1. Introduction
The aim of this guidance is equitable access to oral healthcare for patients with a diagnosis of cancer across England. Those who require access to an ‘oral health in cancer pathway’, gaining specific support with oral health prior to and during cancer care, include:
- patients with a diagnosis of head and neck cancer
- this is defined as “a group of epithelial malignancies involving the upper shared respiratory/digestive tract (lips, oral cavity, oropharynx, nasal cavity, nasopharynx, hypopharynx and larynx/upper trachea), the salivary glands and lymphadenopathy associated with these diseases.”
- patients undergoing radiotherapy to the jaws (includes those irradiated for lymphoma and skin cancers)
- patients who will receive chemotherapy or immunotherapy for any cancer type and location
- patients who will undergo bone marrow transplantation
- patients receiving antiresorptive/bone protective therapy in the form of denosumab or bisphosphonates
Patients should be able to achieve stable oral health to progress with cancer treatment in a timely manner. This will maximise chances of good cancer outcomes while minimising urgent care episodes and deviation from/derailment of the patient cancer treatment plan.
This guidance should be read alongside:
- The oral management of oncology patients requiring radiotherapy, chemotherapy and/or bone marrow transplantation
- Medication-related osteonecrosis of the jaw
- British Association of Head and Neck Oncologists (BAHNO) standards
- Delivering better oral health (DBOH)
- relevant NICE and SDCEP guidance
- Head and neck cancer: United Kingdom national multidisciplinary guidelines
The clinical standards and example pathways shared in this guidance describe care that will maximise cancer treatment outcomes.
Oral healthcare requires face-to-face delivery using the entire dental team, who are required to liaise with the responsible consultant (oncology/medicine/surgery), Consultants in Restorative Dentistry working as core members of Head and Neck Cancer Multidisciplinary teams and link nurses managing and supporting the patient. These local systems must have the infrastructure, workforce, and capability to meet patient needs during their cancer therapy.
This guidance sits alongside a series of dental commissioning standards produced to support the transformation of NHS England dental services. Each standard sets out a framework for local work and should be read in conjunction with the Introductory Guide for Commissioning Dental Specialties.
Pathway development will require integrated care boards (ICBs) to consider the breadth of dental teams within primary (NHS and private), secondary and tertiary settings during construction and implementation.
We are keen to focus on providing local populations with timely access to high quality, evidence-based oral healthcare, and confidence that the service is designed at a local level to meet local needs.
2. Relationship between cancer and oral health
People of all ages are advised to access oral health advice, support and care from primary care dental teams, usually within general dental practices. Primary dental care teams enable people to maintain good oral health, including advice regarding the prevention of cancers. Crucially, they provide a referral route for patients with suspected oral cancer.
Patients with a diagnosis of cancer may require professional support from dental teams, who provide advice, care and specific treatments to maintain effective cancer treatment cycles.
This care reduces the oral health side-effects of the cancer and/or cancer treatment modalities and improves quality of life. The severity and duration of the side-effects often depends on the treatment regime.
Patients who have good oral health before treatment have a lower risk of the following complications in the mouth: inflammation, infection, disruption of taste, and dysfunction of salivary glands, alongside increased susceptibility to dental decay and gum disease.
Experiencing these oral health effects and problems may negatively affect the delivery of the cancer therapy and quality of life. Dental infections can lead to sepsis, and this risk is increased with unmanaged tooth decay during episodes of low neutrophil counts in patients receiving cancer therapy.
3. Current provision
There is no nationally recognised facilitated pathway to prioritise patients with a diagnosis of cancer requiring the specific therapies described above, that would allow faster access for prevention and stabilisation during the prescribed stages of cancer care.
There is anecdotal evidence, from patient advocate organisations and national providers (such as Healthwatch and Cancer Alliance, respectively) across England to suggest that some patients cannot access oral care once diagnosed with cancer when they are not already known to a dental practice .
Data to quantify this problem is not available.
Patients with a diagnosis of cancer require prioritisation to prevent delay of vital medical care due to oral health problems; this guidance supports practices and commissioners to take a clinical prioritisation approach.
This will allow those with a diagnosis of cancer and receiving the therapies described above to access oral health assessment and subsequent required care in a timely manner.
As there is no registration of dental patients, unlike general medical practice, proactive measures are needed to support those without access to a dentist to secure care.
