Participation of Canadian Oral and Maxillofacial Surgeons in Oral, Lip, and Oropharyngeal Cancer Care



Participation of Canadian Oral and Maxillofacial Surgeons in Oral, Lip, and Oropharyngeal Cancer Care




Journal of Oral and Maxillofacial Surgery, 2015-12-01, Volume 73, Issue 12, Pages 2440-2445, Copyright © 2015 American Association of Oral and Maxillofacial Surgeons


Purpose

The purpose of this study was to assess the participation of Canadian oral and maxillofacial surgeons (OMSs) in the various phases of oral, lip, and oropharyngeal cancer care.

Materials and Methods

A survey was conducted to quantify participation in oral, lip, and oropharyngeal cancer care and assess participation ranging from screening for malignancy to active treatment and rehabilitation of those with late-stage disease.

Results

Three hundred ninety-one surgeons were contacted and 206 (52.7%) responded to the online survey. The survey showed 98.1% of respondents were involved with cancer screening and 97.1% were involved in prevention and early intervention (monitoring and treatment) of premalignant lesions. In addition, 95.1% of respondents participated in diagnosis and staging of tumors. Early-stage cancer was managed surgically by 49.5% of respondents, whereas 11.2% of respondents managed late-stage disease. Management of oral rehabilitation was performed by 79.0% of respondents.

Conclusion

OMSs are an integral part of all phases of oral and oropharyngeal cancer care, including primary surgical oncology, in Canada. Although OMSs in Canada participate widely in integral prevention and survivor rehabilitation programs, few members participate in late-stage disease management and regional multidisciplinary care teams.

Oral, lip, and oropharyngeal cancers encompass up to 75% of all head and neck cancers, accounting for 2% of all cancers in women and 4% in men. In Canada, it is estimated that 4,000 people were diagnosed with oral cancer in 2012. With an incidence of 12 in 100,000, oral cancer is the seventh most common cancer in Canadian men, with a lifetime probability of developing oral cancer of 1 in 66. Globally, oral and pharyngeal cancer is a greater burden than in North America. Incidence rates are as high as 42 in 100,000 in southeast Asia. Outcomes for patients with oral and oropharyngeal cancer are largely dependent on early detection and stage at diagnosis of disease. Early-stage lesions that require less invasive surgical procedures and potentially no medical therapy have a higher survival rate, less morbidity, and better quality-of-life outcomes. Five-year survival rates for early (stage 1 and 2) oral and oropharyngeal cancer range from 60 to 80%, whereas late-stage (stage 3 and 4) cancers have a 20 to 50% 5-year survival. Two-year survival in stage 1 upper aerodigestive tract cancer (including oral, lip, and oropharyngeal cancer) is approximately 90% versus 50% for 2-year survival for stage 4 cancer of the same sites. Despite the importance of early detection, only 14% of adults in the United States have reported having an oral cavity examination at any point during their life and only 7% within the past year. Although this percentage might be larger in some areas of the world, it highlights the lack of surveillance present in an industrialized country.

Dentists in Canada are the primary point of care for oral cavity examination and screening. Common dental visits, such as those for the treatment of caries, periodontal maintenance, recall visits, and prosthodontic reconstruction (ie, visits excluding specific examinations for symptoms of neoplasia and cancer), provide an opportunity to perform oral cancer screening alongside other investigations. General dental practitioners (not primary care physicians) are the most likely primary care providers to identify early-stage malignancies incidentally while performing history and physical examination of the oral and maxillofacial complex. The frequency of routine examination of the mouth and jaws and the larger amount of time devoted to oral and maxillofacial pathology in North American dental training compared with medical training likely account for dentists' increased detection of early-stage oral and oropharyngeal cancer compared with primary care physicians.

Cancer care as a whole is not limited to primary oncologic surgery. Education about the risk factors for cancer, disease prevention through risk factor modification, and appropriate screening play important roles in minimizing the impact of these cancers. After identification of a suspicious lesion, diagnosis and staging using tissue biopsies and appropriate imaging are important steps to characterize the lesion, ultimately directing definitive management of the disease. Survivorship programs and the management of common morbidities and complications affecting the oral cavity that subsequently influence quality of life after treatment of lip, oral, and oropharyngeal cancer are critical. These morbidities are listed in Table 1 .

