergoing RT. Otherwise, clear for treatment. Fabricate some Flouride trays, rx flouride rinses if they lose some salivary function. I'm all about teeth are secondary to saving someone's life.

I love what you guys do. I have a kid in med school, and I wouldn't mind them looking at Radiation Oncology. I wish I could hear the job outlook isn't as dire as it seems.

My experience is awesome with Radiation Oncology. A lot of my family has Dupuytren's including a brother. I noticed a little tightening in my palm. This would really screw up my career. I had to do some research as RT for Dupuytren's doesn't appear to be common in the states (at least currently). As an example, two hand surgeon friends never heard of it being done. I think there are actual clinics in Europe.

I was able to reach out to a fantastic Radiation Oncologist who was sort of excited to try this. I'm not sure if he ever did it before. Anyway 18 treatments and 3-4 years later I am great. We will never know if it would progress, but I was willing to deal with the long-term ramification if any. I am very grateful. I will admit getting on the table when you are "healthy" sure gets your attention.........lol.

My hand hasn't been an issue for me I haven't really thought about this in 3-4 years. Maybe some of you treat Dupuytren's? What an amazing gift and I am sure it would be a nice adjunct to what you normally do.

Our dupuytrens numbers has been going up due to word of mouth successes like yours, and discontinuing of other helpful medication in Canada. We see a lot of successes.

 

[TheWallnerus]

Eighteen fractions is an interesting regimen for Dupuytrens. Can anybody guess what dose this might imply?