4. Pathway development
ICBs should review and ensure prioritised access for appropriate oral health assessment, prevention (advice and interventions), and treatment for patients diagnosed with cancer who cannot access a dentist prior to their intended start date for cancer therapy; and to make appropriate provision available if gaps are identified.
At the point of cancer diagnosis, an individual should be advised by the team managing the cancer to have a comprehensive oral assessment with their dentist or, in the case of patients with Head and Neck Cancer, with the local Head and Neck Cancer multidisciplinary team and gain relevant advice on oral health maintenance.
Patients do not need to change their current dental provision to a specific team if they have access prior to the start of therapy; all dentists (NHS or independent) can support their care and should have access to appropriate secondary and tertiary care support in their region.
If the patient lacks a dentist, the requirement for a comprehensive oral assessment may activate the ‘oral health in cancer pathway’ so that oral health can be stabilised in the context of their general needs and welfare.
The pathway for oral health support and care may include the breadth of dental teams within primary (NHS and independent), secondary and tertiary settings.
Some patients may only require oral health advice regarding prevention and possible preventative interventions during the cancer therapy. The assessment should include a risk assessment of future oral health based on lifestyle factors, history and any cancer therapy interventions that may negatively affect oral health.
Patients requiring a more specific approach, for example by using an ‘oral health in cancer pathway’, should be managed in the following manner:
Patients with head and neck cancer:
- should be assessed by a consultant in restorative dentistry who works with the surgeon in the multidisciplinary team
- should remain with the specialist team until any necessary advanced restorative care and rehabilitation is complete
- any interventions that do not require specialist input will be referred to the patient’s usual primary care provider (see Clinical standard for restorative dentistry, NHS England 2022)
All other patients:
- should attend their usual primary care dentist (NHS and independent), who should gain timely support from colleagues in secondary and tertiary care, where the status of the patient complicates the delivery of specific dental interventions
- for example, profound immunological and haematological side effects, extensive oral complications
Where a patient indicates they do not have access to a dentist, ICBs should ensure that an appropriate primary care pathway is available.
Access to a consistent dental team for the duration of cancer treatment is desirable, to ensure:
- access to urgent advice is available from a team who have both baseline information and access to information provided by the medical team managing the cancer care of the individual
- recall intervals are agreed through a consistent approach and varied according to the status of the individual (see NICE CG19, Dental checks: intervals between oral health reviews)
- stabilisation of oral health, and opportunities to proceed to definitive treatment by the dental team are informed by the principles of shared decision making (see NICE NG197, Shared decision making)
Upon discharge from cancer therapy, ongoing management of oral health may require more frequent recall intervals, and patients with an increased risk of osteonecrosis may require referral to specialist advice for orthodontics and extractions.
Patients who have required facilitated access to an NHS pathway will be discharged and encouraged to seek regular oral healthcare from the range of available providers.
Once cancer treatment is concluded the patients would then exit any facilitated cancer-specific pathway and seek regular oral healthcare from the range of available providers.
4.1 Assessing need
As stated in NICE QS139, the planning of oral healthcare services must be underpinned by an oral health needs assessment.
In the context of this guidance the needs assessment should be used to determine if current oral healthcare service provision for patients who require access to an ‘oral health in cancer pathway’ is meeting local needs.
The needs assessment should be supported by a consultant in dental public health who is also able to advise the ICB of the most efficient way of securing the pathway.
4.1.1 Principles of assessment
ICBs and local dental networks (LDNs) will need to agree a timeframe for conducting a strategic needs assessment, being mindful of the potential savings to the NHS and improvement in quality of life for patients with a diagnosis of cancer.
Chestnutt et al (2013) describe a process for undertaking a systematic oral health needs assessment, involving the identification of the oral health needs of the local population including vulnerable groups, as well as ascertaining gaps in service provision and use to meet these needs and providing recommendations.
Surveillance of the data should be continuous, with the stages outlined as a cycle. Patients and the public should be involved throughout, as well as other stakeholders, which may include other healthcare professions and cancer charities.
4.2 Health data
To determine regional need, ICBs would need to reflect on local diagnosis data, both pre- and post-pandemic.
