Cancer-Related Oral Health Care Services and …patients with cancer, oral complications have been associ-ated with considerable morbidity. Oral mucositis has been reported as the

Journal of the Canadian Dental Association302 May 2004, Vol. 70, No. 5

P R O F E S S I O N A L I S S U E S

Prevention and management of oral complications ofcancer and cancer therapy are important for improv-ing quality of life and oral function, reducing

morbidity and reducing the cost of care (Table 1).1–6 Oralmucositis is an acute complication of cancer therapy thatlimits the intensity of therapy, and may result in breaks intherapy and cessation of therapy, thus limiting successfultreatment of the cancer.

Infections in patients with neutropenia may result inmorbidity and mortality. After hematopoietic stem celltransplant (HSCT), patients may have chronic complica-tions such as hyposalivation, infections, increased dentalcaries, mucosal sensitivity, changes in taste and oral graft-versus-host disease. Acute and chronic complications have agreat impact on quality of life. Oral assessment, and oral

and dental care have been strongly recommended beforecancer therapy and should be continued during and aftercancer therapy.1

The purpose of this survey was to assess the resourcesavailable for oral care in Canadian cancer centres.

MethodsA questionnaire was developed and pretested at 2 hospi-

tals. The questionnaire (see Appendix 1, Cancer-relatedoral health care survey, at http://www.cda-adc.ca/jcda/vol-70/issue-5/302.html) was mailed to 24 provincialcancer centres in 1999. The administration was asked tohave dental providers or knowledgeable oncology staffcomplete the survey and to return it to the investigators.Two follow-up mailings were forwarded to nonrespondingcentres at 2-month intervals. Data from the returned

Cancer-Related Oral Health Care Services andResources: A Survey of Oral and Dental Care

in Canadian Cancer Centres• Joel B. Epstein, DMD, MSD, FRCD(C) •

• Ira R. Parker, DDS, MA, MPH •• Matthew S. Epstein •

• Peter Stevenson-Moore, BDS, MRCD(C) •

A b s t r a c tPurpose: Prevention and management of oral complications of cancer and cancer therapy will improve oral function

and quality of life, and reduce morbidity and the cost of care. Oral assessment, and oral and dental care havebeen strongly recommended before cancer therapy and should be continued during and after cancer therapy. Thepurpose of this survey was to assess the resources available for oral care in Canadian cancer centres.

Methods: Provincial cancer centres were assessed by questionnaire to determine the resources available for oralcare in these facilities.

Results: Wide variability in oral and dental care of patients with cancer across Canada and a lack of documentedstandards of care were reported. Very few cancer centres had institutionally supported dental staff to supportthe oral care of patients with cancer, and few had dental treatment capability on site. The majority of centresmanaged oral care needs in the community with the patient’s prior dentist.

Conclusions: We recommend that national guidelines be developed for medically necessary oral and dental carefor patients with cancer.

MeSH Key Words: antineoplastic agents/adverse effects; Canada; comprehensive dental care; health resources; mouth neoplasms

© J Can Dent Assoc 2004; 70(5):302–4This article has been peer reviewed.

May 2004, Vol. 70, No. 5 303Journal of the Canadian Dental Association

Cancer-Related Oral Health Care Services and Resources

questionnaires were entered in a Microsoft Excel spread-sheet and reviewed.

ResultsResponses were received from 20 cancer centres in all

provinces except New Brunswick. The overall response ratewas 83% of surveys mailed.

All centres provided treatment for head and neck squa-mous cell carcinoma. Responding centres recorded a totalof 2,415 cases per annum. Radiation treatment units available at responding centres were cobalt at 17 centres, fora total of 21 units; linear accelerators at 18 institutions, fora total of 45 units; and brachytherapy or implant sources at12 centres. Nineteen centres used chemotherapy; 12 ofthese did so in an in-patient treatment setting. HSCT wasdone in 7 centres. A total of 27 patients received matchedunrelated donor transplants; 79, allogenic transplants; 174,autologous transplants; and 88, peripheral stem cell trans-plants in the prior year.

Nine respondents indicated that medical staff managedtreatment-associated oral or dental complications. Thirteenstated that oral complications were managed by commu-nity-based private dental practitioners, the majority ofwhom were the patients’ own private dentists; 9 were hospi-tal dentists and 5, dentists at the cancer centre. A total of4.7 full-time equivalent (FTE) dentists were on the staff ofthe reporting centres.

Six centres had dental departments and 4 of these wereinvolved in research. Dental facilities reports indicated atotal of 8 facilities with dental operatories, 4 with officespace for dental staff and 5 with dental radiographic facili-ties. Two reported regularly scheduled operating room timeand hospital beds available for oral and dental treatment.Five centres had a dental coordinator.

