Oral health and dental hygiene are often overlooked before, during, and after cancer treatment. Chemotherapy, radiation therapy, and other drugs used in the treatment of cancer can have compounding effects that result in increased risk of infection, delayed wound healing, dental caries, and chronic periodontal disease.

In their session during the ONS 41st Annual Congress, Colleen Palay, BSN, RN, and Maureen Sullivan, DDS, discussed dental oncology, an expanding area of dentistry focused on prevention, treatment, and maintenance of oral and dental health in both patients with cancer and survivors in an effort to increase quality of life during and after cancer therapy.

With the rise of oral cancers, dentists are becoming a more integral part of the multidisciplinary healthcare team. Oral complications are also associated with the treatment of head and neck cancer, so it is “crucial to have the dentist involved at diagnosis,” Sullivan stressed.

She noted the importance of conducting all invasive dental procedures prior to cancer treatment for the best chance of eradication of dental disease, better access, and post-treatment considerations. Although time is often limited once a cancer diagnosis is made, patients should be cleared of dental issues prior to treatment.

Table 1. Dental-Related Emergency Department Visits per Insurance Status

Payment Source Dental-Related Emergency Department Visits
Private 19%
Medicare 7%
Medicaid 30%
Uninsured 40%
Other 4%

 

Patients who undergo radiation for head and neck cancer, often have immediate radiation effects, including mucositis, pain, hypoguesia, dysphagia, and erythema. Secondary effects include xerostomia, trismus, dysphagia, impaired speech, fungal infections, velo pharyngeal insufficiency, osteoradionecrosis, and xerostomia-induced decay.

  • Control, treat, and prevent infection
  • Control and treat pain
  • Maintain oral function
  • Manage oral complications due to both the cancer and the treatment
  • Improve and maintain quality of life. Patients should also be educated before and during treatment on the following.
  • Review of proper oral care
  • Management of xerostomia and mucositis
  • Inspect for signs of infection
  • Reinforce proper use of fluoride products
  • Pain control
  • Denture care

Palay went on to discuss what nurses can do to encourage oral health concepts, including assessing patients’ dental history, social habits, and current dental practices; evaluating and examining the patient; educating patients; and making a referrals to dentists. “Advocate for patients so they get the care they need,” Palay said. “By getting patients in to the dentist prior to treatment, we can help them reduce side effects of treatment.” The timing of dental care is also important in that it can save some teeth prior to treatment. “Post-op dental care is difficult,” she noted. The nurse is in a position to advocate for patients to obtain dental care before, during, and after cancer treatment.

Nurses should relay the following information to the dentist for the best patient care.

  • Diagnosis
  • Expected treatment
  • Hematologic status
  • Past medical history
  • Medications
  • Need for antibiotic prophylaxis

Dental recall should take place every six months, perhaps even as few as every three to four months for patients with head and neck cancer. Survivors will also need assistance managing the functional implications (e.g., eating, swallowing, speaking), psychosocial implications (e.g., appearance, social interactions), employment limitations, and financial aspects (e.g., insurance, medical bills).

Palay then described the challenges to getting patients dental care after diagnosis.

  • Sense of urgency to get patient into treatment often outweighs waiting for dental care to happen
  • Availability and willingness of providers with experience in caring for this complex patient population
  • Location of appropriate dental practices
  • Willingness of patient to obtain care and seek appropriate treatment
  • Financial and insurance issue 

She discussed treating the challenging patient population of those with disabilities, of whom 75% are insured with Medicaid. (See TABLE 1 for insurance status of patients visiting emergency departments for dental issues.) Consider the following questions for patients who are experiencing dental issues during cancer treatment.

  • Can they perform oral care?
  • Can they tolerate dental procedure?
  • Are they able to access care?

The patient population has poor reimbursement rates, and many providers do not accept Medicaid. Patients may need to travel quite a distance to find a dental provider that can accommodate them in a variety of ways. Patients can experience distressed “caused by the need for expensive life-long dental care,” Palay noted. “Unless the patient gets dental care, the underlying issue will remain,” she stressed.

Palay concluded by providing some future initiatives to better incorporate dental needs into oncology care.

  • Incorporate dentistry into the primary care provider setting.
  • Increase Medicaid reimbursements.
  • Increase loan forgiveness for dental professionals.
  • Create a pathway for mid-level dental practitioners.