Abstract
Background.
Patients who are oral hygiene noncompliant (OHNC) are more likely to lose teeth after radiation therapy (RT) for head and neck cancer (HNC), which increases the risk of developing osteoradionecrosis. A previous study revealed that patients who were OHNC at baseline (BL) who became oral hygiene compliant during follow-up had the best tooth-failure outcomes. The purpose of this study was to identify factors associated with oral hygiene compliance (OHC), overall, and among those who were BL OHNC.
Methods.
This was an observational, prospective, cohort study of 518 patients with HNC assessed before RT and at post-RT follow-up visits every 6 months for 2 years. Patient and treatment-related information was collected at BL and during follow-up, including self-reported OHC. OHC was defined as toothbrushing at least twice daily and flossing at least once daily.
Results.
Of the 296 patients who self-reported being BL OHNC, 44 (14.9%) became oral hygiene compliant at all follow-up visits. Among this group, those who had dental insurance (P = .026), surgery before RT (P = .008), limited mouth opening before RT (P = .001), compliant fluoride use (P = .023), primary RT site of oral cavity (P = .004), and primary surgical site of larynx and hypopharynx (P = .042) were more likely to become oral hygiene compliant post-RT.
Conclusions.
The reasons for the cohort of patients with HNC in this study being OHNC are multifaceted and relate to socioeconomic factors and cancer characteristics.
Practical Implications.
Finding ways to increase OHC and fluoride use among patients with HNC who are at greatest risk of being OHNC should be explored.
Keywords: Head and neck cancer, radiation therapy, oral hygiene compliance
In the United States, approximately 54,000 people were diagnosed with head and neck cancer (HNC) in 2022,1 with men being twice as likely to be diagnosed as women. Treatment of HNC may include surgical resection, chemotherapy, and radiation therapy (RT), all of which can lead to oral sequelae. If surgery is part of a treatment plan, it can be extensive and can cause substantial deformation of the face and neck. RT to the structures of the head and neck can lead to acute and chronic sequelae such as mucositis, mucosal infections, taste disturbances or loss, salivary hypofunction (decreased salivary production) and xerostomia (perceived sensation of dry mouth), limited mouth opening (LMO), increased rate of caries, tooth loss, and increased risk of developing osteoradionecrosis.2–5 Although there is no standard guideline, it is recommended that patients with HNC undergo a dental evaluation and receive oral hygiene instruction before major surgery, chemotherapy, or RT.6,7 Oral hygiene compliance (OHC) can help mitigate some of the chronic effects of RT.3,4
Our study was a multicenter, prospective, observational study that followed patients with HNC before they were treated with RT and then every 6 months post-RT for 2 years. The goal of the study was to address gaps in the knowledge of oral and dental outcomes and dental management strategies for patients with HNC, including oral hygiene habits. A previous analysis concluded that patients who were oral hygiene noncompliant (OHNC) (ie, not brushing at least twice per day and flossing daily) at baseline (BL) were 30% more likely to have a tooth loss event in the 2 years after RT than patients who were BL oral hygiene compliant.4 The objective of this analysis, as part of the OraRad study, was to report factors associated with OHC during the first 2 years of follow-up post-RT.
METHODS
We enrolled patients at 6 US centers who met the following inclusion criteria: diagnosed with head and neck squamous cell carcinoma or a salivary gland cancer to be treated with external beam RT with curative intention with or without chemotherapy, or diagnosed with a non–squamous cell carcinoma or non–salivary gland cancer malignancy of the head and neck region to be treated with external beam RT with curative intention with or without chemotherapy; expected to receive at least 4,500 centigray to at least 1 of 26 sites in the head and neck region; 18 years or older; able to give consent; have at least 1 natural tooth remaining or expected to remain after pre-RT extractions, if any; and comply with all study procedures and participate for the entire duration of the study. The exclusion criteria were underwent palliative RT, had a history of curative RT to the head and neck region for a previous malignancy, incarcerated during time of screening, or anything that would place patient at increased risk or prevent full compliance with completion of the study. This study was reviewed by the institutional review board at each enrollment site, and all participants signed a consent form.