Table 1
Common Morbidities and Complications Affecting the Oral Cavity That Subsequently Influence Quality of Life After Treatment of Lip, Oral, and Oropharyngeal Cancer
Pain Ingestion Voice and Speech Psychosocial
Odontogenic—caries Decreased masticatory ability Loss of anterior dentition required for ideal speech Diminished self-confidence
Odontogenic—pulpal Poor diet quality Oral antral or nasal fistulae, velopharyngeal insufficiency Poor dental cosmetic outcomes, eg,- loss of lip and smile esthetics
Odontogenic—periapical and space infection Dysphagia Poor soft tissue support or position Poor maxillofacial cosmetic outcomes, eg, poor position of jaws and subsequent facial asymmetries
Osteoradionecrosis Dysgeusia Limited prosthesis feasibility Loss of enjoyment of food
Xerostomia or mucositis Trismus Poor prosthetic function Mood disorders
Odynophagia Fibrosis Poor intelligibility

Canadian health policy is set by regional or provincial advisory committees, resulting in discrepancies in policy outlining which health care providers comprise treatment teams across the country. Oral and maxillofacial surgeons (OMSs) are involved in all of these forms of oral, lip and oropharyngeal cancer care, but are not currently involved as primary oncologic surgeons in tertiary care multidisciplinary head and neck cancer teams in all provinces in Canada. Multiple fellowship-trained head and neck surgeons with OM surgery as their core surgical specialty are currently facing obstacles obtaining privileges to perform the full scope of head and neck cancer care. As a result of this lack of involvement of OMSs as primary oncologic surgeons, there can be a disconnect between the dental and medical professions in the diagnosis and surgical management of patients with oral and oropharyngeal cancer. Multiple visits to uninvolved general medical and dental practitioners and specialists can lead to delays in definitive treatment. Delays in time from identification of the suspected cancer to definitive treatment result in poorer patient outcomes. Because the most important prognostic factor in oral and oropharyngeal cancer is the stage at diagnosis, initiating treatment as soon as possible is essential to improve outcomes. In addition, a lack of true multidisciplinary approach could result in a surgical reconstruction not reflecting feasible prosthodontic and oral prosthetic rehabilitation plans, thus contributing to a lower quality of life for the patient after treatment.

Despite the lack of OMSs on some regional multidisciplinary head and neck cancer teams, OMSs provide many phases of oral and oropharyngeal cancer care on a routine basis across Canada. OMSs are trained in and involved with the rehabilitation of these complex patients. To quantify the participation of Canadian OMSs in oral, lip, and oropharyngeal cancer care, a survey was conducted identifying participation at various phases of care.


Materials and Methods


Survey Design

Six questions were developed to evaluate the participation of OMSs in head and neck cancer care, specifically the participation in management of oral, lip, and oropharyngeal cancer. Six phases in cancer care spanning screening, prevention, and education to early intervention, premalignant lesion management, and surgical oncologic management to post-treatment rehabilitation were identified in the survey's design. The specific detailed questions are presented in Table 2 . The response to each question was yes or no, indicating an OMS's involvement in the various phases of cancer care.

Table 2
Questions 1 to 6 Were Emailed to Canadian Oral and Maxillofacial Surgeons to Quantify Participation at Various Phases of Lip, Oral, and Oropharyngeal Cancer Care
1 I am involved in at least 1 of the following screening methods (examining oral cavity for lesions, palpating for lymph nodes, use of ancillary screening tools, ie, VELscope, Invisilight) Yes or no
2 I am involved in prevention and early intervention in at least 1 of the following ways (risk factor management; education on impacts of smoking, alcohol, human papillomavirus, etc; identification or treatment of premalignant lesions such as leukoplakias) Yes or no
3 I am involved in diagnostics and staging through at least 1 of the following modalities (biopsy examination, computed tomography, magnetic resonance imaging, etc) Yes or no
4 I am involved in primary surgical management of stage 1 or 2 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are <2 cm and do not involve the lymph nodes or bone or 2-4 cm not involving lymph nodes or bone) Yes or no
5 I am involved in primary surgical management of late stage 3 or 4 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are of any size involving the lymph nodes and bone or >4 cm) Yes or no
6 I am involved in any or all of the following forms of rehabilitation (mastication, preprosthetic surgery, vestibuloplasties, dental implants, prosthetics, management of trismus [mouth opening], speech, or swallowing) Yes or no


Survey Implementation

OMS registration information with the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) was used to identify OMSs licensed to practice in Canada. In addition, regional OMS registration lists were used to contact nonmember OMSs. Three hundred ninety-one surgeons were identified and contacted electronically by the authors in conjunction with the CAOMS Maxillofacial Oncology and Reconstructive Surgery clinical interest group. Second and third reminder emails were sent 1 and 2 weeks after the initial notification. The survey was closed 1 month after initial contact. No financial incentive was used to encourage participation.


