Learning from Clinicians and Their Patients: Why Oral Health Collaboration is Essential to Overall Health Outcomes
Judith Haber, PhD, APRN, FAAN, Ursula Springer Leadership Professor in Nursing at New York University Rory Meyers College of Nursing
Larry Coffee, DDS, Founder of the Dental Lifeline Network
Lisa Kennedy Sheldon, PhD, ANP-BC, AOCNP, Past Chief Clinical Officer of the Oncology Nursing Society and Associate Professor, University of Massachusetts-Boston
Matthew Cooper, MD, Director of Kidney and Pancreas Transplantation at the MedStar Georgetown Transplant Institute (MGTI) and a Professor of Surgery at Georgetown University School of Medicine, President elect, Board of Directors, United Network for Organ Sharing
Gwen Nichols, MD, Chief Medical Officer, Leukemia and Lymphoma Society
Christopher J. Smiley, DDS, Editor in Chief, Journal of the Michigan Dental Association
Cancer therapy and organ transplant surgery are prime examples of why obtaining dental “clearance“—an oral examination and provision of any necessary treatment —is essential to ensure patients are in good oral health before beginning the cancer therapy or transplant surgery. Oral health surveillance must then continue over the course of treatment and afterwards to deal with any side effects or long-term consequences affecting oral and other tissues.
That is why the second webinar in the Continuum series convened an oncology nurse practitioner, a kidney transplant surgeon and an oncologist associated with The Leukemia and Lymphoma Society to explain why integrating medicine and dentistry in health care is essential and why they collectively urge establishing a collaborating team of medical, dental and other health professionals to follow patients throughout their treatment to achieve the best overall health outcomes.
Dr. Kennedy-Sheldon, the oncology nurse practitioner, began by extolling the role of nurses in cancer care. She noted that nurses dominate the health professional workforce in America and globally, numbering 4.2 million in America. Those with advanced training include some 300,000 nurse practitioners and 110,000 oncology nurses, specialists who spend the most time with cancer patients and their families. They offer aid and comfort, answer questions, and advise how to handle problems that may arise during treatment. They may also have conducted the dental clearance exam. Here Dr. Kennedy-Sheldon noted the additional education many nurses now obtain qualifying them to conduct the “HEENOT” exam: for Head, Eyes, Ears, Neck, Oral, and Throat, with the oral part including a careful survey of all the soft and hard tissues of the oral cavity, in this way also providing a screening for oral cancers.
Dr. Kennedy-Sheldon paused at this point to mention alcohol and tobacco use as known risk factors for oral cancers and then remarked on the increasing incidence of oral-pharyngeal (OP) cancers. Seventy percent of these cancers are now associated with Human Papilloma Virus (HPV) infection, a virus that is quite common, affecting 80 percent of individuals over a lifetime, and usually sloughed off by the body. However, certain HPV subtypes have long been associated with sexually transmitted infections that cause cervical cancer and other cancers affecting genital or anal tissues. Their occurrence in OP cancers is assumed to be the result of similar viral transmission during unprotected oral sex. The good news is that there is now a vaccine —one that can be administered by dentists in many states—specifically targeted to the HPV subtypes of interest, the first ever cancer-prevention vaccine to be developed, with recommendations that inoculations begin at 11 or 12 years of age.
As for the vulnerability of the oral tissues to harm, not just from OP cancers, but in reaction to the treatment of cancers elsewhere, the evidence is all too abundant. The potent chemotoxic drugs that kill cancer cells also kill cells in other rapidly dividing tissues such as hair, or in the mouth, the oral mucosa, leading to sores and ulcers that can interfere with eating, drinking, and swallowing. Chemotherapy, radiation, and immunotherapies also can weaken the immune system, increasing the risk of infections, including dental caries and periodontal disease. Drugs such as bisphosphonates used to prevent or treat boney metastases, can lead to osteonecrosis of the jaw. Which side effects, when and where they occur, depend on the type of cancer, the specific treatment, and the individual patient’s response. Their management calls for continuous monitoring over the course of treatment, with the provision of preventive and treatment measures that may require consultation with other specialists. Nor does monitoring end with the patient’s last cancer treatment. Dr. Kennedy-Sheldon listed a host of possible lasting effects, among them, dysphagia, lymphedema, ototoxicity, thyroid dysfunction, taste disorders, trismus, and xerostomia. Indeed, “it takes a village,’ was the phrase she used, indicating the need for a collaborating and communicating team of dental, medical, and other health professionals in carrying out the treatment plan and scheduling any necessary oral care appropriately over the course of cancer treatment. Maintaining an interoperable electronic health record carefully annotating the patient’s dental and medical history would be especially beneficial. The team should also be prepared to advocate for and justify any third-party reimbursements, given the variety of complications and specialists whose expertise may be necessary to resolve them. .
