Oncologists' Perspective on Dental Care Around the Treatment of Head and Neck Cancer: A Pattern of Practice Survey

PURPOSE:

Patients with head and neck cancer are at risk of long-term dental complications. Proper dental assessment pre- and post-treatment can improve outcomes but is logistically challenging. We surveyed oncologists to better understand their perspectives surrounding dental care in this unique population.

METHODS:

We surveyed oncologists at institutions associated with an ongoing national study of oral health after treatment of head and neck cancer. Seventeen questions were used to assess provider characteristics, patterns of practice, patterns of referral, barriers to referral, and willingness to apply fluoride varnish in the oncology clinic.

RESULTS:

Ninety-seven oncologists were invited from six institutions, of whom 40 (41%) responded. Surgeons represented 45% of the sample, followed by radiation oncologists (40%) and medical oncologists (15%). Both generalists and subspecialists were included. All practiced in a metropolitan area with an academic dental practice, and many felt that this improved access to care. Despite this, most oncologists thought that financial factors were a significant barrier to obtaining timely dental care. Most oncologists performed a dental assessment during visits. Oncologists felt qualified to identify the most significant complications of treatment, such as exposed bone, but felt underqualified to identify early changes in need of intervention. When asked if the oncology clinic could apply fluoride varnish during follow-ups, most stated that this seemed feasible but would require education and financial support.

CONCLUSION:

Oncologists often perform limited dental evaluations during their routine visits. Given the challenges associated with access to proper dental care for this population, these oncology visits may provide a window for preventative intervention.

INTRODUCTION

Head and neck cancer accounts for more than 50,000 cases and 10,000 deaths in the United States annually.¹ Radiation therapy is critical in the management of head and neck cancers and is often combined with surgery to reduce recurrence rates or to allow organ preservation. Despite advances in modern radiation therapy treatment planning, detrimental effects to normal tissue remain. Late dental sequelae are particularly common and concerning. Salivary and microvasculature damage after ionizing radiation contribute to a phenomenon called osteoradionecrosis.² This condition is debilitating for the patient, and treatment is burdensome.

Adequate dental care before and after radiation reduces the risk of osteoradionecrosis and dramatically improves long-term outcomes.³ Before radiation therapy, it is common practice to seek an evaluation with a dentist, so that any necessary extractions can be performed and allowed to heal before delivery of radiation therapy.⁴ Similarly, post-treatment follow-up evaluations are an opportunity to improve hygiene, prescribe fluoride, and provide preventative restorations. For this patient population, dental care is critical to avoid severe late complications.

Despite its importance, access to proper dental care is a significant challenge and many patients with cancer find themselves unable to maintain routine follow-up preventative care with a dentist.^5-8 However, these patients may be willing and able to follow up with their oncology team for examinations and scans. For this reason, the oncology office may provide an opportunity to improve compliance with dental care. We performed a multi-institutional survey of oncologists to better understand the challenges associated with dental care in this population, the oncologists' capacity for dental evaluation, and their attitudes toward future opportunities.

METHODS

Sampling and Survey Administration

We surveyed oncology care physicians active in treating head and neck cancer. Participants were identified on the basis of their association with the Clinical Registry of Dental Outcomes in Head and Neck Cancer Patients (OraRad) study (ClinicalTrials.gov identifier: NCT02057510). These six institutions were Atrium Health (Charlotte, NC), Brigham and Women's Cancer Center (Boston, MA), University of North Carolina (Chapel Hill, NC), New York University (New York, NY), University of Connecticut (Farmington, CT), and University of Pennsylvania (Philadelphia, PA). Physicians identified included surgeons and medical and radiation oncologists. Both general oncologists and subspecialists focusing on head and neck cancers were invited.

Electronic invitations were sent via e-mail to department contacts who forwarded the invitations to their respective practitioners. Data were recorded using REDCap software.⁹ The survey did not request personal identifiable information and was returned anonymously. Approval from the Atrium Health Institutional Review Board was obtained before start of the study.