At the BL visit (0–42 days before start of RT), the patient gave consent for study participation and for an initial assessment, which included clinical examination; periodontal measures (ie, probing depths, presence of plaque, and bleeding on probing); panoramic radiograph information; decayed, missing, and filled surface (DMFS) score; number of teeth; whole salivary flow rate; various questionnaires; and medical information. The questionnaires included questions about OHC. As part of the OHC questionnaire, the following questions were asked: “How often do you usually brush your teeth?” “Aside from brushing your teeth with a toothbrush, how often do you usually use dental floss or any other device to clean between your teeth?” Patients were not asked to keep a log of oral hygiene practices. After the BL visit, it was verified that the patient actually had undergone at least 1 round of RT to confirm eligibility and remain enrolled for follow-up visits. At each followup visit (6, 12, 18, 24 months post-RT), a clinical examination was completed, which included obtaining the DMFS score, number of teeth, whole salivary flow rate, mouth opening distance and medical data as well as filling out questionnaires. OHC information was self-reported by patients.
We followed the Strengthening the Reporting of Observational Studies in Epidemiology statement guidelines (eTable, available online at the end of this article).8
Outcome and variables
We defined OHC in our study on the basis of the American Dental Association’s recommendation of brushing teeth at least twice per day and flossing at least once per day.9 To be considered oral hygiene compliant at follow-up, patients would need to report brushing their teeth at least twice per day and flossing at least once per day at all follow-up visits they attended. As this was an observational, prospective, cohort study, no additional oral hygiene instructions were provided at any visits. A full description of the study protocol has been described in a previous article.10
To understand the factors associated with OHC, we conducted 2 types of comparisons : (1) comparing factors based on compliance status at follow-up visits, regardless of BL compliance status, and (2) comparing factors based on compliance status at follow-up only among patients who were OHNC at the BL visit. Specific variables that we compared included education, sex, tobacco use, alcohol use, LMO (defined as < 35 mm of mouth opening regardless of measurement type: tooth to tooth, tooth to alveolar ridge, or alveolar ridge to alveolar ridge),11 having received oral health care in the past 12 months, having any dental insurance (ie, private or public, including Medicaid), compliance with prescription fluoride (defined as daily application, either brush on or in a tray), number of teeth at BL, dental extractions performed at BL, undergoing surgery as an additional therapy to RT, use of a feeding tube, and persistent, recurrent, or new disease at follow-up.
Statistical analyses
We summarized continuous variables using medians and quartiles and made comparison between groups using Wilcoxon rank sum tests. We summarized categorical variables using percentages and made comparison between groups using χ2 tests, unless otherwise noted. We conducted analyses using R Version 4.2.0 (R Core Team). All P values were 2-sided and not adjusted for multiple comparisons.
RESULTS
Patient characteristics
We enrolled 572 patients. We included participants who provided self-reported oral hygiene practices during at least 1 follow-up visit, totaling 518 participants. Of this cohort of 518 participants, 473 (91.3%), 427 (82.8%), 394 (78.0%), and 420 (84.7%) provided oral hygiene practice information at the 6-, 12-, 18-, and 24-month follow-up visits, respectively. Patients missed appointments due to various reasons including being too ill to attend, unable to be reached to schedule the visit, too busy to attend, withdrew voluntarily from the study, or died. Most patients were male (78.0%) and White (82.8%), with a median age of 58 (range, 21-89) years. Squamous cell carcinoma was the most common pathology (82.6%), and oropharynx was the most common primary site for RT (47.1%).
Of the 518 patients, 222 (42.9%) self-reported being BL oral hygiene compliant, and 296 (57.1%) reported being BL OHNC (Table 1). Of the 222 BL oral hygiene compliant patients, 130 (58.6%) reported remaining oral hygiene compliant, and 92 (41.4%) reported being OHNC during follow-up. Of the 296 who were BL OHNC, 252 (85.1%) reported remaining OHNC, and 44 (14.9%) reported becoming oral hygiene compliant during follow-up.
Table 1.
Oral hygiene compliance at BL* and during follow-up.
| ORAL HYGIENE COMPLIANCE STATUS | ORAL HYGIENE NONCOMPLIANT DURING FOLLOW-UP (N = 344), NO. | ORAL HYGIENE COMPLIANT AT FOLLOW-UP (N = 174), NO. |
|---|---|---|
| Oral Hygiene Noncompliant at BL Visit (N = 296) | 252 | 44 |
| Oral Hygiene Compliant at BL Visit (N = 222) | 92 | 130 |
BL: Baseline.