Dr. Kennedy-Sheldon’s concluding remarks stressed the need for greater emphasis on oral health in educating students and clinicians in oncology care and the recommendation that oral assessments be required as part of clinical oncology competencies and adopted as a standard of care. Ultimately, she envisioned a future in which oral health is integrated in primary and specialty care, embodied in interprofessional workforce teams where dentists, physicians and other health professionals work together to provide health care for patients—an approach calculated to achieve what has been termed “the triple aim”: improved quality of care, greater patient satisfaction and reduced health care costs.
A major threat to the health of organ transplant patients comes from their need to be maintained on long-term immunosuppressive drugs to prevent transplant rejection, and thus subject to increased risk of infections. There is no question then that dental clearance should be required as part of the pre-screening of transplant patients, said Dr. Matthew Cooper, Director of Kidney and Pancreas Transplant Surgery at Medstar Georgetown Transplant Institute. And he cited one study among several that showed that patients presenting with only one dental problem prior to transplant were seven times more likely to be hospitalized within two months of surgery. In addition to requiring a clean bill of oral health, transplant patients are also screened for colon and prostate cancer and other cancers if they are smokers, and women have pap smears and mammograms. Vaccine status, allergies, advice on limiting exposures to infection, the importance of oral hygiene, and in general, instructions on how to stay healthy are all part of the transplant plan and follow-up.
Sadly, the demand for transplants far exceeds the supply of donor organs and is particularly acute for African Americans where, in terms of kidneys, only about a third of patients on wait lists can be accommodated. Repeated dialysis, costly and time-consuming, can keep patients alive, but generally for fewer and more uncomfortable years in comparison with transplants, which add more ‘‘quality life years.” A further barrier is cost—not of the transplant itself, but of any needed dental care to qualify for the surgery. Yes, there are volunteer dentists who provide pro bono services but not enough to meet demand. Nor are transplant patients the only category of patient whose overall health is compromised by lack of access or affordability of oral care. Dr. Cooper’s concluding remarks took note that the United Network of Organ Sharing (UNOS), the organization of which he is the newly-elected President has now signed on to the national “Community Statement on Medicare Coverage for Medically Necessary Oral and Dental Health Therapies,” along with more than 140 other advocacy and civic groups.
In thanking Dr. Cooper for his presentation, Dr. Judith Haber mentioned that the Santa Fe Group continues to play a leading role in rallying support for the change to include a medically necessary dental benefit in Medicare and that the number of organizations signing on to the national statement has grown even more since Dr. Cooper prepared his talk.
The third presenter, oncologist Dr. Gwen Nichols, is the Chief Medical Officer of the Leukemia and Lymphoma Society. She said that the goal of putting patients first truly underscores the need to integrate oral and medical care in cancer treatment. She chose two case histories by way of illustration. John, an acute myeloid leukemia patient, had had dental work completed before his cancer treatment and is now in remission but he has not been able to afford dental care resulting from chemotherapy and radiation. He has cracked teeth, pain and difficulty eating, resulting in poor nutrition; he suffers fatigue, sleep disturbance and has an overall poor quality of life. Anne Marie, a lymphoma patient, did not have an oral evaluation at the start of treatment. The very potent chemotherapy she had was effective for the lymphoma but severely compromised her bone marrow and oral cavity, resulting in neutropenia and platelet depletion causing infections and hypotension that required hospitalization. An oral examination then revealed she had thrush, poor dentition and periodontal disease, the latter causing sepsis from periodontal bacteria circulating in the bloodstream. Her poor state of oral and systemic health now threatens the cure of her lymphoma.
It is unlikely that any of these disastrous outcomes would have happened had there been attention to oral health and collaboration between dental and oncology providers from the start, Dr. Nichols said. Now that so many problems need attention, she added, it was particularly important that their treatments avoid times when the patient’s neutropenia and platelet depletion were at their worst. Also important is to list and compare medications prescribed by either the oncology or dental team. Dr. Nichols went on to commend the role of dental professionals in diagnosing head and neck cancers, in noting lymphadenopathy, which can be a sign of infection or malignancy, and in identifying gingival hyperplasia, which can be a sign of leukemic infiltrates.