Questionnaire Design, Measures, and Analysis

The 17-question survey was intended to gather data regarding the status and feasibility of dental evaluations during routine care of head and neck cancers. The complete survey is given in the Data Supplement (online only).

The survey contained five questions to assess provider and practice characteristics (1-4 and 16). Two subsequent questions assessed pretreatment referral and dental evaluation (5-6). Four subsequent questions (7-10) assessed the dental component of the providers' follow-up care, and four questions assessed referral patterns and barriers to dental care (11-14). One question (15) assessed enthusiasm for placing fluoride varnish in a hypothetical future situation. The first 15 questions were administered via Likert scale, whereas two final questions asked for location of practice and for general comments in free text.

Descriptive analyses were tabulated and plotted. Likert scale responses were grouped for convenience of presentation in the figures and tables. The response rate was calculated with a denominator including the number of practitioners in each department who were invited via e-mail. Comparisons of frequency of asking patients about dental problems, frequency of clinically assessing dental problems, and confidence in recognizing dental problems (questions 7-9) during oncology follow-up visits between specialty groups used Fisher's exact test. Analyses were not adjusted for multiple comparisons.

RESULTS

Physician Characteristics and Practice Environment

The survey was administered between February 18, and June 12, 2020. A total of 97 physicians were invited, and 40 responses were recorded, a response rate of 41%. Surgeons composed the largest portion of the sample (n = 18, 45%), followed by radiation oncologists (n = 16, 40%) and medical oncologists (n = 6, 15%). Years in practice varied with nine in practice for 5 years or less, 10 between 5 and 10 years, seven between 10 and 15 years, five between 15 and 20 years, and nine in practice for 20 or more years. Most (85%) were subspecialized in treatment of head and neck cancer. More than half (55%) reported evaluating at least 20 patients with new head and neck cancer every month.

Clinical Evaluation

Question seven inquired if the oncologist asked the patient about various dental challenges. Most providers responded that they at least occasionally ask patients about dental cavities (70% occasionally or frequently), toothache (70%), or periodontal disease (63%) during evaluation (Table 1). Exposed bone was the most frequent focus with 85% of providers stating that they frequently assess patients for this clinical sign. Dental decay and infection were also very frequently assessed by providers, with periodontal disease subjected to the least investigation.

TABLE 1.

Components of the Dental Examination When Performed by Oncologists

Most providers felt confident with their ability to assess the presence of exposed bone, with 50% feeling very confident and another 38% feeling somewhat confident. Providers reported feeling either not confident or somewhat confident when assessing dental decay, dental infection, and periodontal disease with 83%, 80%, and 88%, respectively.

Experience With Dental Referral

All respondents judged that it is necessary to see a dentist before head and neck therapy, with 16 (42%) responding usually and 22 (58%) responding always necessary. Although pretreatment referral was judged necessary, one respondent reported ≤ 25% of patients in their experience actually see a dentist in the two months before cancer treatment. Thirty-five oncologists (88%) stated that pretreatment dental evaluation was accomplished for more than 50% of the patients, one stated 1%-25%, and four were unsure.

Figure 1 shows the likelihood that an oncologist would refer a patient to a dentist post-treatment for various reasons. Tooth decay, abscess, pain, infrequent dental care, and exposed bone were the most likely reasons for referral to a dentist, with more than two thirds of respondents stating that they would refer for these reasons. Self-report of infrequent oral hygiene and prescription fluoride use was less common reason to refer a patient to a dentist.

FIG 1.

Likelihood that an oncologist would refer a patient for dental evaluation.

Regarding access to dental care, 19 oncologists (48%) stated that it was somewhat or very difficult to find a local dentist for their patients. The location and ease of access to a dentist affected the likelihood that an oncologist would place a referral (occasionally or very frequently 80%). Insurance coverage and family resources (occasionally or very frequently 80%) and findings during the clinical examination (occasionally or very frequently 78%) also influenced the oncologists' decision to refer. Most respondents stated that they (or the office staff) at least occasionally call a dental office to make an appointment (n = 29, 73%), give the patient the name of a dentist (n = 27, 68%), or provide the dental office with medical records or a summary of the patient's care (n = 33, 83%).