Factors associated with follow-up OHC in the full cohort (N = 518)
Sociodemographic and BL Dental Characteristics
In the full cohort, there were no statistically significant differences between patients who were BL oral hygiene compliant vs OHNC with respect to smoking status, alcohol use, BL number of teeth, preradiation dental extractions, and having dental insurance. Those who were oral hygiene compliant at follow-up were more likely to have more than a high school education (P = .005), be female (P ≤.001), have a dental visit within the 12 months before the BL visit (P = .015), and be compliant with fluoride at BL and during follow-up (P = .003, P ≤ .001, respectively) (Table 2). Follow-up OHC was not associated with LMO at BL or at follow-up visits.
Table 2.
Characteristics of the full study cohort.
| VARIABLE | OVERALL (N = 518) | ||
|---|---|---|---|
| Follow-Up Compliant, No. (%) (n = 174) | Follow-Up Not Compliant, No. (%) (n = 344) | P Value* | |
| Education | |||
| ≤ High school | 34 (19.5) | 107 (31.1) | .005 |
| > High school | 140 (80.5) | 235 (68.3) | |
| Declined to answer | 0 (0) | 2 (0.6) | |
| Sex | |||
| Female | 59 (33.9) | 55 (16.0) | ≤ .001 |
| Male | 115 (66.1) | 289 (84.0) | |
| Smoking † ‡ | |||
| Current use | 4 (2.3) | 17 (4.9) | .354 |
| Former use | 85 (48.9) | 175 (50.9) | |
| Never used | 85 (48.9) | 151 (43.9) | |
| Declined to answer | 0 (0.0) | 1 (0.3) | |
| Alcohol Use § | |||
| ≥ 1 drink per wk | 107 (61.5) | 203 (59.0) | .796 |
| Not current user | 61 (35.1) | 125 (36.3) | |
| Declined to answer or do not know drinks per week | 6 (3.4) | 16 (4.7) | |
| BL No. of Teeth (Range) | 25.0 (21.0, 28.0) | 25.0 (20.0, 28.0) | .183 |
| Preradiation Dental Extractions | |||
| No | 129 (74.1) | 235 (68.3) | .205 |
| Yes | 45 (25.9) | 109 (31.7) | |
| Dental Insurance | |||
| No | 52 (29.9) | 132 (38.4) | .070 |
| Yes | 122 (70.1) | 212 (61.6) | |
| Dental Examination in Past 12 Mo | |||
| No | 34 (19.5) | 103 (29.9) | .015 |
| Yes | 140 (80.5) | 241 (70.1) | |
| Fluoride Compliant at BL ‡,¶ | |||
| No | 110 (63.2) | 263 (76.5) | .003 |
| Yes | 63 (36.2) | 80 (23.3) | |
| Unknown | 1 (0.6) | 1 (0.3) | |
| Fluoride Compliant During Follow-Up ¶ | |||
| No | 100 (57.5) | 264 (76.7) | ≤ .001 |
| Yes | 74 (42.5) | 80 (23.3) | |
| LMO** at BL | |||
| No | 147 (84.5) | 295 (85.8) | .862 |
| Yes | 26 (14.9) | 47 (13.7) | |
| Unknown | 1 (0.6) | 2 (0.6) | |
| LMO During Follow-Up ‡ | |||
| No | 133 (76.4) | 248 (72.1) | .520 |
| Yes | 38 (21.8) | 86 (25.0) | |
| Unknown | 3 (1.7) | 10 (2.9) | |
| Surgery | |||
| No | 59 (33.9) | 170 (49.4) | ≤ .001 |
| Yes | 115 (66.1) | 174 (50.6) | |
| Primary Site of Radiation Therapy ‡ | |||
| Larynx or hypopharynx | 8 (4.6) | 26 (7.6) | .066 |
| Oral cavity | 30 (17.2) | 38 (11.0) | |
| Oropharynx | 75 (43.1) | 169 (49.1) | |
| Other | 39 (22.4) | 84 (24.4) | |
| Salivary gland | 22 (12.6) | 27 (7.8) | |
| Feeding Tube BL | |||
| No | 168 (96.6) | 324 (94.2) | .341 |
| Yes | 6 (3.4) | 20 (5.8) | |
| Feeding Tube Follow-Up | |||
| No | 160 (92.0) | 290 (84.3) | .022 |
| Yes | 14 (8.0) | 54 (15.7) | |
| Persistent, Recurrent, or New Disease | |||
| No | 151 (86.8) | 274 (79.7) | .061 |
| Yes | 23 (13.2) | 70 (20.3) | |
Fisher exact test P value was used for testing the difference in education, smoking status, alcohol status, baseline (BL) fluoride compliance, and BL and follow-up limited mouth opening (LMO) between groups. χ2 tests were used for other categorical variables, and Wilcoxon rank sum tests were used for testing differences in continuous measures between groups.