Clear oral health data is challenging and has been affected by the pandemic for children. The methodological differences between children’s oral health surveys occurring in public sector educational settings do mean that direct comparison is challenging. However, in areas where they have occurred, they will provide a sense of the oral health burden in children.
ICBs should reflect on the data from national adult oral health surveys where it is available but be aware that the most recent survey cannot be directly related to previous surveys due to the change in methodology.
Data regarding the lifestyle factors of smoking and alcohol consumption indicate a detrimental effect on oral health and are also factors for increased risk of developing cancer. Patients with a cancer diagnosis related to smoking or alcohol consumption may also have poorer oral health, requiring more challenging treatment options and multidisciplinary management.
During the development of a needs assessment, ICBs should engage with public health colleagues, including a consultant in dental public health to research and understand the needs of the specific group of patients indicated in the introduction.
4.3 Service data and capacity
Collecting local data regarding access and care/treatment pathways for patients prior to cancer therapy commencement is recommended, as well as cancer patients whose prognoses and experiences have impacted their oral health.
The national service data related to oral healthcare is inconsistent. It only addresses NHS dental care and, in that domain, has been measured and reported in varying ways between 2007 and 2023.
Factors affecting access to oral health care include personal anxiety related to treatments, local availability, transport and costs related to treatment to name a few. Some people choose to access only urgent care, as opposed to regular care and support.
To establish whether a new pathway for the target demographic is required, evaluation of existing dental services must first take place. Evaluation may include efficacy of existing primary care providers.
There is annual data available regarding the fulfilment of GDS contracts; significant under-delivery in a local GDS contract may indicate sufficient capacity for more people to be seen. Equally, the potential to develop or extend other services provided by Level 2 providers, postgraduate dental training providers, specialist community dental services and dental schools could be considered.
Developing pathways outside of primary care or bespoke specialist services would require consideration of the level of training and experience of the General Dental Council (GDC) registrants.
5. Oral health pathway
Dentists and dental care professionals are expected to work in a multidisciplinary manner. For patients whose cancer therapy relies on the successful stabilisation of oral health, GDPs could be the driving force managing a patient’s care at this crucial moment.
The GDP will involve the patient and oncology team and, where indicated, specialists in:
- restorative dentistry
- paediatric dentistry
- special care dentistry
- oral surgery
This list is not exhaustive and should relate to the patient and their presenting needs.
A flexible approach to clinical delivery needs an equally flexible approach to patient flow across primary, secondary and tertiary care boundaries, if and/or when specialist assistance is required for the patient.
Pathways should include prioritised access for patients with a diagnosis of cancer, so cancer therapy is not delayed or interrupted due to the management of referrals across care or organisational interfaces.
This is of particular importance for patients whose general health is severely impacted, or where the nature of the cancer and treatments requires involvement of specialists and/or consultants.
Clinicians delivering oral healthcare should be cognisant of and responsive to the underlying general health of the patient and treatment cycles for the cancer. The dental team must be flexible around timings of care and, where appropriate, should prioritise stabilisation over definitive care.
Stabilisation, for the purposes of this guideline, is informed by Janssens et al 2018:
“Oral health stabilisation involves the provision of any treatment, in the opinion of a dentist, making it unlikely that any urgent or emergency dental need will occur before the next planned review, as indicated by NICE guidelines”.
The treatments may be temporary or definitive in nature provided they can endure until the next planned review. It is possible patients may need access to oral health support before the planned review due to the impact of the cancer therapy, for example mucositis, fungal infection, or lack of saliva.
5.1 Models of provision
As previously defined, patient care can occur across all settings; example pathways structures include:
Hub and spoke model
The individual carrying out the oral health assessment would distribute the patient’s care to secondary or tertiary care teams through locally identified priority pathways.
‘One-stop-shop’
The team carrying out the oral health assessment would also carry out any oral healthcare. Ideally, the fewer referrals involved in a pathway, the faster the patient will have their oral health stabilised, enabling commencement of cancer therapy.
5.1.1 Pilot models of care
As shown in appendix 1, pilot models of care, the South West model demonstrates an approach to stabilisation and ongoing care for patients with a diagnosis of head and neck cancer.
This works well in the South West due to the availability of a consultant-led model, operating across a dental hospital and specific outreach facilities (4 district general hospitals) for the pre-cancer therapy element of the pathway.
