Clinical Scenario

A 78‐year‐old patient with a history of oral cancer presents to the dental clinic complaining of poorly located dull pain from the teeth in the lower left quadrant. The discomfort commenced several days earlier and is exacerbated when drinking or eating. No painkillers or antibiotics have been taken.

Radiological Examination

• Orthopantomogram undertaken (Figure 13.1.1)
• Right‐sided segmental mandibulectomy
• Osteosynthesis plate to bridge the bone defect and another to reinforce the marginal mandibulectomy area
• Generalised advanced alveolar bone loss; exposed furcation #36

Structured Learning

1. What is the likely cause of this patient’s oral pain?
   • The most likely cause is in relation to the advanced periodontal disease and gingival recession associated with the 3 remaining lower teeth, #34, #35 and #36
   • However, in view of the patient’s cancer history, it is important to exclude recurrence of the oral squamous cell carcinoma, particularly as he did not complete the full course of postsurgical radiotherapy and did not receive chemotherapy
2. Following discussion of the oral findings, which teeth would you recommend for extraction?
   • Extraction of teeth associated with a poor prognosis/infection risk: #34, #35, #36 and #22 retained root
   • Elective extraction of the #18 and #28 should also be discussed as they are associated with mucosal trauma, are non‐functional and are difficult to reach for cleaning
3. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Lives alone/need to identify a suitable escort
     • Lack of perceived importance of dental care when compared with the systemic problems/oral cancer
     • Impaired communication due to partial glossectomy
     • Fear of tumour recurrence
     • Psychosocial impact of cancer and the disfigurement caused by surgical removal
   • Medical
     • Risk of tumour recurrence
     • Sequelae of cancer treatment, including dysphagia
     • Risk of an ischaemic heart disease episode (see Chapters 8.2 and 8.6)
     • Bleeding tendency due to acenocoumarol see (see Chapter 10.3)
     • There is a risk of a hypertensive crisis due to arterial hypertension (see Chapter 8.1)
     • Hypoglycaemia/hyperglycaemia, increased risk of infection and poor wound healing related to diabetes (see Chapter 5.1)
     • Drug interactions
   • Dental
     • Poor oral hygiene and irregular dental attendance
     • Sequelae of the surgical therapy can hinder dental management (e.g. partial glossectomy in this patient is associated with an altered cough reflex, choking and aspiration risk)
     • Oral rehabilitation is more challenging as there is no bony reconstruction of the mandible
4. What specific precautions should be implemented for this patient when dental extractions are undertaken?
   • Confirm preoperative international normalised ratio (INR) because the patient is taking acenocoumarol
   • Confirm diabetic control (haemoglobin A_1c) and blood glucose due to diabetes
   • Monitor vital signs (oxygen saturation, blood pressure and pulse) due to the ischaemic heart disease and arterial hypertension
   • Avoid a fully reclined position and limit irrigation during the procedure due to aspiration risk
5. Following completion of the dental extractions and healing, the patient asks for a lower denture. What factors would you need to consider when assessing him for this?
   • Lack of bone reconstruction after segmental mandibulectomy
   • Lack of sulcus depth in the region of the resection due to surgical scarring
   • Position of the osteosynthesis plates/screws
   • Volume and morphology of the remaining mandibular bone
   • Degree of lateral mandibular deviation
   • Number and condition of the remaining natural teeth

6. It is determined that there is insufficient support and access for construction of a mandibular prosthesis. The patient asks if dental implants can be placed instead. What would you discuss?
   • Osseointegrated dental implants can provide stability to a dental prosthesis
   • Radiation therapy does not worsen the prognosis, because the patient was administered a very small dose, and the implants would be located distant to the radiation field
   • However, there are several other factors to consider, including:
     • Poor oral hygiene
     • Periodontal disease
     • Degree of diabetes control
     • Cancer prognosis (recurrent tumour; not having undergone adjuvant therapy)

General Dental Considerations