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Participation of Canadian Oral and Maxillofacial Surgeons in Oral, Lip, and Oropharyngeal Cancer Care Karl K. Cuddy BSc, DDS, MD , Wendall Mascarenhas DDS and Graham Cobb BSc, DDS, MD, MSc Journal of Oral and Maxillofacial Surgery, 2015-12-01, Volume 73, Issue 12, Pages 2440-2445, Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Purpose The purpose of this study was to assess the participation of Canadian oral and maxillofacial surgeons (OMSs) in the various phases of oral, lip, and oropharyngeal cancer care. Materials and Methods A survey was conducted to quantify participation in oral, lip, and oropharyngeal cancer care and assess participation ranging from screening for malignancy to active treatment and rehabilitation of those with late-stage disease. Results Three hundred ninety-one surgeons were contacted and 206 (52.7%) responded to the online survey. The survey showed 98.1% of respondents were involved with cancer screening and 97.1% were involved in prevention and early intervention (monitoring and treatment) of premalignant lesions. In addition, 95.1% of respondents participated in diagnosis and staging of tumors. Early-stage cancer was managed surgically by 49.5% of respondents, whereas 11.2% of respondents managed late-stage disease. Management of oral rehabilitation was performed by 79.0% of respondents. Conclusion OMSs are an integral part of all phases of oral and oropharyngeal cancer care, including primary surgical oncology, in Canada. Although OMSs in Canada participate widely in integral prevention and survivor rehabilitation programs, few members participate in late-stage disease management and regional multidisciplinary care teams. Oral, lip, and oropharyngeal cancers encompass up to 75% of all head and neck cancers, accounting for 2% of all cancers in women and 4% in men. In Canada, it is estimated that 4,000 people were diagnosed with oral cancer in 2012. With an incidence of 12 in 100,000, oral cancer is the seventh most common cancer in Canadian men, with a lifetime probability of developing oral cancer of 1 in 66. Globally, oral and pharyngeal cancer is a greater burden than in North America. Incidence rates are as high as 42 in 100,000 in southeast Asia. Outcomes for patients with oral and oropharyngeal cancer are largely dependent on early detection and stage at diagnosis of disease. Early-stage lesions that require less invasive surgical procedures and potentially no medical therapy have a higher survival rate, less morbidity, and better quality-of-life outcomes. Five-year survival rates for early (stage 1 and 2) oral and oropharyngeal cancer range from 60 to 80%, whereas late-stage (stage 3 and 4) cancers have a 20 to 50% 5-year survival. Two-year survival in stage 1 upper aerodigestive tract cancer (including oral, lip, and oropharyngeal cancer) is approximately 90% versus 50% for 2-year survival for stage 4 cancer of the same sites. Despite the importance of early detection, only 14% of adults in the United States have reported having an oral cavity examination at any point during their life and only 7% within the past year. Although this percentage might be larger in some areas of the world, it highlights the lack of surveillance present in an industrialized country. Dentists in Canada are the primary point of care for oral cavity examination and screening. Common dental visits, such as those for the treatment of caries, periodontal maintenance, recall visits, and prosthodontic reconstruction (ie, visits excluding specific examinations for symptoms of neoplasia and cancer), provide an opportunity to perform oral cancer screening alongside other investigations. General dental practitioners (not primary care physicians) are the most likely primary care providers to identify early-stage malignancies incidentally while performing history and physical examination of the oral and maxillofacial complex. The frequency of routine examination of the mouth and jaws and the larger amount of time devoted to oral and maxillofacial pathology in North American dental training compared with medical training likely account for dentists' increased detection of early-stage oral and oropharyngeal cancer compared with primary care physicians. Cancer care as a whole is not limited to primary oncologic surgery. Education about the risk factors for cancer, disease prevention through risk factor modification, and appropriate screening play important roles in minimizing the impact of these cancers. After identification of a suspicious lesion, diagnosis and staging using tissue biopsies and appropriate imaging are important steps to characterize the lesion, ultimately directing definitive management of the disease. Survivorship programs and the management of common morbidities and complications affecting the oral cavity that subsequently influence quality of life after treatment of lip, oral, and oropharyngeal cancer are critical. These morbidities