Oral prehabilitation for patients with head and neck cancer: getting it right - the Restorative Dentistry-UK consensus on a multidisciplinary approach to oral and dental assessment and planning prior to cancer treatment.

Historically, oral and dental issues for head and neck cancer patients were often not considered until after cancer treatment was complete. As a result, outcomes for oral rehabilitation were sometimes suboptimal. Inconsistencies in service delivery models and qualification, training and experience of staff delivering dental care often compounded this problem, making research and audit almost impossible. Collaborative working by consultants in restorative dentistry from all over the UK as part of a Restorative Dentistry-UK (RD UK) subgroup, renamed more recently as the RD-UK Head and Neck Cancer Clinical Excellence Network (CEN), has re-emphasised the importance of specialist restorative dentistry intervention at the outset of the head and neck cancer pathway to optimise outcomes of patient care. The CEN has driven several initiatives, reflecting Getting It Right First Time (GIRFT) principles aimed at reducing unwarranted variation. This improved consistency in approach and optimised collaborative working of the team now presents a better environment for multicentre audit and research. Ultimately, this should result in a continued improvement in patient and carer experience.

Differential regulation of NPY and SP receptor expression in STRO-1+ve PDLSCs by inflammatory cytokines.

OBJECTIVES: The aims of this study were to investigate neuropeptide receptor expression regulation on STRO-1 +ve periodontal ligament stem cells (PDLSCs) in response to inflammatory cytokines and to investigate a potential osteogenic effect of neuropeptides. BACKGROUND: Nerve fibres innervating the periodontal tissues in humans contain several neuropeptides including neuropeptide Y and substance P. The role of neuropeptide receptors on PDLSCs, including their response to the local inflammatory environment of periodontitis, is currently unknown. METHODS: A homogenous population of STRO-1 +ve PDLSCs was prepared by immunomagnetic separation of cells obtained by the tissue out-growth method from healthy premolar teeth from a single donor. Regulation of gene expression of the neuropeptide Y Y1 receptor and substance P receptor tachykinin receptor 1 was investigated. A potential osteogenic effect of neuropeptide Y and substance P was also investigated by measuring alkaline phosphatase (ALP) activity, Alizarin red staining and quantifying osteogenic gene expression. RESULTS: Treatment of STRO-1 +ve PDLSCs with tumour necrosis factor-alpha or interleukin 1-beta up-regulated the expression of the neuropeptide Y's Y1 receptor, but down-regulated substance P's receptor. Significantly increased ALP activity was observed in STRO-1 +ve PDLSCs treated with neuropeptide Y but not substance P. Further studies showed that neuropeptide Y had a modest osteogenic effect on cells at both a functional level and a gene level. CONCLUSIONS: Expression of the neuropeptide Y Y1 receptor gene on STRO-1 +ve PDLSCs was sensitive to local inflammatory cytokines. Treatment of cells with neuropeptide Y was found to produce a modest enhanced osteogenic effect.

Long-term impact of living with an obturator following a maxillectomy: A qualitative study.

OBJECTIVES: To explore the long-term impact for patients living with an obturator prosthesis, following a maxillectomy for a head and neck neoplasm. METHODS: A qualitative approach was employed, using semi-structured interviews. A purposive sample of eight men and four women, living with an obturator prosthesis for at least five years, were recruited. Interviews were digitally recorded and transcribed. Using thematic analysis, two researchers analysed the data. RESULTS: The data were categorised into four themes: 1. Preparedness for living with an obturator, 2. Impact of living with an obturator - what changes to expect, 3. Stability and retention of the obturator, and 4. Coping strategies to aid adjustment. Long-term effects of living with an obturator spanned many aspects of life to include: chewing and eating, speaking, dealing with nasal leakage and altered body image, employment and intimacy issues, along with embarrassment during social encounters. Optimal retention and stability of the obturator, as perceived by the patient, lead to improved social confidence and engagement. The emotional impact varied greatly on peoples' lives. CONCLUSIONS: Patients experiencing the greatest long-term challenges had larger defects, were of employment age and had not returned to work. Gaining an improved understanding of the psychology of coping overtime is clearly important, as this can inform interventions to facilitate adjustment for those who are emotionally struggling. Furthermore, the findings of this study could inform the design of a communication tool to facilitate shared-decision making and aid preparedness for living with an obturator following a maxillectomy. CLINICAL SIGNIFICANCE: The multidisciplinary head and neck team should provide patients with detailed pre-operative information, including potential effects on social, work and personal relationships. The restorative dentistry team has a pivotal role in the long-term management of these patients, as obturators have a finite lifespan with ongoing maintenance necessary to promote optimal retention and stability.