Twelve centres reported providing dental examinations,10 dental treatment and 11 patient education before treatment for cancer. Fourteen centres stated that urgentdental care was available if needed, 12 provided oral anddental care during treatment for cancer and 13 providedongoing care after treatment for cancer. Palliative care wasprovided at 10 clinics. Separate dental records were kept at10 centres.

Dental treatment before radiotherapy was provided for all patients at 12 centres and for patients with oral ordental complications at 2 centres, and was not required in1 centre. No definite protocol for dental treatment beforeradiotherapy was available in 4 centres. For patients receiving chemotherapy, no centre required assessment ofall patients, 8 centres requested treatment for those withoral or dental complications, 2 did not require assessmentfor any of their patients and 9 had no definite protocol forevaluation and treatment before chemotherapy. Patientsabout to receive HSCT were seen routinely before treat-ment at 4 centres and at 1 centre when oral or dentalcomplications were noted, but no definite protocol was inplace at 4 centres. Routine follow-up of patients afterHSCT by dental staff was reported for 2 of 7 centres.

DiscussionThis survey demonstrated that provincial oncology

centres had programs for oral and dental care in patientsreceiving radiation therapy to the head and neck, but fewerwell-established programs for patients receiving chemother-apy and HSCT. The programs varied from care deliveredin-house to community dentists, some of whom had additional experience and some of whom had no additionaltraining or experience who were the patient’s prior generaldental provider. Across the country few FTE positions (4.7 FTEs) were reported, and only some facilities hadinstitutionally based clinical services. Over half of the clinics required dental assessment and treatment in preparation for cancer therapy. Fourteen of 20 centresstated that urgent dental care was available, but just overhalf provided care during cancer treatment. Protocols wereless well established for patients receiving chemotherapy. In high-risk HSCT patients, 4 of 7 centres providedsupportive oral care, although no definite protocols werein place in 4 centres. In addition, routine follow-upof these patients was provided by only 2 of 7 centres, despite well-known oral complications of transplanta-tion. Approximately 60% of facilities reported that

Table 1 Oral complications of and preventiveprograms for cancer therapy

Acute complications: care before and during cancer therapy

Mucositis: mucosal ulceration, oropharyngeal painHyposalivation: increased viscosity, reduced volumeMucosal infection: fungal, viralExacerbation of dental or periodontal diseaseCaries or demineralization risk; gingivitisTaste disturbance

Preventive programs before and during cancer therapy

Mucositis: preventive program, pain management, diet instructionGingival health: oral or dental hygieneCaries prevention: oral hygiene, fluoride, chlorhexidine, diet, salivaSaliva management: sialogogue, fluid intake, mucolyticManagement of dental emergenciesManagement of oral mucosal infectionsExercises for range of motion of the jaw for patients having radiationReinforcement of tobacco or alcohol cessation

Chronic complications: care after cancer therapy

Mucosal conditions: fibrosis, atrophy, sensitivitySalivary gland dysfunction: flow rate, consistency, functionTaste dysfunctionCaries or demineralization riskProblems with dental prosthesis fit or functionSoft tissue conditions or osteoradionecrosisFibrosis of muscles or soft tissueNeuropathySpeech, esthetic concernsOropharyngeal or head and neck pain

Journal of the Canadian Dental Association304 May 2004, Vol. 70, No. 5

Epstein, Parker, Epstein, Stevenson-Moore

complications were managed in community dental offices,the majority of which were those of the patient’s priordentist; less than half of the patients were treated by dentistswith additional experience and training.

Oral care has been increasingly recognized as an indispensable part of overall health care.7 Specifically, forpatients with cancer, oral complications have been associ-ated with considerable morbidity. Oral mucositis has beenreported as the most distressing of all complications forpatients having head and neck radiation therapy, andhematopoietic cell transplant.5,6 Oral mucositis is an acutecomplication of cancer therapy that limits a patient’s abilityto complete a course of therapy, may require modificationof the treatment schedule and can interrupt cancer therapy.In addition to being the most distressing complication ofsome cancer treatment protocols, oral mucositis in HSCThas a major impact on the cost of care.3 A 1989 NationalInstitutes of Health developmental conference on oralcomplications of cancer therapies strongly recommendedprecancer treatment and oral-care assessment and treatment,and reviewed state-of-the-art practices for the preventionand management of the oral complications commonly seenin these patients.1 In addition, osteoradionecrosis is reducedin patients who have had comprehensive oral or dentalassessment and management before radiation.8 Thus, oralor dental programs for patients with cancer have beensupported as an integral component of precancer therapycare and for patients during and after cancer therapy. Oralcomplications of outpatient cancer therapy have been thesubject of few studies.9,10 At least in part because of this, theInstitute of Medicine of the National Academy of Scienceshas recommended enhanced dental and medical educationto prepare future providers for the care of medicallycomplex patients. Unfortunately, as in medicine, outcomemeasures of such interventions have limited support in theliterature.11,12 Ongoing research is needed to identify beneficial outcomes of a comprehensive program for oralassessment and care for patients with cancer. In the absenceof population-based outcome studies, anecdotal reportingof the complications of cancer treatment remains common,although the number of studies about oral management of these patients is increasing.