are listed in Table 1 . Table 1 Common Morbidities and Complications Affecting the Oral Cavity That Subsequently Influence Quality of Life After Treatment of Lip, Oral, and Oropharyngeal Cancer Pain Ingestion Voice and Speech Psychosocial Odontogenic—caries Decreased masticatory ability Loss of anterior dentition required for ideal speech Diminished self-confidence Odontogenic—pulpal Poor diet quality Oral antral or nasal fistulae, velopharyngeal insufficiency Poor dental cosmetic outcomes, eg,- loss of lip and smile esthetics Odontogenic—periapical and space infection Dysphagia Poor soft tissue support or position Poor maxillofacial cosmetic outcomes, eg, poor position of jaws and subsequent facial asymmetries Osteoradionecrosis Dysgeusia Limited prosthesis feasibility Loss of enjoyment of food Xerostomia or mucositis Trismus Poor prosthetic function Mood disorders Odynophagia Fibrosis Poor intelligibility Canadian health policy is set by regional or provincial advisory committees, resulting in discrepancies in policy outlining which health care providers comprise treatment teams across the country. Oral and maxillofacial surgeons (OMSs) are involved in all of these forms of oral, lip and oropharyngeal cancer care, but are not currently involved as primary oncologic surgeons in tertiary care multidisciplinary head and neck cancer teams in all provinces in Canada. Multiple fellowship-trained head and neck surgeons with OM surgery as their core surgical specialty are currently facing obstacles obtaining privileges to perform the full scope of head and neck cancer care. As a result of this lack of involvement of OMSs as primary oncologic surgeons, there can be a disconnect between the dental and medical professions in the diagnosis and surgical management of patients with oral and oropharyngeal cancer. Multiple visits to uninvolved general medical and dental practitioners and specialists can lead to delays in definitive treatment. Delays in time from identification of the suspected cancer to definitive treatment result in poorer patient outcomes. Because the most important prognostic factor in oral and oropharyngeal cancer is the stage at diagnosis, initiating treatment as soon as possible is essential to improve outcomes. In addition, a lack of true multidisciplinary approach could result in a surgical reconstruction not reflecting feasible prosthodontic and oral prosthetic rehabilitation plans, thus contributing to a lower quality of life for the patient after treatment. Despite the lack of OMSs on some regional multidisciplinary head and neck cancer teams, OMSs provide many phases of oral and oropharyngeal cancer care on a routine basis across Canada. OMSs are trained in and involved with the rehabilitation of these complex patients. To quantify the participation of Canadian OMSs in oral, lip, and oropharyngeal cancer care, a survey was conducted identifying participation at various phases of care. Materials and Methods Survey Design Six questions were developed to evaluate the participation of OMSs in head and neck cancer care, specifically the participation in management of oral, lip, and oropharyngeal cancer. Six phases in cancer care spanning screening, prevention, and education to early intervention, premalignant lesion management, and surgical oncologic management to post-treatment rehabilitation were identified in the survey's design. The specific detailed questions are presented in Table 2 . The response to each question was yes or no, indicating an OMS's involvement in the various phases of cancer care. Table 2 Questions 1 to 6 Were Emailed to Canadian Oral and Maxillofacial Surgeons to Quantify Participation at Various Phases of Lip, Oral, and Oropharyngeal Cancer Care 1 I am involved in at least 1 of the following screening methods (examining oral cavity for lesions, palpating for lymph nodes, use of ancillary screening tools, ie, VELscope, Invisilight) Yes or no 2 I am involved in prevention and early intervention in at least 1 of the following ways (risk factor management; education on impacts of smoking, alcohol, human papillomavirus, etc; identification or treatment of premalignant lesions such as leukoplakias) Yes or no 3 I am involved in diagnostics and staging through at least 1 of the following modalities (biopsy examination, computed tomography, magnetic resonance imaging, etc) Yes or no 4 I am involved in primary surgical management of stage 1 or 2 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are <2 cm and do not involve the lymph nodes or bone or 2-4 cm not involving lymph nodes or bone) Yes or no 5 I am involved in primary surgical management of late stage 3 or 4 cancers of the lip or oral cavity or oropharynx (ie, of cancers that are of any size involving the lymph nodes and bone or >4 cm) Yes or no 6 I am involved in any or all of the following forms of rehabilitation (mastication, preprosthetic surgery, vestibuloplasties, dental implants, prosthetics, management of