Figure 2 presents factors that oncology providers perceived as inhibiting patients from receiving dental care. Most providers found it difficult for patients to receive dental care if the patient was uninsured, received Medicaid benefits, or had Medicare-only benefits. Private dental insurance was associated with increased access, with 30 (75%) respondents stating that it was at least somewhat straightforward for their patients with cancer to receive dental care. Patient factors such as living in an institutional setting or having a language barrier were reported as decreasing access. Emergency dental care access was also felt to be challenging with 18 (45%) respondents noting that it was very or somewhat difficult for patients to receive care at night or on the weekend.

FIG 2.

Oncology providers' perception of factors inhibiting patients' receipt of dental care.

Fluoride Use

One question evaluated the oncologists' interest in applying fluoride varnish in their oncology clinic: “If fluoride varnish placed every 3 months in an oncology practice was found to prevent dental problems, and this was reimbursed by medical insurance payers, would this be something your practice would be interested in completing for your head and neck patients?”

Respondents were open to this practice, assuming that convenience and financial support were available. If the varnish required less than 10 minutes to place, 28 (70%) said that they were somewhat or very likely to consider administering. Similarly, if the initial investment was < $1,000 US dollars or varnish could be placed by a nurse or advanced-practice provider, then 20 (50%) and 26 (68%), respectively, would be somewhat or very likely to consider implementing the practice into their clinic.

Differences in Oncology Specialty

We compared survey responses for the (1) frequency of asking; (2) frequency of clinically assessing; and (3) confidence in assessing dental decay, dental infection, periodontal disease, and exposed bone between the three speciality groups (surgical oncology = 17, radiation oncology = 16, and medical oncology = 6; Table 2). The three groups significantly differed in their reported frequency of clinically assessing for exposed bone (P = .002) with medical oncologists rarely assessing (67% of responses) and radiation and surgical oncologists frequently assessing (88% for both groups) for this concern. Surgical oncologists were very confident (94%) in screening for exposed bone compared with 0% of medical oncologists and 19% of radiation oncologists (P < .0001) Finally, surgical oncologists were very confident (39%) in their ability to recognize dental infections compared with 0% of radiation oncologists and 17% of medical oncologists (P = .05).

TABLE 2.

Comparisons of In-Clinic Follow-Up Dental Evaluation Practices by Specialty

Comments

The final question allowed respondents to write free-text comments. Multiple responses highlighted the lack of access in the community to dental care, particularly for those with limited resources. At least three respondents mentioned that they practice in a specialized academic environment that allows access, but that community access would be much more challenging.

The timing of dental care before cancer treatment was highlighted by multiple respondents, stating that delays in anticancer treatment initiation are common, particularly when dental procedures are required. One comment stated that at their institution, medical oncology follow-ups were not common and instead were more often completed by radiation and surgical oncologists.

Another respondent discussed that oncologists do not have adequate training to assess and evaluate dental issues and that access to dental care is a major challenge for patients with head and neck cancer. This respondent emphasized that lack of care leads to significant detriments to quality of life.

DISCUSSION

This study describes oncologists' perspectives regarding dental care in their clinics. Overall, dental care was felt to be very important for this population. Oncologists were usually but not always able to facilitate referral for dental care for their patients in the peritreatment period. Sometimes, this induces delays, and factors that made access more difficult were identified. Physicians felt confident that they could identify major dental complications on examination but felt underqualified to identify early problems requiring intervention. However, differences were identified between oncology specialties in level of confidence in identifying exposed bone and dental infections and frequency in assessing for exposed bone. Many felt that the application of fluoride varnish during oncologic follow-up visits may be possible, with support.

The importance of preradiation dental evaluation was emphasized in the survey responses. This is congruent with various clinical practice guidelines published by national organizations such as the American Academy of Oral Medicine, the Veterans Administration, and National Comprehensive Cancer Network.^10-12 However, access to dental care is a major challenge from the oncologist's perspective.¹³ Many of the respondents practice at large academic centers with dental resources far beyond those available to the general public, and it seems likely that access to dental care may be even more of a problem for patients outside of academic centers. Oncologists responding to this survey seemed to suggest that improved dental coverage for patients who have received radiation therapy would likely increase access to care.

