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Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we examine the immense value of dental implants for the oral cancer patient. Joining me in this physician round table panel today is Dr. Michael Kase. He's a Maxillofacial Prosthodontist and the Assistant Director of the Advanced Education in Maxillofacial Prosthetics and Dental Oncology Fellowship. And Dr. Anthony Morlandt. He's a Head and Neck Surgeon, Head and Neck Surgical Oncology and Oral and Maxillofacial Surgery. And he's also an Associate Professor at UAB Medcine.

Doctors, I'm so glad to have you join us today. And Dr. Morlandt, I'd like to start with you. If you would set the table for us a little bit about the prevalence of oral cancer and what you're seeing in the trends.

Anthony Morlandt, MD, DDS, FACS (Guest): Well, thank you so much. I appreciate the chance to talk with you, Melanie, and provide this Med Cast for our physician and dental colleagues. Dental implants they're certainly not new. They've been around since the 1960s and 70s, when an orthopedic surgeon and researcher named Per-Ingvar Brånemark, based in Sweden, began to investigate the use of a titanium screw placed directly into bone.

And because of the unique property of titanium and that it has a very thin dioxide layer on the surface that's almost completely biocompatible, that unique property makes these implants integrate into the bone. And so similar to other orthopedic implants, they can't be unscrewed, and these are permanent fixtures.

And so because of that unique biomechanical property, these can actually be used to support the immense chewing forces that are generated during massification. And the implant itself, as many of you may be aware, involves a screw, a titanium screw that's actually threaded into the maxilla or the mandible that has to be placed to precisely because the next phase called the abutment actually comes through the soft tissue into the mouth; and is the platform for the actual dental restoration. The dental restoration is something made by a dentist or a prosthodontist, someone like Dr. Kase, with his expertise and that restoration can take the form of a porcelain or metallic or even acrylic or plastic based tooth shaped structure. It can be removable or screwed in and fixed.

And for the average patient who loses a tooth, it's truly the Cadillac or the state-of-the-art treatment in 2022. For the cancer patient, someone who's had radiation therapy, who's had major surgery, including reconstructive surgery using microvascular free flaps, dental implants are absolutely essential.

Without a dental implant, these patients cannot retain a denture. They don't have enough saliva because of dry mouth, xerostomia from radiation therapy. They don't have enough saliva to retain a denture normally. So, they're stuck using adhesives or just going without teeth. And the literature tells us that, that is a significant detriment to a patient's quality of life after suffering through oral cancer. So it's not a short answer, but dental implants are important and certainly state-of-the-art.

Host: Wow. Really fascinating information Dr. Morlandt. And Dr. Kase, how is the oral rehabilitation of a patient with oral cancer such a challenge for clinicians, as Dr. Morlandt has just gone through some of the options available. Speak a little bit about some of the challenges, and you can even speak about the optimal timing of this implant placement regarding survival rates and the oral cancer patient.

Michael Kase, DMD (Guest): Well, the challenge is associated with any implant prosthesis with one of these cancer patients is, very difficult to manage. There's things such as the xerostomia, the lack of saliva, the inability to open the mouth, the trismus, things like that, which just inhibit my access to get into these implants.

And once I'm able to access the implants, then we have to worry about things such as how the tissue is going to behave after these large procedures that Dr. Morlandt or Dr. Yang do, where they are essentially transforming the entire jaw with a different bone from a different part of the body.

So, the tissue essentially doesn't know how to react. It overreacts. And then we're left trying to manage this tissue to get it to a point where it's predictable and we can move forward and make some sort of prosthesis, whether it's fixed or removable. And varying other options that we have sometimes that involves tissue splints, or tissue conditioning, stuff like that, splints that get screwed down, splints that the patient can take out, anything to manage that area, to give us enough space where we can make the eventual prosthesis.

As far as failure rates, that's where we run into things related a lot to potential for radiation therapy and the osteoradionecrosis, which may occur. So, generally we like to place these implants before any radiation occurs. So, optimal timeline would be at the time of surgery, of course, but sometimes that can't be done.

So we got to try and get it in before the radiation begins or we got to plan it very, very, very carefully, so we don't end up in tissue that has been radiated. But there is slew of problems and challenges that come with all these patients. But as a team, we work together, overcome them and, give the patient prosthetics that help them function and have a much improved quality of life.