trismus [mouth opening], speech, or swallowing) Yes or no Survey Implementation OMS registration information with the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS) was used to identify OMSs licensed to practice in Canada. In addition, regional OMS registration lists were used to contact nonmember OMSs. Three hundred ninety-one surgeons were identified and contacted electronically by the authors in conjunction with the CAOMS Maxillofacial Oncology and Reconstructive Surgery clinical interest group. Second and third reminder emails were sent 1 and 2 weeks after the initial notification. The survey was closed 1 month after initial contact. No financial incentive was used to encourage participation. Results Of the 391 OMSs contacted, 206 responded to the online survey, resulting in a 52.7% response rate. Canadian OMSs provide patient care in all phases of oral, lip, and oropharyngeal cancer care ( Fig 1 ), including primary oncologic surgery for malignant disease. In addition, 98.1% of respondents are involved with cancer screening as assessed through question 1 ( Table 2 ), and 97.1% are involved in early intervention, prevention of cancer, and management of precancerous lesions as assessed through question 2 ( Table 2 ), including education about the risks of smoking, tobacco use, and the benefits of smoking cessation, the risks of alcohol, human papillomavirus (HPV), and identification, monitoring, and treatment of premalignant lesions. Diagnosis and staging of cancer (question 3, Table 2 ) is performed by 95.1% of OMSs. Primary surgical treatment of oral, lip, and oropharyngeal cancer was divided into early-stage (stage 1 and 2 oral, lip and oropharyngeal cancer; question 4, Table 2 ) and late-stage (stage 3 and 4 oral, lip, and oropharyngeal cancer; question 5, Table 2 ) disease management. Early-stage oral, lip, and oropharyngeal cancer is managed by 49.5% of OMSs, whereas 11.2% of OMSs manage late-stage disease. Management of rehabilitation is performed by 79.0% of respondents as assessed by question 6 ( Table 2 ). Figure 1 Involvement (percentage of respondents involved) of Canadian oral and maxillofacial surgeons in 6 phases of lip, oral, and oropharyngeal cancer care. Discussion OMSs are actively involved in the treatment and overall management of patients with head and neck cancer. Nearly all Canadian OMSs (98.1%) indicate participation in screening. Owing to a lack of specificity, screening tests for oral cavity cancer using adjunctive aids, such as brush biopsy and the VELscope, are not publically funded for routine oral and oropharyngeal cavity screening for oral cancer. Despite the lack of support for universal routine oral cancer screening examinations, thorough examination of the oral cavity should be carried out while treating or examining patients for other diseases, such as caries and periodontal disease, because it detects earlier-stage tumour. Prevention, early intervention, and treatment of premalignant lesions is carried out by 97.1% of respondents. The relative abundance of respondents indicating primary surgical management of early-stage (49.5%) and late-stage (11.2%) oral and oropharyngeal cancer was expected. Traditionally in Canada, post-residency fellowship training for head and neck cancer surgery has been available to otolaryngologists and plastic surgeons. The corresponding author completed his DDS, MD, and MSc degrees and OM surgical training at a Canadian university center. Subsequently, post-residency fellowship training in maxillofacial oncologic and microvascular reconstructive surgery was carried out in the United States and Germany. Similar to colleagues in otolaryngology and plastic surgery, appropriate fellowship training is available to Canadian OM surgical residents. With the recent increase of post-residency fellowships for OMSs in head and neck cancer in North America, the authors expect to see an increase in the number of OMSs treating these diseases in Canada. The lack of widely available operating room time in a tertiary care center, fiscal constraints on public health care, and few fellowship-trained OMSs likely account for the small number of OMSs treating late-stage cancer in Canada. In the United States, 25% of residency training programs feature oncologic surgery with microvascular reconstruction as part of the core surgical curriculum. A medical degree is often required to complete post-residency fellowship training in maxillofacial oncologic and reconstructive surgery in North America and western Europe. Currently, 62% of residents entering Canadian OM surgical training programs complete their MD and surgical training. Maxillofacial oncology and reconstructive surgery fellowship training is occurring at 1 Canadian academic center (McGill University) and faculty with fellowship training in maxillofacial oncology and reconstructive surgery are present at some Canadian OM surgical training programs. As a result, more graduates from North American