Here is a 5-step approach oncology practices can take to include oral health for each of their patients. 

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1. Risk Assessment

2. Screening

3. Education

4. Preventive intervention: Fluoride Varnish Application

5. Referral

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Adapted from: Integrating Oral Health Care and Primary Care Learning Collaborative: A State and Local Partnership, COHSII, National Maternal and Child Health Oral Health Resource Center. Below is a review of each element:

 

Risk Assessment

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Ask here about the potential factors which influence oral health and risk for tooth decay, like diet, having a dental home, exposure to community water fluoridation. 

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Examples of questions include:

• Dental concerns/pain: Do you have any dental problems or concerns? Does anything hurt? Explain.

• Diet/nutrition: Do you have sugary foods or drinks between meals (including juice, soda, energy drinks)?

• Cancer-related symptoms: Does your mouth frequently feel dry?

• Health behaviors: Do you use tobacco?

• Fluoride. Do you brush your teeth with fluoride toothpaste? Do you drink water from the tap/faucet?

• Last dental visit/dental home- Have you had your teeth cleaned in the past 12 months?

• Concerns about getting oral health care- Do you currently have a dentist? If yes, list the dentist. Do you have insurance coverage that supports regular dental use?

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Note: Questions and responses can be built into an oral health section of the EMR.

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Here please find a video describing cancer risk assessment in dental hygiene:

https://vimeo.com/736904656

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Screening

 

Examine the mouth as part of your overall History and Physical. Turn HEENT to HEENOT by adding the oral cavity. Document in EMR.

 

1. Supplies: Light, tongue depressor, gloves.

2. Clinical findings

   1. Obvious decay/broken teeth Yes/No

   2. White spot lesions (early decay) Yes/No

   3. Inflamed/bleeding gums  Yes/No

   4. Visible plaque/calculus (tartar)  Yes/No

   5. Saliva flow Normal/Reduced

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Here please find a video describing oral health screenings: oral health evaluation: https://www.youtube.com/watch?v=qZp7-1sYTWg 

 

Education

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Recognize options and strategies to address oral health needs identified by a comprehensive risk  assessment and health evaluation.

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Competencies: Primary care providers

• Implement appropriate patient-centered preventive oral health interventions and strategies.

• Introduce strategies to mitigate risk factors when identified

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Direct patients to the resources for patients and caregivers found on the PRCRI’s Rhode Island Cancer and Oral Health Resource Guide. 

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Here please find a video describing communication and education in the dental field: https://youtu.be/bnqoWq7DM6Q

 

Preventive Interventions

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Recognizes options and strategies to address oral health needs identified by a risk assessment and oral health evaluation.

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Competencies: Primary Care/ Oncology Providers

• Implement appropriate patient-centered preventive oral health interventions and strategies.

• Introduce strategies to mitigate risk factors when identified.

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Preventive intervention during the oncology visit: fluoride varnish

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Fluoride varnish is a preventive modality to strengthen teeth and reduce risk of demineralization often associated with reduced saliva flow. It is recommended for patients at high risk for tooth decay and may be applied by non-dental providers.

Considerations…

1. Does your oncology team understand current guidance for oral health care during oncology treatment?

2. At what oncology visit will fluoride varnish be applied? Note: Only select one oncology visit to start, you can scale up later.

3. Who will apply fluoride varnish? Note: Consider reviewing state practice acts and Medicaid guidelines to determine who can administer and bill for fluoride varnish.

4. How will you document and track fluoride varnish applications applied during oncology visits in the EMR?

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Here please find a video describing prevention interventions: https://www.youtube.com/watch?v=OzM4UQxP67Q

 

Referral

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Interprofessional collaboration benefits patients and can take multiple forms:

1. Dental office is co-located in the same facility as the oncology practice. This has the benefit of allowing warm hand-offs, shared EMRs, and efficient referrals

2. Communication between oncology providers and dental teams in the community

3. Dedicated dental appointments for patients going through oncology care.

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Goals:

• Exchange meaningful information among health care providers to identify and implement appropriate, high quality care for patients.

• Apply interprofessional practice principles that lead to the planning and delivery of patient-centered oral health care.

• Facilitate patient navigation in the oral health care delivery system through collaboration and communication, and provide referrals.

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Considerations…

1. At what visit will you refer the oncology patient to the dentist/ dental department?

Note: Only select one oncology visit to start, you can scale up later.

1. What is the workflow for referrals to the dentist/ dental department?

2. How are referrals documented and tracked? Can your EMR send referrals? Are the referrals trackable?

3. Who is responsible for scheduling dental appointments for referred oncology patients?

4. What is the follow-up process for referrals?

5. What is the capacity of the dental clinic to see referred oncology patients?

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Here please find a video describing interprofessional collaborative practice: https://youtu.be/RIf-JbKO514

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For more information about the late effects of pediatric cancer therapy and oral health, see these resources:

 

• Late Effects for Treatment for Childhood Cancer - National Cancer Institute

• Prosthodontic management of abnormal tooth development secondary to chemoradiotherapy: a clinical report - Samuel R Zwetchkenbaum, Won-suck Oh

• Long-term Effects of Childhood Cancer Treatment on Dentition and Oral Health: A Dentist Survey Study from the DCCSS LATER 2 Study - Multidisciplinary Digital Publishing Institute

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You may also wish to learn about:

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• Nutrition During Cancer Care

• Finding & Financing Oral Healthcare

• Mucositis

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