Dr. Morlandt: I'd also like to add to what Dr. Kase said. The ideal time to place these implants, however, is not after the radiation. And so what a lot of major academic centers struggle with, is when the patient comes in and has their initial surgery, let's say to remove cancer of the tongue or cancer of the upper or lower jaw, that patient may have reconstructive surgery, but then go on to receive radiation without ever having their dental implants placed.

And unfortunately that then renders that patient essentially unable to ever receive a prosthetic. And unable to ever have proper oral function and that impacts nutrition and it impacts their psychosocial performance and their quality of life. And so what we've really tried to do at UAB is with a fantastic team in MSO, a fantastic team in our billing and compliance office, is work with the dental insurance carriers and even medical insurance carriers before the patient ever has their major cancer surgery.

And that way we can place the implants the same day as they're having their major oral surgery, before they've ever received radiation. So dramatically lowers the risk of implant failure, and it makes that patient wake up from their operation feeling whole and that hasn't been done in the past. And we're seeing that there is quite a bit of benefit just changing that order, making those initial extra steps happen.

Host: Dr. Morlandt, can you speak a little bit about patient selection? And how, or when you might use each of these options that you've mentioned today? Are you working with the patient and we've talked about your multidisciplinary team, and we're going to talk about that a little bit more coming up, but can you speak a little bit about patient selection for these?

Dr. Morlandt: Every patient who comes to UAB with a new diagnosis of oral cancer should be seen by a dentist. Many of them do come from an existing general dentist and maybe an oral maxillofacial surgeon or an ear nose and throat surgeon performs the biopsy. But regardless of how they come to us, they need to be managed by a general dentist.

So, by collaborating with that general dentist, we can understand if they've been a patient with good long-term compliance. If these are patients who only go to the dentist once in a great while when they have pain or infection, these may not be ones who can tolerate a complex elegant state-of-the-art implant-based restorative plan.

So, the greatest contributor to success for some of the things we can offer, is maintenance and oral hygiene and having good follow-up from a local general dentist. So, that probably is the greatest factor in patient selection. And then we have some patients who we really are looking for them to have realistic expectations after a devastating injury.

Even if it's a surgically created injury or radiation induced injury, both necessary to treat their cancer. After an injury like this, they need to understand that there will be permanent changes to speech and chewing and swallowing. There may be permanent limitations in mouth opening, and though we can overcome a lot of that; we want to have a patient who understands these are all attempts to make them whole, but never will be quite the same as their pre-surgical state. And so there's a good bit of psychology. There's a good bit of just managing expectations before we ever take that patient to surgery. And think that's really important.

Dr. Kase: Yes, I would like to echo what Dr. Morlandt just said is that's probably one of the single most important things we need to worry about with these patients. Selection is definitely management of expectations. Just a simple number to throw out there is for a non oncologic patient that's just getting your standard complete dentures, I always have the conversation with them to say, you know, all of your teeth are no longer there. So, your chewing function is going to be inhibited. And I try and explain that even with the best fitting dentures, you're only going to get about 60 to 70% chewing efficacy as you would with your normal teeth. So, you can imagine that these patients that undergo so much surgery, so much radiation, or chemotherapy, all the comorbidities they have along with it; the problems that are inherent to a prosthetic with them is going to be pretty great. So, as long as you manage their expectations, you can kind of tailor the appropriate treatment to them, and the echo is his first comment about managing the tissues with the general dentist, that also plays a huge role in how we decide things. Because if you make a really large restoration on a patient's lower jaw after a fibula free flap reconstruction and all this tissue change and management and they can't clean underneath it; well, there's really no point in having done that because it's probably going to end up with it poor results. So, in that case, we probably want to move to something that's more removable that allows the patient to clean things a lot better.

Dr. Morlandt: Mike, let me ask you a question. Have you noticed in your experience that regardless of someone's background, they come in with the expectation, with the knowledge, the understanding that implants are available. What I've noticed in the past 10 years of doing this is, patients now expect to have dental implants. They know they're available, they know they're state-of-the-art and they find ways to make it happen. It's a little different than what it used to be. People would come in and say, geez, I'm just happy to survive this oral cancer. Please help me. But now I think people are living longer. We have proton therapy. We have immunotherapy, we have all of these outstanding adjuvant treatment modalities. And patients want the best. When they come to UAB, we can offer that. I'm happy and proud of our work to be able to do that.

