Clinical Scenario

A 79‐year‐old man with a history of oral cancer presents to your dental clinic requesting a replacement upper denture. Although he has worn a removable maxillary prosthesis for the last 4 years, it is unstable and he cannot chew properly. In addition, when he drinks fluids, drops of liquid escape through his nose.

Structured Learning

1. What is an adenoid cystic carcinoma (ACC) and what does the staging of T2N2aMx mean?
   • ACC is an uncommon type of malignant tumour that arises within glandular tissue (type of adenocarcinoma), most commonly the major and minor salivary glands of the head and neck region; other sites include the trachea, lacrimal gland, breast, skin and vulva
   • It has a relatively indolent but relentless course; although disease‐specific survival is 89% at 5 years, it falls to 40% at 15 years due to a higher rate of recurrence/progression
   • Although it seldom metastasises to regional lymph nodes, distant metastasis, particularly to the lung, is the more common; perineural invasion is also a characteristic feature and is indicative of a poor prognosis
   • T2N2aMx confirms the staging of the tumour (see Table 13.1.2)
     • T2: tumour measuring 2–4 cm with an invasion depth <10 mm or measuring <2 cm with an invasion depth of 5–10 mm
     • N2a: metastasis in an ipsilateral lymph node measuring 3–6 cm in diameter, with negative extranodal extension
     • Mx: distant metastasis cannot be assessed

2. What is primary biliary cholangitis?
   • It is a chronic, autoimmune disease in which the bile ducts in the liver are slowly destroyed, causing cholestatis and eventually hepatic cirrhosis
   • Common symptoms are fatigue, pruritus and, in advanced cases, jaundice
   • Complications include portal hypertension secondary to cirrhosis, fat malabsorption and osteoporosis/osteomalacia
3. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Psychosocial state in response to cancer diagnosis and therapy
     • Managing expectations
   • Medical
     • Although the patient has reached 5 years after cancer therapy and is currently disease free, recurrence of ACC should be considered
     • Bleeding tendency (liver cirrhosis secondary to primary biliary cholangitis)
     • Avoid drugs metabolised in the liver
     • There is a risk of a hypertensive crisis due to arterial hypertension (see Chapter 8.1)
     • Drug interactions
   • Dental
     • Sequelae of oral cancer surgical treatment (e.g. risk of choking)
     • Chronic and late complications of radiation therapy (e.g. radiation caries and osteoradionecrosis)
     • Large oroantral/nasal defect with limited support for a maxillary prosthesis
4. What are the considerations for extracting the retained roots in the upper right quadrant?
   • A risk–benefit analysis should be undertaken as there are occasions when leaving the roots is the most prudent clinical decision
   • Risks:
     • The patient has received high‐dose radiation therapy (60 Gy) which is associated with a higher risk of osteoradionecrosis (ORN) (see Chapter 13.2)
     • The retained roots are on the right alveolar ridge which is likely to have been in the field receiving the highest dose of radiotherapy
     • The roots may displace into the oroantral/nasal communication during extraction, particularly if a surgical approach is required (fluid/debris may also be displaced)
     • The retained roots may become problematic at a later date, particularly if a new maxillary prosthesis is constructed and the area is loaded
   • Benefits:
     • The retained roots were a coincidental finding and they are likely to have been in place for at least 5 years when the precancer dental extractions were undertaken (with a recovered immune system, the likelihood of infection is low)
     • Submergence of dental roots has been shown to maintain alveolar bone for prosthodontic purposes
     • Implants have been shown to successfully integrate around dental root fragments with cementum
5. Although the retained maxillary roots are not clinically visible and are covered by mucosa, further examination confirms they are palpable. The decision is made to extract the retained roots prior to further prosthodontic procedures. Other than the dose of radiation therapy, what other factors need to be considered when assessing the risk of postoperative ORN?
   • It has been more than 2 years since he finished the radiation therapy
   • The patient has not smoked since the age of 59 years
   • Alcohol consumption is nil
   • Good oral health
   • Balanced diet/good nutritional status
   • There are no infectious foci in relation to the retained roots or the remaining teeth
   • The roots are located in the maxilla which is generally more vascular (ORN incidence is higher in the mandible)
6. Following successful extraction of the retained roots and confirmed healing at 3 months, it is determined that insertion of dental implants as anchoring elements is the best option for constructing a stable and functional prosthesis. The CBCT confirms that the quantity and quality of the bone in the left maxillary ridge region are sufficient for dental implant placement (Figure 13.3.1). What precautions should be taken when inserting the dental implants?
   

   

   • Consider the increased risk of bleeding due to liver disease/arterial hypertension:
     • Coagulation tests and platelet counts should be performed to assess the need for haematological support
     • Blood pressure reading should be taken before starting the procedure
     • Bleeding is typically controlled with local haemostasis measures
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