The experience among patients with multiple dental loss as a consequence of treatment for head and neck cancer: A qualitative study.

OBJECTIVES: To explore the experience among patients with multiple dental loss as a consequence of treatment for head and neck cancer. METHODS: Semi-structured qualitative interviews were conducted with a purposive sample of fifteen people with head and neck cancer, who had multiple teeth removed as part of their tumour resection or extracted pre-radiotherapy. The interviews were digitally recorded and transcribed for analysis by two researchers, independently. RESULTS: The interview data were categorised into four themes: 1. Pretreatment experience of being informed that teeth had to be removed, 2. Impact of dental loss post-treatment, 3. Coping with dental loss, and 4. Getting dentures and implants. Patients receiving primary radiotherapy felt the time between being informed of requirement for dental extractions and actual extractions was short. Dental loss was detrimental to all patients in terms of eating, speaking, socially and their intimate lives. CONCLUSIONS: Patients whose primary treatment was surgery, appeared more accepting of dental loss. Whereas, those having primary radiotherapy, there seemed to be a focus on prevention of radiotherapy-induced complications, with limited choices and recognition on post-treatment dental functionality. This study showed the negative impact of dental loss on patients' quality of life. CLINICAL SIGNIFICANCE: Dentists should be aware of the post-treatment implications of dental loss on patients' lives; presenting this, as well as the clinical advantages for extractions, to aid decision-making. Patients should be informed of the lack of conclusive research evidence regarding pre-radiotherapy dental extraction. There should also be clear pathways regarding post-treatment dental-related rehabilitation.

Oral Health Status of Patients Undergoing Treatment for Head and Neck Oncology in Northern Ireland.

This study aimed to collect data on the oral health status of patients undergoing treatment for head and neck oncology across Northern Ireland. Data were collected on all patients referred to the Northern Ireland Multidisciplinary Head and Neck Oncology Team for discussion and treatment planning. Each patient underwent pre-treatment dental assessment in the Centre for Dentistry, Queen's University Belfast, between June 2013 and November 2014. Data were collected from clinical oral examinations supplemented with intra-oral radiographs. During the course of the study 96 patients were assessed and the levels of dental disease observed in this cohort were high. On clinical examination 43% were diagnosed with caries and 46% with periodontal disease. Ten patients were completely edentate. The disease profile of this patient group presents significant challenges to dental services tasked with rendering patients dentally fit prior to undergoing oncology treatment.

Impact of Referral Protocols on the Dental Management of Patients Undergoing Treatment for Head and Neck Oncology in Northern Ireland.

Management of head and neck oncology necessitates an extensive multidisciplinary approach. Throughout Northern Ireland all oral care for Head and Neck Oncology patients is overseen within the Centre for Dentistry, Queens University Belfast via referral from the Head and Neck Multidisciplinary Team. The aim of this study was to develop and introduce a referral pro-forma to improve communication between members of the multidisciplinary team and ultimately expedite provision of oral care prior to patients undergoing treatment for Head and Neck Oncology. The study period ran from June 2013 until November 2014. All patients undergoing treatment for Head and Neck Oncology in Northern Ireland were included in the study. A referral pro-forma was introduced in June 2014 in an attempt to streamline the referral process. Data was gathered on patient waiting times, extraction protocols with comparisons made between the period before and after introduction of the pro-forma. In total 137 patients were included in the study: 96 patients were referred to the service using referral letters, confidential emails and via telephone; 41 patients were referred using the pro-forma. The introduction of the referral pro-forma resulted in a significant decrease in the mean number of days from referral to assessment (12 to 7 days) (p < 0.05) and significantly increased mean interval time between extractions and patients beginning radiotherapy (13 to 17 days) (p < 0.05). Significant improvements have been made with the introduction of the referral pro-forma where patients are waiting significantly less time for dental assessment and having extractions completed in a more timely manner therefore expediting the commencement of their oncology treatment.