Dr. Kase: I agree. I think that's definitely a part what makes UAB so special is that we have this team that has made these dental and osseous implants a part of our protocol that patients do come here and they expect that they can get that. Whereas we see patients come in from outside institutions that don't have a team such as ours and they had no idea it was even a possibility. So, it's a good thing in that implants are becoming more available and more widespread known, but it's also a very good thing that UAB is leading the way and making that an option for even these oncologic patients.

Host: Well, it certainly shows the benefits of your comprehensive care model and the ability to cut down time from pre-op to getting that prosthesis and from there on treatment. So, I'd like to give you each a chance for a final thought and Dr. Kase, I'd like to just start with you here. The elements that make up your team, because as we're really finding more involvement of multiple sub-specialists and the utilization of this multidisciplinary team; how ideal has this been for managing these complex patients and given the complexity and with these treatment algorithms, more options in your armamentarium? Can you speak about who's in charge of guiding patient care and really a little bit about why this multidisciplinary approach is so ideal for these patients?

Dr. Kase: Certainly. Well, the simple word would be time. Having this multidisciplinary approach with Dr. Morlandt and Dr. Yang and myself as three main practitioners, it allows us to all see the patient at once, on the same day. We essentially can develop a treatment plan right there, and we can get the balls rolling right away rather than the patient needing to come back or go to a different site or even a different institution. So, having two microvascular head and neck surgeons and a maxillofacial prosthodontist, as the practitioner, all being able to see the patient at once is a huge, huge plus the patient. And then, just because we're the practitioners, it doesn't mean we don't have amazing members of our team that do so much, like our PAs, the nursing staff, even the residents and fellows that we have. They all contribute so much and really help us push the boundaries, allowing for technology to come into play. So, that even speeds things up even more, whereas a patient that comes in that ultimately needs a segmental mandibulectomy and a fibula free flap reconstruction, from the time they come in, until the time they would get teeth, historically, it would take close to a year and a half. In some cases we could do it in about six months. So, this multidisciplinary approach really cuts down on time. And I think that's probably the optimal benefit for these patients, as well as getting them the best function and aesthetic outcome as possible.

Host: Dr. Morlandt, last word to you, as we're speaking about the immense value, as you've spoken about today, both of you, of dental implants for the oral cancer patient. I'd like you to speak to other providers about first of all, when you feel it's important they refer to the incredible specialists at UAB Medicine and how it really can help their patients with the overall outcome of the patient experience, improved retention, adherence, compliance, psychosocial, confidence. I mean, there is a lot, this is a complex issue. Can you wrap it up for us with really your final thoughts on this topic?

Dr. Morlandt: It's important to remember, I think Melanie, that oral cancer is too complex for any one type of doctor to manage. And that's true for almost every type of cancer, breast, colorectal, lung, in most cases we're using the team approach. We are very blessed in Alabama to have extremely strong and well-trained community-based practitioners. And we work with all of them. We work with general dentists, oral surgeons, ear, nose, and throat, radiation oncology, medical oncology, speech pathology, that the entire gamut.

So, one thing we offer is certainly for the surgical aspect of the care, when the patient comes to us, we can have that patient mentally and psychologically ready for the next phase in their cancer treatment, which for head and neck, cause usually radiation therapy. And in some cases, chemotherapy or immunotherapy, we can have that patient ready for the next phase when they leave UAB. The challenge that this is really a marathon event for most people who aren't having care at a major medical center like ours, at least in the surgical and dental arenas. They are going from office to office and having months and months of treatment.

And it's exhausting. It's psychologically exhausting and it's financially taxing for the patient to be sort of stretched out. And so what we've tried to do is compress that treatment plan into a very efficient, very well-run operated system that then allows the patient to get on with their treatment and get on with survival.

I think that's what we offer. It's an exciting time. And of course, we're very fortunate to have all of the 3D-based planning and surgical navigation and technology here at the institution. We've been very well supported by the institution to put all of these things in place in the clinic and the operating room, on the floor, for our inpatients. So we're fortunate to be able to offer that to our, community-based providers.

Host: Well, you certainly are. And thank you both so much for sharing your incredible expertise and experience. And I hope that you'll come back on because we didn't even get into the technology involved. And as you said, this is such an exciting time to be in your field and the technology is advancing ever rapidly.

Come back on and let's speak about some of that. And thank you again for joining us. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. Or by visiting our website at uabmedicine.org/physician. That concludes this episode of the UAB Med Cast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.