Her concluding remarks concerned the Leukemia and Lymphoma Society, whose mission she said, is to cure all cancers, not just those that are blood-related. The society serves as an information resource for patients and their families. It also advises patients and providers of the availability of clinical trials and the necessity of dental clearance.
Dr. Christopher J. Smiley, a practicing dentist, was the reactor to the webinar. Dr. Smiley is also Editor of the Journal of the Michigan Dental Association and an ardent supporter of integrating dental and medical care. With regard to the webinar, he spoke of having a dual perspective, as a dentist and also as a patient advocate. In this case the patient was his wife, who had been diagnosed with acute myeloid leukemia and who had had a bone narrow transplant. He and their daughters presided over her treatment and hospitalization, and he was pleased to report that six years had passed since the transplant, and she was doing well.
Not so, however, was an alveolar rhabdomyosarcoma patient whose dental photograph Dr. Smiley showed revealed rampant tooth decay. The patient’s dentist was not able to monitor the patient’s multi-treatment by the cancer team, which included a calorie-rich cariogenic diet to build strength, the avoidance of fluoride because it irritated the gums, and medications with added sugar to treat other oral infections.
How is that situation possible, Dr. Smiley mused, and he reflected on the long tradition of separate modes of education and training, and of care delivery and even consideration of benefits in health plans that have effectively kept dentistry outside the realm of medicine, a tradition that leaves medicine bereft of knowledge of the oral cavity, or even that dental needs may be “medically necessary’’ — a term that now raises concerns among some dentists who worry that could make physicians gatekeepers over what dentists can do.
One way to overcome these limitations, Dr Smiley said, at least for cancer and transplant teams, would be to assure that the hospital centers where the teams operate have a dental service or a general dental residency in place or a dental hospitalist on staff for consultation. He also proposed calling on the American Dental Association to convene a panel to discuss the issues and invite organizations which had signed on to the National Community Statement.
Dr. Smiley also had specific questions for each of the presenters. He asked Dr Cooper, as President-elect of UNOS, what strategies he might invoke to overcome barriers to including dentists on transplant teams. Dr. Cooper said that the UNOS group was not large and frequently talked each to each other so he thought that continuing to tell the kinds of stories they had just been hearing would be effective. Dr. Smiley asked Dr. Kennedy-Sheldon what she would do to create more multidisciplinary teams in cancer care. She agreed that the separation of dentistry from medicine was a detriment but that similar separations excluded nurses, dental hygienists, and other health professionals to the detriment of optimal patient care. She strongly advocated for interprofessional education and joint training so that students in different health professions learn and work together. Dr. Smiley’s question for Dr. Nichols was whether she thought the Joint Commission should require the inclusion of dentists on cancer care teams. She replied that she thought that prescription was too narrow. The real issue, she said, was that much cancer care takes place not in big city academic medical centers where access to dental expertise is readily available, but in communities lacking such facilities, where cancer patients may be in touch with scores of individual dentists each in separate practices. The real issue is education. Patients—and providers—need to understand why oral health is important in cancer treatment. She, too, saw the need for more interprofessional education and beginning the integration of medicine and dentistry early in health professional training.
In the final round of questions from the audience Dr. Haber asked the group what strategies they would employ to address coverage of dental care when so many patients lack dental insurance or other means of payment. And further, what vehicle would best serve to provide that coverage: Medicaid, Medicare or private insurers?
The group agreed that cost-effectiveness was key. The cost of oral health prevention and treatment at the outset of cancer care or transplant surgery followed by monitoring and rapid response to issues arising in due course was minimal compared to the cost of untreated dental problems intensified by treatment regimens that might require hospitalization, delay ongoing treatment protocols, add pain, discomfort and further depress the quality of the patient’s life. There was further agreement that Medicare, already stipulated in the National Community Statement, was the appropriate vehicle for adding dental coverage, at least initially. Indeed, Dr. Cooper said the transplant group had already successfully employed a cost-effectiveness argument to effect a change in Medicare policy. Instead of a limited three-year time period for coverage of immunosuppressive drugs for transplant patients Medicare now extends coverage indefinitely. The reason? The time limits resulted in organ transplant failures, complications. hospitalizations, and returns to costly dialysis. The transplant group was able to demonstrate that by continuing immunosuppressive drug coverage the cost savings to Medicare would amount to $50 million over a 10-year period.