Quality of life issues in head and neck cancer.

UNLABELLED: Head and neck cancer (HNC) constitutes approximately 3% of all cancers in the UK, with in excess of 8500 new cases annually. Management of HNC depends on site, extent, histology, previous medical history and patient choice. A multidisciplinary approach is required to optimize patient wellbeing, owing to the significant functional and psychosocial implications that can impact on quality of life. Members of the dental team, to include the general dental practitioner, have a key role in patient care; therefore the dental team should be knowledgeable in the short-term and longer-term implications and how this impacts on quality of life. CLINICAL RELEVANCE: This article offers the dental team with an overview of how HNC and the various treatments, such as surgery, radiotherapy and chemotherapy, impact upon quality of life, both in the short-term and longer-term.

Human dental pulp fibroblasts express the "cold-sensing" transient receptor potential channels TRPA1 and TRPM8.

INTRODUCTION: Transient receptor potential (TRP) channels comprise a group of nonselective calcium-permeable cationic channels, which are polymodal sensors of environmental stimuli such as thermal changes and chemicals. TRPM8 and TRPA1 are cold-sensing TRP channels activated by moderate cooling and noxious cold temperatures, respectively. Both receptors have been identified in trigeminal ganglion neurones, and their expression in nonneuronal cells is now the focus of much interest. The aim of this study was to investigate the molecular and functional expression of TRPA1 and TRPM8 in dental pulp fibroblasts. METHODS: Human dental pulp fibroblasts were derived from healthy molar teeth. Gene and protein expression was determined by polymerase chain reaction and Western blotting. Cellular localization was investigated by immunohistochemistry, and TRP functionality was determined by Ca(2+) microfluorimetry. RESULTS: Polymerase chain reaction and Western blotting showed gene and protein expression of both TRPA1 and TRPM8 in fibroblast cells in culture. Immunohistochemistry studies showed that TRPA1 and TRPM8 immunoreactivity co-localized with the human fibroblast surface protein. In Ca(2+) microfluorimetry studies designed to determine the functionality of TRPA1 and TRPM8 in pulp fibroblasts, we showed increased intracellular calcium ([Ca(2+)](i)) in response to the TRPM8 agonist menthol, the TRPA1 agonist cinnamaldehyde, and to cool and noxious cold stimuli, respectively. The responses to agonists and thermal stimuli were blocked in the presence of specific TRPA1 and TRPM8 antagonists. CONCLUSIONS: Human dental pulp fibroblasts express TRPA1 and TRPM8 at the molecular, protein, and functional levels, indicating a possible role for fibroblasts in mediating cold responses in human teeth.

Substance P expression by human dental pulp fibroblasts: a potential role in neurogenic inflammation.

Neurogenic inflammation describes the local release of neuropeptides, notably substance P (SP), from afferent neurons and might play a role in the pathogenesis of pulpal disease. The fibroblast is the most numerous cell type in the dental pulp, and recent work has suggested that it is involved in the inflammatory response. Primary pulp fibroblast cell populations were isolated by enzymatic digestion. Whole pulp tissue was obtained from freshly extracted sound (n = 35) and carious (n = 39) teeth. Expression of SP and neurokinin-1 receptor (NK-1) mRNA by pulp fibroblasts was determined by reverse transcriptase polymerase chain reaction (RT-PCR). SP was expressed by pulpal fibroblasts at both mRNA and protein levels. In addition, NK-1 mRNA and protein expression was detected in fibroblast cultures by RT-PCR and Western blotting, respectively. SP levels, determined by radioimmunoassay, were significantly greater (P < .05) in carious compared with sound teeth. These findings suggest that pulp fibroblasts play a role in neurogenic inflammation in pulpal disease.