The use of specific general dental practices, badged as cancer action support practices (CASPs) within the South West model, aims to provide priority access for the ongoing oral health management for the duration of cancer therapy; continuing care is beneficial in all areas of healthcare. Continuity of care shows demonstrable improvements in both efficiency of services and mortality (Kajara-Montag et al, 2024), (Pereira Gray et al, 2018).
The model shared from the North East uses oral health practitioners (OHPs): dental nurses who have developed enhanced skills and competencies working across health and social care.
This model lends itself to supporting patients with a diagnosis of cancer in the settings where they receive their cancer therapy: OHPs advise patients on oral and general health matters and are able to support the patients to navigate access to oral health care with their usual dentist, or through a specific pathway for patients who do not have a dentist.
There are many opportunities within current pathways, services and funding to support patients with a diagnosis of cancer beyond those shared above. They include consideration of, but are not limited to:
- postgraduate training pathways in dentistry
- involvement of postgraduate trainees will enhance their learning opportunities ensuring a sustainable professional resource for the future who feel able to manage the ongoing needs of patients with a diagnosis of cancer
- links to care navigators who could be supported in their roles by the dental profession
- they may be a significant contact for patients via their general medical practitioner (GMP)
- supporting the development of advanced nurse practitioners in oncology teams to understand and act as navigators for pathways to oral health services
- consideration of advanced roles and responsibilities funding to support oral health outreach activity.
Pathway providers, including the teams managing the cancer and those managing oral health, will require mutual support to enable a holistic understanding of the abilities and challenges of each part of the pathway. The support should be undertaken in conjunction with the regional deanery and the following managed clinical networks (MCNs):
- special care dentistry
- paediatric dentistry
- oral surgery
- restorative dentistry
- orthodontics
- urgent care (where it exists)
- secure settings
The dental team includes all 7 groups of GDC registrants, as well as the different substages of each of these registrants as they engage in postgraduate training positions.
The involvement of the whole dental team should be encouraged to participate in a cancer pathway. Participants should be supported to gain further training in cancer management, patient engagement, education and motivation, and clinical assessment and treatment.
6. Clinical delivery
The progress of oral healthcare, for those that require it, will be affected by the general health of the patient and any cancer therapy effects. As patients progress through their cancer therapy, the type of oral healthcare provided by clinical dental teams should be informed by both the patient and their oncology team.
An example of how this communication might be carried out is provided as a suggested referral form supplied in appendix 4 (separate to this guidance).
The first phase of treatment should aim to support preventive measures and stabilisation of oral health if required so that cancer therapy can commence as outlined by the oncology team. The patient would have subsequent reviews of both their oral and general health to determine the best time to proceed to definitive treatments if required.
Definitive treatment goes beyond the management of pain or discomfort and the removal of infected tissues. Definitive treatment aims to restore the oral health and function of the tissues within the oral cavity. This may include the removal of teeth, where they are beyond repair. It is expected that restoration of function would be achieved using the least invasive treatment options while the patient undergoes intense medical treatments.
The Patient Management Matrix, supplied in appendix 3, provides an example of when and where a patient may receive care throughout their cancer therapy.
6.1 Cancer diagnosis and oral health assessment
As part of a patient’s general health assessment, oncology teams should enquire whether the patient has access to a dentist. Patients who attend an existing general dental practice should be directed to approach the existing provider prior to the commencement of cancer therapy.
Appendix 4 provides an example of how the details of cancer care can be communicated.
Attending the usual provider ensures a prior understanding of the past oral health history and care delivered, prior knowledge of existing oral health conditions and detailed records of maintenance programmes.
Where a patient diagnosed with cancer does not have access to oral healthcare, the patient should be referred to the most appropriate dental team, as recommended by a commissioned pathway.
It is intended that oncology teams will engage in any oral care cancer pathway and will encourage patients to maintain good oral health to maximise the outcomes of cancer therapy.
In any proposed pathway, every patient should be offered a comprehensive oral health assessment (NHS England, 2019), (Scottish Dental Clinical Effectiveness Programme, 2011), as soon as is practicable following a cancer diagnosis. The appointment needs to occur and allow for the provision of oral healthcare before the anticipated start date of cancer treatments.