OM surgical programs are gaining considerable experience in the comprehensive management of patients with head and neck cancer. As a result of the increased incidence of tongue, tonsillar, and HPV-related oropharyngeal cancer in young patients, there is the need for vigilant prevention and subsequent management of the potential complications of disease because survivors of this disease will have a long time to live with the results of their reconstruction and complications of disease. In addition to the increased incidence of young patients developing oropharyngeal cancer, incidence rates of lip cancer in the Canadian population are among the highest in the world. With this increased exposure in the United States and a similar recent increase in exposure to maxillofacial oncologic surgery in Canadian OM surgical programs, it is conceivable that the number of Canadian OMSs providing definitive surgical management for oral, lip, and oropharyngeal cancer will increase, and the background training involving knowledge about comprehensive oral and dental rehabilitation can be maximized to minimize the loss of oral function in these patients. To do so most effectively, the presence of OMSs on true tertiary care multidisciplinary head and neck cancer teams in all Canadian provinces is required to align these head and neck cancer teams with those seen in other industrialized countries, such as the United States, the United Kingdom, Australia, and Germany, where OMSs are among the core primary oncologic surgeons working in conjunction with all other allied professionals, including other surgeons, in the management of these complex patients. Despite appropriate training, OMSs in Canada have faced resistance from many regional cancer centers when attempting to join multidisciplinary head and neck surgery teams as primary ablative and reconstructive oncologic surgeons. The resistance faced by Canadian OMSs in some regions is likely multifactorial in origin and can be attributed in part to the fact that historically in Canada OMSs have not established relationships with medical and radiation oncologists as primary oncologic surgeons owing to a lack of interest or appropriate training in this discipline of care. Other factors hindering the ability of OMS to establish a role as oncologic and reconstructive surgeons at Canadian cancer centers include provincial guidelines (in some provinces created without the input of OMSs) advising which background of surgeons (ie, otolaryngology, plastic surgery) is appropriate to provide oncologic surgery or that practitioners already established as head and neck surgeons wish to keep all surgery at a regional center within their respective surgical specialty. On a national level, the most important role of OMSs or any practitioner involved in head and neck oncologic care is the detection and early identification of premalignant lesions and malignancy. OMSs can fill 2 distinctly separate roles on a tertiary care multidisciplinary team. An OMS can act as an adjunctive surgeon providing oral rehabilitation consisting of preprosthetic and dental implant surgery and management of complications. Alternatively, or in addition to these services, an OMS can operate as a primary oncologic and reconstructive surgeon. Contemporary management of head and neck cancer typically involves a multidisciplinary approach involving radiation oncology, medical oncology, surgical oncology, diagnostic pathology, dentistry, prosthodontics, speech pathology, physiotherapy, social work, nursing, and dietary support. Surgical management of more extensive lesions (stages 3 and 4) often results in large ablative defects requiring more advanced reconstructive techniques (ie, microvascular free tissue transfer), cervical lymphadenectomy, and intensive medical support. As a result, these patients are unlikely to be cared for outside a tertiary care center. The surgical training required to treat these cancers should include extensive experience (post-residency fellowship training) in major head and neck surgery, including cervical lymphadenectomy, and major maxillofacial reconstructive techniques, which are not part of the core residency training in all programs in North America. Post-cancer rehabilitation, including preprosthetic surgery, management of trismus, rehabilitation of speech, swallowing, and management of masticatory deficiencies including placement of dental implants, is currently performed by 79.0% of OMSs in Canada. Although this is being performed by a large number of OMSs, these surgical services are being completed on and being offered to few patients with head and neck cancer in Canada. Historically, funding has limited access to dental implant and prosthodontic reconstruction by some patients with head and neck cancer in Canada because this has not been covered as part of the universal health care (funded by the government) in all provinces. Funding for such rehabilitation is currently in the