ConclusionsResults of this survey showed a wide variability in the

oral and dental care of patients with cancer across the country and a lack of documented standards of care. Thesurvey also showed a wide disparity in the supervision of oral care: fewer than 5 FTE positions existed across the country. We recommend that a national consensusstatement about the medically necessary oral and dentalcare, before, during, and after cancer therapy, be developed

and guidelines established. C

Dr. Epstein is professor and head of oral medicine anddiagnostic sciences, College of Dentistry, and director ofthe interdisciplinary program in oral cancer, College ofMedicine, Chicago Cancer Center, Chicago, Illinois,and was formerly on the medical–dental staff of theBritish Columbia Cancer Agency and VancouverHospital, Vancouver, British Columbia.

Dr. Parker is associate clinical professor of medicine,University of California at San Diego, San Diego,California.

Mr. Epstein is research associate, Fred HutchinsonCancer Research Center, Seattle, Washington.

Dr. Stevenson-Moore is provincial practice leader,department of dentistry, British Columbia CancerAgency, Vancouver, British Columbia.

Correspondence to: Dr. Joel Epstein, Department of Oral Medicineand Diagnostic Sciences, College of Dentistry, University of Illinois atChicago (MC 838), 801 S. Paulina St., Chicago, IL 60612. E-mail:[email protected] authors have no declared financial interests.

References1. National Institute of Health Consensus Development Conference onOral Complications of Cancer Therapies: Diagnosis, Prevention, andTreatment. Bethesda, Maryland, April 17–19, 1989. NCI Monogr 1990;9:1–184.2. Miller CS, Epstein JB, Hall EH, Sirois D. Changing oral care needs inthe United States: the continuing need for oral medicine. Oral Surg OralMed Oral Pathol Oral Radiol Endod 2001; 91(1):34–44.3. Sonis ST, Oster G, Fuchs H, Bellm L, Bradford WZ, Edelsberg J, and others. Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation. J Clin Oncol 2001;19(8):2201–5.4. Epstein JB, Robertson M, Emerton S, Phillips N, Stevenson-Moore P.Quality of life and oral function in patients treated with radiation therapyfor head and neck cancer. Head Neck 2001; 23(5):389–98.5. Bellm LA, Epstein JB, Rose-Ped A, Martin P, Fuchs HJ. Patient reportsof complications of bone marrow transplantation. Supp Care Cancer2000; 8(1):33–9.6. Rose-Ped A, Bellm LA, Epstein JB, Trotti A, Gwede C, Fuchs HJ.Complications of radiation therapy for head and neck cancers. CancerNurs 2002; 25(6):461–7.7. Institute of Medicine Report. Dental education at the crossroads: challenges and changes (1995). Washington (DC): National AcademyPress; 2000.8. Epstein JB, Rea G, Wong FL, Spinelli J, Stevenson-Moore P.Osteoradionecrosis: study of the relationship of dental extractions inpatients receiving radiotherapy. Head Neck Surg 1987; 10(1):48–54.9. McCarthy GM, Awde JD, Ghandi H, Vincent M, Kocha WI. Risk factors associated with mucositis in cancer patients receiving 5-fluorouracil. Oral Oncol 1998; 34(6):484–90.10. McCarthy GM, Skillings JR. Orofacial complications of chemother-apy for breast cancer. Oral Surg Oral Med Oral Pathol 1992; 74(2):172–8.11. Patton LL, White BA, Field MJ. Extending Medicare coverage tomedically necessary dental care. J Am Dent Assoc 2001; 132(9):1294–9.12. Patton LL, White BA, Field MJ. State of the evidence base formedically necessary oral health care. Oral Surg Oral Med Oral Pathol OralRadiol Endod 2001; 92(3):272–5.

mailto:[email protected]


May 2004, Vol. 70, No. 5 304aJournal of the Canadian Dental Association

Appendix 1 Cancer-related oral health care surveyOral/Dental care survey of comprehensive cancer centers

Oncology Treatment Services Survey Number ___

1. Please estimate the number of head and neck cancer patients your cancer center treats annually: ____

2. Does your cancer center provide radiation therapy services? Yes No(If your answer to question 2 is “Yes”, please complete the following section; otherwise, please proceed to question 3).

