Abstract

Purpose:

Patients with head and neck cancer (HNC) should have a consultation with a dentist experienced in radiotherapy (XRT) side effects prior to the start of XRT, ideally before simulation (sim). In our institution, patients frequently had their sim and dental consultation on the same day resulting in confusion as to whether to proceed with or delay sim. Additionally, some patients who had dental extractions (DEs) after sim required a repeat sim (resim) due to a change in the resting jaw position, which subsequently delayed the start of XRT. The aim of this quality improvement (QI) initiative was to prevent unnecessary resims and delays to starting XRT for HNC patients by improving the communication between the Departments of Dentistry and Radiotherapy.

Materials and Methods:

An email communication template was developed collaboratively between the Departments of Dentistry and Radiotherapy. The template included information on: the date of planned DEs; which teeth were to be extracted; whether the DEs would cause a change to the resting jaw position; and the suggested number of days for healing. From October 2020 – October 2021, 70 HNC patients seen in consultation with Dentistry required DEs. Emails were sent by the dentist to the Clinical Specialist Radiation Therapist (CSRT) for triaging. A collaborative decision with the Radiation Oncologist (RO) was made to: delay sim or start of XRT; proceed with XRT with mandatory review of first day verification images by the RO and/or CSRT; include an oral assessment by the RO during sim; order a resim; or proceed without intervention.

Results:

Of the 70 patients triaged by the CSRT, 32 (46%) required an intervention. The HNC medical physicist evaluated the dosimetry of 7 cases where DEs were done after sim and found that only 3 showed insignificant increases to max doses when the high dose volume was adjacent to the extraction, and none had any significant dose increases to adjacent organs at risk. A decision tree was developed collaboratively with the HNC Radiation Site Group that identified 5 clinical scenarios for HNC patients who require DEs and the possible decisions required by the ROs. A change to practice was implemented in which the sim radiation therapists (RTTs) were made responsible for triaging the Dentistry team’s email communications.

Conclusions:

The new channel of communication between the two Departments allow RTTs and ROs to appropriately identify which patients need an intervention to prevent unnecessary resims or delays in starting XRT. This QI initiative also increased awareness amongst the RTTs on the impact of DEs, promoted professional autonomy, and strengthened collaborative decision making. Challenges involved the execution of the referral pathway since referrals for Dentistry and sim were sent at the same time, which increased the likelihood of DEs occurring after sim. A future QI initiative will be undertaken to improve the referral pathway.