Head and Neck Cancer

Head and Neck Cancer
13.1 Surgery

Section I: Clinical Scenario and Dental Considerations

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.

Medical History

  • T1N0M0 oral squamous cell carcinoma of the gingivae adjacent to the lower molar teeth diagnosed 6 years earlier
    • Surgical treatment included tumour removal and marginal mandibulectomy
  • Recurrence of the oral carcinoma 3 years earlier with a T3N1M0 presentation
    • Partial glossectomy
    • Segmental mandibulectomy; reconstructive surgery not undertaken; plates in situ
    • Ipsilateral lymph nodes removal (neck dissection)
    • Postsurgical sequelae include dysglossia and occasional episodes of choking
    • Postoperative radiotherapy received but discontinued at the fifth session (10 Gy) due to the onset of severe mucositis
    • Chemotherapy not planned due to the presence of comorbidities
  • Ischaemic heart disease (coronary stents)
  • Atrial fibrillation
  • Arterial hypertension
  • Type 2 diabetes


  • Acenocoumarol
  • Nitroglycerine
  • Enalapril
  • Atenolol
  • Furosemide
  • Metformin

Dental History

  • Soft diet since carcinoma recurrence
  • Only attends the dentist when in pain
  • Brushes teeth only at night
  • Anxious about choking when brushing his teeth
  • Patient requested a dental prosthesis but was told it was not feasible

Social History

  • Widowed and lives alone
  • Active life (walks 2 hours daily)
  • Does not drive but can travel independently
  • Ex‐smoker (15 cigarettes/day until 12 years ago)
  • Alcohol: rarely (<2 units/week)

Oral Examination

  • Poor oral hygiene
  • Numerous lost teeth
  • Buccal caries in teeth #14, #25, #34, #35 and #36
  • Retained root #22
  • Periodontal disease with associated gingival recession
  • Grade II mobility of teeth #34 and #36
  • Trauma to the buccal mucosa bilaterally from the unopposed upper third molar teeth
  • Surgical scars on the oral mucosa in relation to the mandibulectomy have resulted in sulcus obliteration

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
Photo depicts orthopantomogram showing segmental mandibulectomy reconstructed with an osteosynthesis plate and severe periodontal disease (M/L).

Figure 13.1.1 Orthopantomogram showing segmental mandibulectomy reconstructed with an osteosynthesis plate and severe periodontal disease.

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 A1c) 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

Sequelae of Surgical Treatment

  • Primary tumour resection

Stay updated, free dental videos. Join our Telegram channel

Nov 6, 2022 | Posted by in Implantology | Comments Off on Head and Neck Cancer

VIDEdental - Online dental courses

Get VIDEdental app for watching clinical videos