The benefits of the assessment and care include:
- improved outcomes to cancer therapies, where prompt oral health care reduces the likelihood of delays to initiation of cancer therapy and contributes to holistic improvement and continuation of care
- early recognition of oral health complications related to the cancer, or the associate therapies enables the oral health team to reduce their impact and duration
- reduced oral health complications occurring as a result of cancer therapy
Where the cancer treatment requires a more urgent approach any oral health care may need to be delayed.
The assessment protocol should be as thorough as the patient can allow with potential variance relating to age, behaviour/anxiety and general health. Any variance to a full assessment should be noted and described.
Examples of comprehensive oral health assessments are shown in appendix 3, for children, young people and adults.
The dentist should address the level(s) of complexity of oral health stabilisation required for the patient. Some patients may need no further treatment following an assessment, some may need simple oral healthcare, and some may require complex care/interventions.
All patients should be offered oral health prevention advice and professional interventions pertinent to their oral health needs and planned cancer treatment.
6.2 Prevention
High quality preventive care to support good oral health should be provided to all patients and is a requirement of the GDS contract. The OHP role described in appendix 1 provides an additional, more flexible approach to delivery, with the practitioners able to attend non-dental settings to support patients: oncology clinics, GMP practices, residential settings.
6.3 Urgent oral healthcare
The management of pain or discomfort, whether independent of the patient health status or related directly to the cancer or associated therapy, would be managed in an appropriate setting. An example of urgent oral healthcare management is presented in appendix 3.
Where the patient’s medical status is uncomplicated, provision of urgent care would occur within their identified primary dental care setting during usual opening hours.
Outside usual service hours, the protocol described in the Clinical Standard for Urgent Care should be followed. To ensure safer and more efficient provision of urgent care, all patients receiving their oral healthcare on the pathway should retain a patient held record in relation to dentistry; this could be provided electronically or in hard copy by the provider.
The patient held oral health record would enable the provider of out-of-hours (OOH) care to have all the requisite information they need to ensure oral healthcare is provided in the OOH setting.
Where the health of the patient adversely affects the provision of dental treatment, the pathway to OOH urgent care needs to be agreed with the appropriate providers and be known and accessible to the patient at all times.
7. Quality and outcome measures
Providers of healthcare services, including dentistry, are encouraged to reflect on the quality of care delivered to service users to identify opportunities for improvement. It is suggested that ICBs consider the following as key performance indicators (KPIs), and how they will access the data, as they develop the pathway:
- breaches to start of cancer care or in treatment delays due to access to oral health services or oral health complications
- access urgent care services: numbers, clinical presentation and treatment provided
- incidents, including significant events
KPIs should be an integral part of the pathway planning and specification for the service and be co-produced with patient representatives.
The ICB should involve the MCNs in the pathway design, especially when considering the auditing of agreed quality measures.
The ICB should indicate the need for local dental providers and oncology colleagues to liaise, ensuring a common understanding of quality measures and triangulation of information regarding the efficacy and quality of oral health services.
Resources to support the involvement of people and communities can be accessed on the Get Involved section of NHS England’s website or by emailing the NHS Public Partnership Team at england.engagement@nhs.net.
Patient reported outcome and experience measures that may be considered for the specification include:
- did the care enable you/your child to start your treatment for cancer in the time frame stated by the medical team?
- did you understand what treatment you/your child needed?
- Commissioning considerations
The clinical care required by patients with a diagnosis of cancer in high street dental practices falls within the definition of Mandatory Services. However, there may be some circumstances where commissioners wish to secure a specific commitment on the part of some dental contractors to see these patients accompanied by rapid access to care. As noted in Section 4.1, estimating the specific capacity required can be challenging and will be influenced by underlying levels of access to dental care, whether privately or NHS funded as well as the cancer diagnosis rates. Given this, determination of capacity of specific services is for ICBs to determine.
Where an ICB determines that it wishes to commission a specific commitment on the part of dental contractors to see these patients who do not have an existing relationship with a dental practice, this should be progressed in line with the guidance on flexible commissioning and be compliant with the Provider Selection Regime. It would be advisable for any such services to be managed as discrete contracts to facilitate the submission of FP17 data to understand the demand, impact and outcomes of any such service. Payment terms would be at the discretion of the commissioner and should be fully described in the associated contract, the required activity and how this exceeds Mandatory Services requirements, and procurement documents.