Current active smoker, former but not current smoker, and never smoked (never smoked > 100 cigarettes or used other inhaled tobacco products).
Total does not equal 100% due to rounding.
Consuming at least 1 drink per week on average for the past 12 months.
Compliant prescription fluoride was daily application (either brush on or in a tray).
LMO or < 35 mm of opening regardless of measurement type (tooth to tooth, tooth to alveolar ridge, alveolar ridge to alveolar ridge).
Cancer Characteristics
Patients who underwent surgery as part of their HNC treatment were more likely to be follow-up oral hygiene compliant (P ≤ .001) (Table 2). Neither surgery site nor primary site of RT was associated with OHC.
Treatment Characteristics
Although not statistically significant at the threshold P value of .05, those who experienced persistent, recurrent, or new disease were more likely to be follow-up OHNC (P = .061) (Table 2). OHC at follow-up visits was not associated significantly with BL feeding tube use. However, patients who used a feeding tube during follow-up were more likely to be OHNC during follow-up (P = .022) (Table 2).
Factors associated with follow-up OHC (n = 44) among those who were BL OHNC (N = 296)
Sociodemographic and BL Dental Characteristics
Among those who were BL OHNC, no statistically significant associations were found between followup OHC and smoking status, alcohol use, BL number of teeth, and pre-RT dental extractions. However, among those who were BL OHNC, those who became follow-up oral hygiene compliant were more likely to have dental insurance (P = .026) and more likely to be compliant with fluoride use (P = .023) than those who remained OHNC during follow-up (Table 3).
Table 3.
Characteristics of patients who were BL* oral hygiene noncompliant.
| VARIABLE | BL NONCOMPLIANT (N = 296) | ||
|---|---|---|---|
| Follow-Up Compliant, No. (%) (n = 44) | Follow-Up Noncompliant, No. (%) (n = 252) | P Value† | |
| Education | |||
| ≤ High school | 12 (27.3) | 90 (35.7) | .409 |
| > High school | 32 (72.7) | 161 (63.9) | |
| Declined to answer | 0 (0) | 1 (0.4) | |
| Sex | |||
| Female | 12 (27.3) | 36 (14.3) | .053 |
| Male | 32 (72.7) | 216 (85.7) | |
| Smoking ‡,§ | |||
| Current use | 2 (4.5) | 14 (5.6) | .393 |
| Former use | 18 (40.9) | 134 (53.2) | |
| Never used | 24 (54.5) | 103 (40.9) | |
| Declined to answer | 0 (0.0) | 1 (0.4) | |
| Alcohol Use ¶ | |||
| ≥ 1 drink per wk | 26 (59.1) | 144 (57.1) | .960 |
| Not current user | 16 (36.4) | 97 (38.5) | |
| Declined to answer or do not know drinks per wk | 2 (4.5) | 11 (4.4) | |
| BL, No. of Teeth (Range) | 24.0 (20.0, 27.2) | 25.0 (20.0, 28.0) | .929 |
| Preradiation Dental Extractions | |||
| No | 31 (70.5) | 174 (69.0) | .992 |
| Yes | 13 (29.5) | 78 (31.0) | |
| Dental Insurance | |||
| No | 9 (20.5) | 99 (39.3) | .026 |
| Yes | 35 (79.5) | 153 (60.7) | |
| Dental Examination in Past 12 Mo | |||
| No | 11 (25.0) | 82 (32.5) | .413 |
| Yes | 33 (75.0) | 170 (67.5) | |
| Fluoride Compliant at BL # | |||
| No | 32 (72.7) | 207 (82.1) | .210 |
| Yes | 12 (27.3) | 45 (17.9) | |
| Fluoride Compliant During Follow-Up # | |||
| No | 27 (61.4) | 198 (78.6) | .023 |
| Yes | 17 (38.6) | 54 (21.4) | |
| LMO** at BL | |||
| No | 30 (68.2) | 222 (88.1) | .002 |
| Yes | 14 (31.8) | 29 (11.5) | |
| Unknown | 0 (0) | 1 (0.4) | |
| LMO During Follow-Up | |||
| No | 32 (72.7) | 188 (74.6) | .594 |
| Yes | 12 (27.3) | 57 (22.6) | |
| Unknown | 0 (0) | 7 (2.8) | |
