Incorporating cancer survivorship care in dental education.

Abstract

As modern medicine continues to evolve, pediatric cancer survival rates have significantly improved.1 Over the past few decades, 5-year survival rates have increased from 58% in children (0–14-year-old) and 68% in adolescents (15–19-year-old) to approximately 85% in children and adolescents, according to the National Cancer Institute.2 As survivorship increases, the chronic effects of therapeutic cancer treatment are becoming increasingly apparent.1 In order to manage these systemic chronic consequences, it is vital that the patient's pediatric oncology team complete a successful transition of care to the patient's primary care team as the patient ages from adolescence into adulthood. As pediatric cancer survivors transition from their oncology care team provider to a primary care provider in adulthood, oral healthcare is often not included in this transition of care. Successful transition of patient care from adolescence into adulthood for pediatric cancer survivors should include oral healthcare, and our dental education curriculum should prepare future dental providers to recognize and manage the oral health sequelae of cancer treatment. Oral health care is an important component of cancer survivorship care. Pediatric patients who undergo cancer therapy are likely to develop dental and craniofacial problems.3 Following chemotherapy, patients are at an increased risk for developing caries, having shorter roots, and having developmental enamel defects.4 Patients may experience trismus, temporomandibular joint (TMJ) dysfunction, and stunted growth and development of the dentition and its supporting structures.4 Cancer survivors are also at an increased risk for developing secondary cancers and osteoradionecrosis of the jaw following invasive dental treatment.4, 5 Overall, multispecialty dental treatment is often needed to meet the functional and esthetic needs of these patients. In order to effectively manage the complex oral health sequelae stemming from cancer treatment, it is vital that oral health care be included when these patients transition from adolescence into adulthood. Despite the increased risk of complications following cancer treatment, research shows that cancer survivors experience disparities in accessing adequate and appropriate survivorship care.6 These disparities exist at the provider level and at the level of healthcare coverage. At the provider level, barriers include geographic limitations related to resources or key specialized services, difficulty transitioning a patient to adult survivorship surveillance care, inadequate survivorship care training, and a lack of in-network providers and specialists to provide long-term survivorship care.6 These disparities noted in medicine also exist in dentistry. At the provider level, the ability to manage the oral complications resulting from cancer treatment requires specialized knowledge. If dental providers do not feel adequately trained and prepared to manage these complications, they will not do so. This will ultimately lead to disparities in oral health outcomes stemming from diminished access to care. Including information on the management of cancer survivors within the predoctoral dental education curriculum that targets treating patients with special healthcare needs can help improve provider comfort with managing the complex oral needs for this patient population. The Commission on Dental Accreditation requires that the predoctoral dental education curriculum include didactic and clinical components that aim to prepare students for managing and caring for patients with special healthcare needs. This includes managing and caring for the oral health needs of cancer survivors with complex medical and dental needs. It is difficult to thoroughly prepare students didactically to understand and manage the oral needs of all medically complex patients. However, we can familiarize students with available resources that outline the oral manifestations of cancer treatment and teach students the value of anticipatory guidance and preventive oral health services for this particularly high-risk patient population.5 Teaching the core principles associated with managing patients with special healthcare needs, paired with a focus on improving critical thinking skills related to treatment planning and patient management within the predoctoral curriculum can help improve provider comfort with treating/triaging medically complex patients. It is also important that future oral health providers are taught to recognize when the dental treatment needs of this patient population are beyond their scope of practice and a referral to a specialist is warranted. Improving oral health provider comfort with treating this patient population must be paired with a commitment to ensure that there is a continuation of oral healthcare when transitioning from adolescence into adulthood. Care transition models are becoming an important field of interest to help facilitate a successful and efficient transfer of care that support long term positive health outcomes. Costello et al. argue that the current transition of care from oncology to primary care needs to significantly improve and proposed the use of telemedicine in facilitating successful transition of care from adolescence to adulthood.7 In their study, Costello et al. note that the largest barrier for the use of telemedicine in primary care offices was provider discomfort with technology use.7 Many of the primary care physicians were unable to set up the telemedicine equipment successfully, leading to a logistically difficult telemedicine appointment.7 However, patients did note the importance of having both their oncology team and primary care provider on the same telemedicine appointment for a successful transition of care.7 In a similar manner, oral health providers should be included during this care transition appointment for a team-centered approach. Research indicates that teledentistry improves access to care for underserved populations by facilitating the successful connection between providers and patients in real time.8 Additionally, improvements in oral hygiene habits and oral health knowledge have been noted following the use of teledentistry in vulnerable patient populations.8 Teledentistry can help providers follow up on oral hygiene instructions for patients in a more convenient setting, at more frequent intervals, and in a more cost effective way. Including oral health providers in the telemedicine appointment will not only help oral healthcare providers understand the patient's cancer treatment protocol, but it will also ensure that the patient has access to an oral health care provider. Understanding the patient's cancer treatment protocol is imperative, so that oral health providers are aware of the risks for specific oral complications and are informed of the appropriate and individualized anticipatory guidance needed for each patient. An important factor that facilitates the successful utilization of oral healthcare services is comprehensive dental insurance coverage. Dental care for children is widely covered under both private and public insurance plans. However, as adolescents transition into adulthood, Medicaid dental coverage becomes limited or terminated on a state-by-state basis. For states with Medicaid dental benefits, it is difficult to find available providers, especially is underserved areas. One major challenge of Medicaid programs is dental provider willingness to participate in the programs, which greatly impacts access to care for particularly vulnerable patient populations.9 Consequently, access to care does not always equate to utilization of care. Pediatric cancer survivors are at a higher risk for having unmet dental needs, and those without insurance often have higher reported rates of unmet dental needs due to the difficulty in finding oral healthcare providers.4 Improvements in the Medicaid programs must be made at the patient and provider level when working to reduce disparities in oral health outcomes. It is imperative that as a profession we advocate for the successful transition of oral healthcare for cancer survivors. Equipping our dental students with the tools necessary to understand the clinical sequelae for pediatric cancer survivors is integral in facilitating a successful transition of care from adolescence into adulthood. Oral health is an important component in quality of life measurements, and the transition among oral healthcare providers between adolescence and adulthood should be paired at the time of the transition from the oncology team to the primary care team to ensure a seamless transition of comprehensive care. Integrating dental care with oncology as a part of the pediatric cancer patient's overall care team can vastly improve successful transition of oral health care with primary care as well. In addition, efforts should be increased to improve access to oral health services and reform within Medicaid dental programs that encourages increased Medicaid provider enrollment may be necessary.