Appendix 1: pilot models
South West – head and neck cancer pathway
For patients with a diagnosis of head and neck cancer the suggested pathway is as follows:
On diagnosis, patients requiring radiotherapy or surgical intervention to the head and neck will be referred to specialist/consultants in restorative dentistry based in the South West hospitals:
- University Hospitals Bristol and Great Weston NHS Foundation Trust
- University Hospitals Plymouth
- Royal Cornwall Hospitals
- Torbay and South Devon Foundation Trust
- Somerset Foundation Trust
Their stabilisation is led by these teams preparing them for their cancer care. If the patients indicate they have no ‘dental home’ and have primary dental care requirements, they will be referred to specific general dental practices, referred to as cancer action support practices (CASPs), based in ICBs where the pathway is running.
Patients who do have access to a dentist are advised to attend that practice with a treatment plan to support the GDP from the specialist/consultant.
The South West are hoping to have one CASP per ICB area. The CASPs will receive a sessional rate for providing prioritised supportive care, managing the ongoing needs of the patients, along with ongoing cancer surveillance, peer review and guidance.
They retain the patients for ongoing care and prevention, for 3 years or 5 years, depending on the patient’s discharge from their medically qualified head and neck cancer consultant and ongoing requirements to support dental consultant-led oral rehabilitation.
Patients who have attended a CASP seek regular oral healthcare from the range of available providers after discharge.South West
Oral Health Practitioner (OHP) Programme: North East and North Cumbria, Yorkshire and Humber
Introduction
The programme is for qualified dental nurses to develop additional skills in line with the GDC Scope of Practice and develop skills in general health improvement, including NHS checks.
The programme aims to improve the oral and general health and wellbeing of communities across the region within primary dental services, health and social care environments and educational settings. The programme is supported by a bespoke apprenticeship.
The OHP apprentices are based within a primary care dental practice for three days, primary care network (PCN) GP practice for one day and one day study in college, allowing the apprentice to develop the skills to meet the competencies of the programme and embed the OHP role into the dental and PCN workplace.
By placing the apprentices both in dental practice and non-dental settings, it embeds the OHP role across clinical and community settings.
The model is funded for the duration of the programme, salaried on A4C band 4. As a levy paying organisation, the local education training provider contributes to the programme by drawing down the levy which funds the educational component.
Benefits of the programme
On completion of the programme the OHP will take on a role that focuses on preventative practice with the knowledge, skills, behaviours and competencies to work to the maximum of their scope of practice.
In the dental practice they will support multidisciplinary working, under the direction of a dentist, recording dental plaque and debris scores, apply fluoride varnish, take dental impressions and photographs as well as delivering preventative advice.
In the community setting they will provide integrated general and oral health advice and support to the community that the practice serves, for example alcohol consumption advice, smoking cessation interventions.
They will carry out general health screening activities, alongside oral health ones, to measure the holistic health of the individual, for example NHS health checks, including checks for diabetes, blood tests and recording blood pressure.
The aim is that a dental nurse/oral health practitioner workforce is developed, enabling them to work more autonomously and expand their scope of practice, contributing to improved patient outcomes.