| Surgery | |||
| No | 12 (27.3) | 127 (50.4) | .008 |
| Yes | 32 (72.7) | 125 (49.6) | |
| Primary Site of Radiation Therapy ‡ | |||
| Larynx or hypopharynx | 1 (2.3) | 22 (8.7) | .004 |
| Oral cavity | 13 (29.5) | 24 (9.5) | |
| Oropharynx | 20 (45.5) | 122 (48.4) | |
| Other | 8 (18.2) | 64 (25.4) | |
| Salivary gland | 2 (4.5) | 20 (7.9) | |
| Feeding Tube BL | |||
| No | 42 (95.5) | 238 (94.4) | ≥ .999 |
| Yes | 2 (4.5) | 14 (5.6) | |
| Feeding Tube Follow-Up | |||
| No | 40 (90.9) | 215 (85.3) | .451 |
| Yes | 4 (9.1) | 37 (14.7) | |
| Persistent, Recurrent, or New Disease | |||
| No | 35 (79.5) | 194 (77.0) | .858 |
| Yes | 9 (20.5) | 58 (23.0) | |
BL: Baseline.
Fisher exact test P value was used for testing the difference in education, smoking status, alcohol status, BL fluoride compliance, and BL and follow-up limited mouth opening (LMO) between groups. χ2 tests were used for other categorical variables, and Wilcoxon rank sum tests were used for testing differences in continuous measures between groups.
Total does not equal 100% due to rounding.
Current active smoker, former but not current smoker, and never smoked (never smoked > 100 cigarettes or used other inhaled tobacco products).
Consuming at least 1 drink per week on average for the past 12 months.
Compliant prescription fluoride was daily application (either brush on or in a tray).
LMO or <35 mm of opening regardless of measurement type (tooth to tooth, tooth to alveolar ridge, alveolar ridge to alveolar ridge).
In the BL OHNC group, those who had LMO at BL but had normal opening distance at followup visits were more likely to be follow-up oral hygiene compliant than any other group characterized by BL or follow-up LMO (P = .002) (Table 3). Conversely, those who had normal opening at BL but experienced LMO during follow-up visits were the least likely to be follow-up oral hygiene compliant (P ≤ .001) (Table 4).
Table 4.
Relationship between follow-up oral hygiene compliance and LMO* among patients who were BL† oral hygiene noncompliant.
| ORAL HYGIENE COMPLIANCE STATUS AT FOLLOW-UP | NORMAL BL, NORMAL FOLLOW-UP, NO. (%) | NORMAL BL, LMO FOLLOW-UP, NO. (%) | LMO BL, NORMAL FOLLOW-UP, NO. (%) | LMO BL, LMO FOLLOW-UP, NO. (%) |
|---|---|---|---|---|
| Oral Hygiene Noncompliant During Follow-Up | 183 (88) | 34 (89) | 5 (45) | 23 (74) |
| Oral Hygiene Compliant During Follow-Up ‡ | 26 (12) | 4 (11) | 6 (55) | 8 (26) |
LMO: Limited mouth opening.
BL: Baseline.
P = .001.
Cancer Characteristics
Like the overall group, those who were BL OHNC and underwent surgery before RT were more likely to be oral hygiene compliant at follow-up than those who did not undergo surgery (P = .008) (Table 3). The location of the primary site of RT was strongly associated with follow-up OHC (P = .004) (Table 3), with patients undergoing RT of the oral cavity being the most likely to be oral hygiene compliant during follow-up.
Treatment Characteristics
For the BL OHNC group, there was a statistically significant association between follow-up OHC and surgery site (P = .042) (Table 5), with those who had a primary surgery site of larynx or hypopharynx being the most likely to be follow-up oral hygiene compliant, although there were only 12 patients in this group. Follow-up OHC was not significantly associated with persistent, recurrent, or new disease in the BL OHNC group (Table 3). Among the BL OHNC group, follow-up OHC was not significantly associated with BL or follow-up feeding tube use.