process of obtaining regional approval in some provinces and has been implemented in other provinces to help patients achieve a better quality of life through comprehensive oral rehabilitation involving dental implants and prosthodontics. Nonetheless, funding was not available in all provinces at the time of submission of this report. Prosthodontic rehabilitation consisting of an implant-supported prosthesis results in superior function and higher quality of life than non-rehabilitated mouths. The success of dental implant placement in irradiated patients treated for head and neck cancer is 90% at 3 years. Because it has such an impact on quality of life, this rehabilitation service should be offered as a public service to all survivors of head and neck cancer. After an internal chart audit, the authors found that the rate of definitive oral cavity rehabilitation at Canadian institutions is lower than 5%. Other centers where OMSs are involved on regional tumor boards and where public funding is available to cover costs have up to 49% of patients with oral cancer receiving implant-supported prosthodontics for successful rehabilitation. The authors suspect that these decreased rates of definitive prosthodontic rehabilitation is representative of other sites in Canada and is in need of improvement. Although not as specific as this survey investigating specific roles in treatment phases of oral, lip, and oropharyngeal cancer, an elective national audit of OMS consultant members of the British Association of Oral and Maxillofacial Surgeons (BAOMS) showed that 50% of respondents in the United Kingdom engage in treatment of head and neck cancer, a figure similar to the proportion of Canadian OMSs (49.5%) managing stage 1 and 2 oral, lip, and oropharyngeal cancer. The authors believe that the proportion of BAOMS members managing stage 3 and 4 oral, lip, and oropharyngeal cancer is higher than the 11.2% noted in the present survey as a result of the inclusion of British OMSs on multidisciplinary head and neck cancer teams at multiple sites in the country. The authors were unable to locate demographic statistics indicating the percentage of otolaryngologists and plastic and general surgeons managing head and neck cancer in European or North American practice. As members of the medical and dental communities, OMSs have the opportunity to play an important role in improving the outcomes of oral and oropharyngeal cancer care through early identification, prevention, screening, and diagnosis using the close relationships with primary care dental and medical practitioners. The vast majority of OMSs are actively involved in these phases of care; however, room exists for an increase in the number of OMSs involved in the management of patients after oncologic surgery, radiotherapy, and chemotherapy. In Canada, there is an important need to establish multidisciplinary head and neck cancer teams in all provinces with tertiary care OM surgical departments featuring appropriately trained OM surgical oncologists and OMSs interested in maxillofacial rehabilitation. The unique background (medicine and dentistry) of OMSs with extensive experience in maxillofacial oncology and reconstructive surgery would help improve the education of future dentists and physicians about their role in the management of oral, lip, and oropharyngeal cancer and the benefits of early detection through routine dental screenings. In addition, inclusion of OMSs as primary members of multidisciplinary teams will likely increase the number of patients who proceed to post-treatment rehabilitation, thus increasing quality of life for these patients. Acknowledgments The authors thank the CAOMS Executive and Administration for their support and help conducting this survey. References 1. Werning J.W.: Oral Cancer: Diagnosis, Management and Rehabilitation.2007.Thieme Medical PublishersNew York, NYpp. 1-7. 2. 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Scottish Intercollegiate Guidelines Network (SIGN): Diagnosis and Management of Head and Neck Cancer: A National Clinical Guideline.2006.SIGNEdinburgh, UK 19. Teoh K.H., Patel S., Hwang F., et. al.: Prosthetic intervention in the era of microvascular reconstruction of the mandible—A retrospective analysis of functional outcome. Int J Prosthodont 2005; 18: pp. 42. 20. Schoen P.J., Reintsema H., Bouma J., et. al.: Quality of life related to oral function in edentulous head and neck cancer patients posttreatment. Int J Prosthodont 2007; 20: pp. 469. 21. Wolff K.D., Follmann M., Nast A.: The diagnosis and treatment of oral cavity cancer. Dtsch Arztebl Int 2012; 109: pp. 829. 22. Pace-Balzan A., Rogers S.N.: Dental rehabilitation after surgery for oral cancer. Curr Opin Otolaryngol Head Neck Surg 2012; 20: pp. 109. 23. Shaw R.J., Sutton A.F., Cawood J.I., et. al.: Oral rehabilitation after treatment for head and neck malignancy. Head Neck 2005; 27: pp. 459. 24. 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