aaaAacoa CONTINUITY OF CARE

aaaAacoa
BISPHOSPHONATES
A
DENTAL NEED
A STREAMLINED
REFFERAL SERVICE
BETWEEN
HAEMATOLOGY
&
ONCOLOGY AND
SPECIAL CARE
DENTAL SRVICES
PATIENT EXPERIENCE
NETWORK NATIONAL AWARDS
MARCH 2015
CONTINUITY
OF
CARE
Gill Greenwood BDS FDS RCS
Consultant in Special Care Dentistry , City Healthcare Partnership CIC
Specialist in Oral Surgery, City Healthcare Partnership CIC
Training Programme Director in Special Care Dentistry for Health Education
England , Yorkshire & The Humber Deanery
Oncology Patients
Receiving High Dose
Bisphosphonate Therapy
Bony Metastatic Malignancy
- Breast
- Prostate
- Renal
- Lung
Multiple Myeloma
Plasmacytoma
THESE PATIENTS ARE AT HIGH RISK OF DEVELOPING
BISPHOSPHONATE RELATED OSTEONECROSIS OF THE JAWS
“ BRONJ “
Definition of BRONJ / ARONJ
Remains unchanged since 2006
Criteria :
An exposure to a bisphosphonates or
antiresorptives
Exposed bone within the oral cavity
No history of prior radiation to the jaws
Evidence Based Care
Scottish Dental Effectiveness Programme
April 2011
National Audit on Avascular Necrosis of the Jaws including
Bisphosphonate Related Osteonecrosis of the Jaws BRONJ
Royal College of Surgeons of England
Initial data collection completed May 2011
Follow up data collection June 2012
BRONJ MASTERCLASS 23rd OCTOBER 2013
Royal College of Surgeons of England
International and multi stake holder conference
BIONJ MASTERCLASS OCTOBER 2013
ROYAL COLLEGE OF SURGEONS ENGLAND
INTERNATIONAL AND MULTISTAKEHOLDER EVENT
BONJ **************** BRONJ*******************BIONJ
*************************ARONJ**************************
Antiresorptive osteonecrosis of the jaw : Denosumab
Prevents the activation of osteoclasts . Believed to be as
potent as Zolendronic acid . And seeing the same
incidence of osteonecrosis of the jaw.
DRONJ = Denosumab related
osteonecrosis of the jaw
MRONJ = Medication related osteonecrosis
of the jaw.
The Hull
Mouth
The
“ Brid “
Mouth
10
Barriers to Care
Initial Diagnosis
Access to Services
Appropriate Multidisciplinary Referral
Patient Care Pathways
Fear of Medical & Dental Treatment
Availability of Specialist Services
Finances
(Commissioner/Provider,Patient)
Complexity & Cost of Care: IV antibiotics,
Surgicel, Sutures, Tranexamic
Acid,Transfusions,IV Sedation
‘Just One More Thing ! ‘ Patients’ ability to
cope
Access to Appropriate Dental/Oral Care
Oral and Maxillofacial Surgery
-
Remit of care varies from unit to unit
Restorative Consultants
Oral Medicine Consultants
Specialised Units linked to Oncology Department
Tend to be teaching hospitals
Major city centres
Waiting lists
Access to Appropriate Dental/Oral
Care
Special Care Dentistry
300+ Specialists in UK – Primary Care
-
Services
including approx 30 Consultants
(Primary/Secondary/Tertiary Care)
But strong London/South bias
Patients may often need to pay
for care
No central register
Waiting lists
(Patients need referral)
Catchment Area
Population 1.2million
120 miles
Fuel
Car Parking
Toll
Time
Bridlington
Spouse , time off work
Exhaustion
Withernsea
Pressure on Family
On sick pay or no pay
Sunitib (Sutent) + Bisphosphonates!
(Renal Cell Carcinoma)
A FURTHER 12 MONTHS ON !
Multiple Myeloma 2011, stem
cell transplant and 12 months
of zometa ( Zolendronic Acid )
DEFINATELY NEED A CRYSTAL BALL !
Dentally Fit
For Life ?
Quality of Life Issues
Oral Function
-
ability to eat
ability to eat balanced diet
Oral/Dental Pain
Social Function
-
ability to smile
halitosis
confidence
speech
Ability to Work
Patient Payments
-
“Final Straw”
2010 – 2011
Total number of
patients referred 80
75 were urgent
referrals
Waiting time from
receipt of referral to
initial consultation
Average wait = 11
days
10 pts seen on same
day
Protocol for Referral Care Pathway
1.
Appropriate referral at Point of Diagnosis i.e. pre sutent, pre bisphosphonate,pre
denosunamb therapy ( anti resorptive therapy )
-
by fax
by letter
by email
by phone
}
}
}
}
Need to agree locally
with local Consultant clinical lead
2. Use of proforma referral forms in consulting clinics
3. Needs fast-track referral system to ensure patient is “dentally fit for life” –
holistic approach.
4. Prevention of osteonecrosis is infinitely preferable to “treating” it.
5.
6. High level of dental disease prevention –
Continuing care with appropriate specialist team.
-
High fluoride toothpastes
Specialist toothbrushes
Cost to Service – Cost to Patient
7.
Develop local funding for this care.
Referral form for Haematology and Oncology
Patients
Mahatma Gandhi : Guwahati Hospital , Assam
A patient is the most important visitor on our premises.
He is not dependant on us.
We are dependant on him.
He is not an interruption to our work.
He is the purpose of it.
He is not an outsider to our business.
He is part of it .
We are not doing him a favour by serving him.
He is doing us a favour by giving us an opportunity to do
so.
Letter in the Daily Telegraph October 2011
Thank you for listening
Disclaimer
Views are my own, and not those of the NHS organisations / CHCP
Hull.
Acknowledgements
Patients of Hull, East Yorkshire & Beyond
City Health Care Partnership (,Andrew Burnell, Clive Rowe, John Keating ,Carol
Waudby)
The Queens Centre : Haematology and Oncology Teams: (Dr Upadhyay, Dr Ali, Dr
Sayala, Dr Maraveyas, Dr Butt, Dr Wieczorek, Dr Carter)
The Oral and Maxillo-Facial Teams at HRI ( Mr Crank ,Clinical Director. Mr Nayar
,Consultant in Restorative Dentistry.)
Mr Alistair Speirs Consultant in Restorative Dentistry Scarborough
My Special Care Dental Team and IV Sedation Team,( Chris Pollock ,Charlotte
Wilkinson, Lee Knaggs, Heather Dennington, Diane Jordan, Jacky Wilson, Lianne
Fuller )
StR’s in SCD , Jessica Rowley and Navneet Lad
Westwood Dental Laboratory