Table 5.
Oral hygiene compliance and surgery site for those who underwent surgical treatment before radiation therapy.
| STUDY COHORT | LARYNX OR HYPOPHARYNX, NO. (%) | ORAL CAVITY, NO. (%) | OROPHARYNX, NO. (%) | OTHER, NO. (%) | SALIVARY GLAND, NO. (%) | P VALUE* |
|---|---|---|---|---|---|---|
| Overall (N = 286) | ||||||
| OHNC‡ during follow-up | 4 (57) | 44 (59) | 61 (62) | 19 (68) | 28 (57) | .848 |
| Oral hygiene compliant during follow-up | 3 (43) | 31 (41) | 37 (38) | 9 (32) | 21 (43) | |
| Baseline OHNC (N = 154) † | ||||||
| OHNC during follow-up | 3 (60) | 28 (67) | 43 (80) | 16 (100) | 20 (87) | .042 |
| Oral hygiene compliant during follow-up | 2 (40) | 14 (33) | 11 (20) | 0 (0) | 3 (13) | |
Fisher exact test P value.
Unknown sites (n = 3) excluded from the analysis.
OHNC: Oral hygiene noncompliant.
DISCUSSION
Although the prevalence of fluoride use and OHC12,13 and its effects on post-RT patients with HNC have been studied and reported previously,3 our study is to our knowledge the first multicenter, observational, prospective study to identify and analyze specific factors associated with OHC. Consistent oral hygiene practices and use of fluoridated oral products are important in preventing caries caused by the effects of RT.3,4,14–16 If not appropriately managed, caries can become rampant, which may lead to extraction of teeth. Tooth loss, in turn, increases out-of-pocket costs for oral health care17 and puts patients who have undergone RT at a higher risk of developing osteoradionecrosis.5 In addition, poor oral health is linked to numerous systemic health problems.18
A previous study indicated that those who were BL OHNC and reported becoming oral hygiene compliant during all attended follow-up visits had better primary results (lower rate of tooth loss at 2 years postradiation and a lower DMFS score) than any other group defined via OHC and oral hygiene noncompliance.4 In our study, we identified that among the BL OHNC group, those who had dental insurance (private, public), LMO at BL, compliant fluoride use, a primary RT site of oral cavity, and who underwent surgery were more likely to be OHC at follow-up.
Patients who underwent surgery for their tumor were more likely to be OHC at follow-up visits. It may be that their malignancy did not allow for oral hygiene (ie, the tumor caused LMO, excessive bleeding, and tenderness) due to its size or invasion of muscles. After surgery, mouth opening may have improved to allow for oral hygiene. Those who experienced LMO at BL also were more likely to be oral hygiene compliant at follow-up. These patients may have been more motivated to attempt some oral hygiene even with limited opening.
Among factors associated with OHC at all follow-up visits, having dental insurance and compliant fluoride use are the only factors that can be modified and are not related to the disease process. Dental insurance may be a proxy for higher socioeconomic status and for receiving regular oral health care. According to the data collected by the National Center for Health Statistics through the National Health Interview Survey for 2019-2020, those with any type of dental insurance are more likely to get oral health care19 and use health care services. Especially for patients with HNC, timely and preventive oral care is crucial in attempting to mitigate the severe sequelae of radiation.
It has been suggested that OHC interventions (ie, oral hygiene instructions with a dental hygienist or dentist) do not have lasting effects beyond contact with the providers.20 To have patients be more oral hygiene compliant, studies into having an external change agent have been suggested.21 External change agents include family members or dental care professionals who provide oral hygiene instructions at regular intervals. Sheiham and colleagues22 reported that those who had frequent dental visits had a lower rate of tooth loss and fewer number of teeth with active caries. Having an external change agent (ie, dental care professional) as part of regular follow-up care for patients with HNC may help reinforce OHC behaviors that may result in less active caries.