Please estimate the number of head and neck cancer patients treated with radiotherapy annually: ____

What kind of radiation units do you have? How many?Cobalt Yes No # ___Linear Accelerator? Yes No # ___Other?Please list “other”: __________________________________________ # ___

Do you have facilities for radioactive implant therapy? Yes No

3. Does your cancer center provide chemotherapy services? Yes No (If your answer to question 3 is “Yes”, please complete the following section; otherwise, please proceed to question 4).

Do you provide inpatient chemotherapy services? Yes NoPlease estimate the number of patients treated with inpatient chemotherapy annually: ___Do you provide outpatient chemotherapy services? Yes NoPlease estimate the number of patients treated with outpatient chemotherapy annually: ____

4. Does your cancer center provide bone marrow transplant services? Yes No(If your answer to question 4 is “Yes”, please complete the following section; otherwise, please proceed to question 5).

Please estimate the number of bone marrow transplant patients in the following categories:Matched unrelated donor transplants: ___Allogeneic donor transplants: ___Autologous transplants: ___Peripheral stem cell transplants: ___Other: ___

Oral/Dental Support Services:

When oral or dental problems are identified, how are these problems managed?Medical staff? Yes NoDental provider(s) in the community-based private practice? Yes NoReferral to a hospital-based dental provider? Yes NoReferral to other facility? Yes No

5. From what source(s) do your cancer center patients receive oncology-related dental consultation, interventional dental care and emergency/urgent care?

(Choose all applicable from the list below):

From a cancer center dental department? Yes NoFrom a cancer center-associated dental consultant(s)? Yes NoFrom a dental school? Yes NoFrom the patients’ own community-based dental provider? Yes NoOther: _________________________________________

6. Does your cancer center have a dental department? Yes No(If your answer to question 6 is “Yes”, please complete the following section; otherwise, please proceed to question 7).

Dental Department Personnel and Facilities:Full-time dental professional equivalents (FTEs)? ___Number of dental operatories? ___Administrative office space? Yes NoSterilization facilities within the dental clinic? Yes NoDental radiology capabilities? Yes NoAccess to operating room facilities? Yes NoDedicated hospital bed(s)? Yes NoIs the dental department involved in research activities? Yes No

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Epstein, Parker, Epstein, Stevenson-Moore

304b May 2004, Vol. 70, No. 5

7. Does your cancer center have dental consultants? Yes No(If your answer to question 7 is “Yes”, please complete the following section; otherwise, please proceed to question 8).

Resources Available to the Consultant(s):

Full-time dental professional equivalents (FTEs)? ___Number of dental operatories provided by the center ___Dedicated space for dental examinations? Yes NoAdministrative office space? Yes NoDental radiology capabilities? Yes NoAccess to operating room facilities? Yes NoDedicated hospital bed(s)? Yes No

8. What kind of dental services does your dental department/dental consultant(s) provide to cancer center patients?(Choose all applicable answers from the list below):

N/A-no dental department/dental consultant at this cancer center Yes NoPre-intervention oral/dental examinations Yes NoPre-intervention comprehensive dental care Yes NoHealth education/health promotion counseling Yes NoEmergent/urgent dental care during intervention Yes NoOn-ward patient management Yes NoFollow-up care for cancer or treatment-related complications Yes NoPalliative care Yes No

9. If your cancer center does not have a dental department or a dental consultant(s), do you have a designee who coordinates oncology-related dental consultation and dental care? Yes No

10. Are dental consult requests, dental consult findings, and/or dental treatment records included in the medical record?Yes No

11. Which patients are required to receive a pre-intervention oral/dental examination prior to radiotherapy treatment of the head and neck region?(Circle one answer)

a. all patientsb. only patients with oral/dental complicationsc. no patients are requiredd. there is no defined protocol.

12. Which patients are required to receive a pre-intervention oral/dental examination prior to chemotherapy? (Circle one answer)


13. Which patients are required to receive a pre-intervention oral/dental examination prior to bone marrow transplantation? (Circle one answer)


14. Are routine in-patient oral care follow-up visits provided to every bone marrow transplantation patient? (Circle one answer)


15. Which patients are required to receive a pre-intervention oral/dental care exam prior to radiotherapy treatment, chemotherapy or bone marrow transplantation? (Circle one answer)



May 2004, Vol. 70, No. 5 304cJournal of the Canadian Dental Association

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Documents

Cancer-Related Oral Health Care Services and …patients with cancer, oral complications have been associ-ated with considerable morbidity. Oral mucositis has been reported as the