Appendix 2: Examples of comprehensive oral health assessments
Recommended steps of dental assessment for children and young people (CYP) in a primary care setting upon receiving referral*
Green: Prior to clinical assessment
- Take a full medical and dental history including any previous dental experience or dental trauma
(For older children, consider establishing the use of vapes, smoking or alcohol)
- Establish caries risk status and level of co-operation
- Tailored prevention and dietary advice, considering oncology diagnosis and any medications being prescribed
(Where possible, liaise with medical team to prescribe sugar-free medications)
Amber: Clinical assessment and comprehensive care
- Comprehensive extraoral and intraoral examination
- Radiographic examination is of paramount importance in CYP prior to commencing oncology treatment
- where noted to be high caries risk, or upon visual examination of caries, consider taking bitewings (horizontal or vertical using small films where necessary) or an orthopantomogram (OPG) if the patient has first permanent molars erupted, and if deemed clinically necessary
- Where history of previous dental trauma, sensibility testing should be completed of traumatised teeth and periapical radiographs to ensure no pathology present
- Perform any necessary extractions as soon as possible in liaison with the link oncology nurse to ensure timing of extraction is in line with oncology treatment planned
- Restorations and stabilisation of teeth with caries that are deemed restorable should be completed using evidence-based dentistry, with the use of preformed metal crowns on carious primary molars where necessary
- Ensure oral hygiene is optimal prior to oncology treatment commencing:
- scaling of teeth where necessary
- the application of fissure sealants and fluoride varnish
- prescription of high fluoride toothpaste
- appropriate recall arranged based on NICE Guidance
Red: Referral if not suitable for management in a primary care setting
- If, upon assessment, patient is deemed to be uncooperative for dental treatment in a primary care setting, pathways should be established and in place, co-ordinated by the MCN chair for paediatric dentistry, to ensure dental treatment is expedited and facilitated in the right care setting (CDS or tertiary care) with no/minimal disruption to schedule of oncology care
*With thanks to Dr Urshla (Oosh) Devalia
2. Recommended steps of adult dental assessment
Adapted from UK Chemotherapy Board – MRONJ guidance (2019)
- Comprehensive extraoral and intraoral examination
- Radiographic assessment of teeth including panoramic (OPG) and long cone periapical radiographs, as clinically necessary
- Evaluation of third molars
- Identify and control any periodontal disease
- Perform any necessary extractions as soon as possible
- avoid extractions, implants and surgical procedures in patients on antiresorptive drugs
- Ensure dentures are atraumatic and comfortable
- Eliminate sharp edges of teeth or restorations
- Scaling of teeth and oral hygiene instruction
- Preventative advice and interventions as indicated by the assessment
- Arrangement of regular review of dental health
Appendix 3: Patient management matrix of oral healthcare supporting cancer care
Step 1: Diagnosis
Oncology/surgical team to provide advice, support and navigation to local oral health services.
Step 2: Pre-cancer treatment phase
Patients will progress to one of 4 services:
- General dental service (GDS)
- clinicians will assess, advise and provide appropriate care here
- low risk medication-related osteonecrosis of the jaw (MRONJ) extraction in this setting
- Community dental service (CDS)
- paediatric and adult patients who fit the relevant criteria will progress to CDS
- low risk MRONJ extraction in this setting
- Consultant
- restorative dentistry
- for head and neck (H&N) cancer only
- Oral surgery (OS)
- complex surgical care only
Treatment across these services can involve either intravenous (IV) sedation or general anaesthetic, as below:
- IV sedation
- can be carried out in GDS if service exists
- if GDS service does not exist, refer to CDS
- refer to district general hospital (DGH) if complex surgical treatment is required
- General anaesthetic
- GDS to refer to CDS or DGH, depending on provision
- CDS to conduct if service exists
- if CDS does not have access, or if surgery is required, DGH to conduct
Step 3: Cancer treatment initiation
The oncology team are to enquire on the health of a patient’s mouth on each visit and advise the patient on accessing services if any problems are reported. Providers must advise the oncology team of each patient’s oral health status.
Step 4: Cancer treatment
- GDS:
- personalised dental recall
- refer to urgent care clinical standards if problems
- clinical symptoms/signs of MRONJ
- simple extraction for compromised immune system
- CDS:
- personalised dental recall
- refer to urgent care clinical standards if problems
- clinical symptoms/signs of MRONJ
- simple extraction for compromised immune system
- H&N:
- personalised dental recall
- ongoing management/support
- refer to GDS/CDS dependent on patient for non-specialist activity
- OS:
- complex surgery
- advice/guidance re: extractions for compromised immune system
- clinical/radiographic assessment and commencement of management of MRONJ
- liaise with oncology team to relay MRONJ management plan to align with oncology management
Step 5: Cancer treatment concluded
- GDS:
- personalised dental recall
- CDS
- personalised dental recall
- review ongoing management alongside CDS criteria; if required, advise to return to GDS
- H&N
- when appropriate, return to GDS/CDS dependent on patient criteria
- OS
- usual referral criteria resume
Appendix 4: Sample communication forms
Pathway checklist
- Download a Word version of a pathway checklist.
Form 1A: referral from oncology to assessing dentist
Form 1B: key resources
- Download a Word version of Form 1B: key resources.
Form 1C: : Assessing dentist referral to specialist pathway provider
Sample Contract 1
- Download a Word version of a sample contract.