There are three future directions which this study suggests. The first is that a more comprehensive survey of oncology providers nationally would be useful, particularly if focusing on rural and community regions. Oncologists in these regions may express different responses to the questions in this report. Such data would further the understanding of oncologists' perspective on the necessity of dental care and ease of access, which may vary from our report.

The second future direction is that there exists an opportunity to improve dental outcomes for oncology patients by educating oncology providers about dental examinations. This study provides a basis for this opportunity, given that physicians affirmed they spend part of their assessment asking about and examining for dental complications. Although most felt that they could identify the most serious concerns such as osteoradionecrosis, they were less confident about more subtle findings. Of note, it is unclear to what degree the oncologists' assessment would agree with gold standard dental assessments; overconfidence is possible. However, this finding speaks to an opportunity for education.

The third future direction is that there also exists an opportunity for oncologists to intervene in dental care. Successful implementation of a dental preventative program by medical providers has been demonstrated with the Pediatricians: Into the Mouth of Babes Program (IMBP).¹⁴ The target at-risk population for IMBP was children age younger than 6 years, with the program providing training on recognizing and assessing risk of dental disease and placing fluoride varnish in a pediatrician's office. The program helped reduce dental caries rate in vulnerable children.¹⁵ In future work, we hope to design and implement a similar program but adapted for the postradiation cancer population. Although the generalizability of this program to our target population is currently unclear, this manuscript serves as an important first step in assessing oncologists' perspectives on the feasibility of such a program.

Patients with head and neck cancer are at risk for dental disease with limitations in receiving routine dental care. An estimated 40%-50% of patients with head and neck cancer obtain routine dental care following cancer therapy.^16,17 Patients are more likely to follow up with their oncologist than their dentist because of medical insurance coverage, ongoing symptoms, and fear of recurrence going undetected. We hypothesize that patients who cannot follow up with a dentist could have fluoride varnish placed at the time of their routine oncology follow-ups similarly as in the IMBP program. This survey (questions 15 and 17) suggests that some education and effort would be required to encourage providers to deliver topical fluoride varnish, but that if financial support was available, most would be open to the idea.

Despite the insights provided by the above data, some limitations exist. Generalizability may be low as respondents were chosen from institutions associated with an ongoing national study of dental care in the treatment of head and neck cancer. Although some practitioners were in independent community practice, all are at least within the metro area of a city with an academic dental practice, which may skew results such that access appears easier than in the rest of the nation. The confidence in dental screening reported by the oncologists was not compared with a gold standard, and considering that none are trained dentists, their findings on examination may be inaccurate.

In conclusion, these data provide valuable insight into oncologists' perspectives regarding dental care during and after treatment of head and neck cancer. Financial access to dental care is a major barrier and should be addressed at the national level. Oncologists reported that applying fluoride varnish at follow-up visits may be logistically feasible, with appropriate support. Future work is necessary to determine the feasibility of coordination of screening or preventative care among nondental providers to reduce dental complications in this population.

AUTHOR CONTRIBUTIONS

Conception and design: Matthew C. Ward, Michael D. Carpenter, Benjamin J. Moeller, Rajesh V. Lalla, Michael T. Brennan

Administrative support: Matthew C. Ward, Michael T. Brennan

Provision of study materials or patients: Matthew C. Ward, Michael D. Carpenter, Daniel Carrizosa, Rajesh V. Lalla, Michael T. Brennan

Collection and assembly of data: Matthew C. Ward, Michael D. Carpenter, Jenene Noll, Michael T. Brennan

Data analysis and interpretation: Matthew C. Ward, Daniel Carrizosa, Erika S. Helgeson, Rajesh V. Lalla, Michael T. Brennan

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Oncologists' Perspective on Dental Care Around the Treatment of Head and Neck Cancer: A Pattern of Practice Survey

The following represents disclosure information provided by the authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center.

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