For patients to have regular access to a dental care professional external agent, developing strategies to reduce barriers to oral health care by identifying and addressing the social determinants of health may be necessary. Social determinants of health are “nonmedical factors that influence health outcomes.”23 They are the environment and condition in which a person is born, lives, works, and ages. Although addressing social determinants of health is important for everyone, it may be especially important for those with HNC so that treatment is not delayed. Not having access to oral health care due to lack of dental insurance for patients with HNC can result in devastating consequences. Having a social worker be a part of the multidisciplinary team that can help patients with HNC navigate health care resources and obtain dental insurance may help increase the number of patients with HNC who have dental insurance. A dentist who has experience and knowledge in seeing patients who have had HNC also may be advantageous to have on a multidisciplinary team.
We must consider psychological factors that play a role in completing oral hygiene practices. Those diagnosed with an HNC experience a higher rate of clinical depression than those with any other type of cancer.24 Depressive symptoms before25 and after26 diagnosis have been shown to be greatly associated with mortality.27 These psychological factors may contribute to high rates of oral hygiene noncompliance in this patient population, as shown in our study. This again highlights the importance of having a multidisciplinary team so that these issues can be screened for and patients can be referred to the appropriate providers.
There were limitations to our study. First, there was a lack of diversity. Although our study included multiple centers, the study population was majority male and White. HNCs affect men more than women (2:1), so this finding was consistent with existing literature. The cohort had limited racial diversity, and this may affect the generalizability of the findings.
Second, our study included cancer centers with multidisciplinary teams including oral oncology care, and thus these results may not be generalizable to all populations. The potential benefits of being enrolled in the study included close monitoring of oral and dental status at no charge, which could have resulted in higher rates of OHC than seen in other HNC populations.
Third, OHC is a self-reported measure that is susceptible to self-reporting bias and recall bias. Therefore, caution should be taken in interpreting the results. Desirability bias also should be considered. Desirability bias is the tendency for people to desire to be seen in a positive light,28 so they overreport behaviors that are seen as being positive and underreport behaviors that are seen as negative. In the context of our study, patients simply may have reported being oral hygiene compliant because it was seen as what they were supposed to do. Because the design of our study was not interventional, no additional oral hygiene instructions were provided by the study staff members, although study participants may have had oral hygiene instruction from other oral health care professionals.
Finally, this is a secondary analysis of an observational study, and some of the identified trends could be spurious findings due to type I error. The results should be interpreted as exploratory.
CONCLUSIONS
Our study has shown that the reasons for oral hygiene noncompliance are multifaceted and relate mainly to socieoeconomic and cancer characteristics. Now that the factors associated with oral hygiene noncompliance in patients with HNC have been identified, emphasis on increased oral hygiene instruction for those at high risk of being OHNC and finding ways to address social determinants of health to increase the number of patients with HNC with dental insurance should be considered.
Supplementary Material
Acknowledgments
The OraRad research was supported by grant 1U01DE-22939-01 from the National Institutes of Health, National Institute of Dental and Craniofacial Research.
ABBREVIATION KEY
- BL
Baseline
- DMFS
Decayed, missing, and filled surface
- HNC
Head and neck cancer.
- LMO
Limited mouth opening
- OHC
Oral hygiene compliance
- OHNC
Oral hygiene noncompliant
- RT
Radiation therapy
Footnotes
DISCLOSURES
None of the authors reported any disclosures.
Contributor Information
Jiwon Lim, Atrium Health Carolinas Medical Center, Charlotte, NC when the work described in this article was conducted. National Institute of Dental and Craniofacial Research, Bethesda, MD.
Erika S. Helgeson, University of Minnesota, Minneapolis, MN.
Rajesh V. Lalla, University of Connecticut School of Dental Medicine, Farmington, CT.
Thomas P. Sollecito, Department of Oral Medicine, University of Pennsylvania, Philadelphia, PA.
Nathaniel S. Treister, Divisions of Oral Medicine and Dentistry, Harvard School of Dental Medicine, Boston, MA.
Brian L. Schmidt, New York University School of Dentistry, New York, NY.
Lauren L. Patton, Adams School of Dentistry, University of North Carolina, Chapel Hill, NC.
Alexander Lin, Department of Radiation Oncology, Perleman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Zvonimir Milas, Section of Head and Neck Surgical Oncology, Atrium Health Levine Cancer Institute, Charlotte, NC, and School of Medicine, Wake Forest University, Winston-Salem, NC.
Michael T. Brennan, Department of Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, and Wake Forest University School of Medicine, Winston- Salem, NC.
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