Blakaj A, Bonomi M, Gamez ME, Blakaj DM. Oral mucositis in head and neck cancer: Evidence-based management and review of clinical trial data. Oral Onc. 2019; 95:29-34
Mouth Care for Head and Neck Cancer Patients – a Dental Hygienist's Perspective Jocelyn Harding Dental Update 2024 47:10, 707-709.
Authors
JocelynHarding
CEB DipDH
Clinical Ambassador for the Mouth Cancer Foundation, OMFS HNC Dental Hygienist, Gloucestershire Royal Hospital and Confident Dental and Implant Clinic, Gloucestershire, UK
A proactive approach to the mouth care of head and neck cancer patients, from their initial visit to their discharge, is vitally important. This area of care is complicated by many factors, of which some patients will not be aware when they start their difficult journey. This article is written to give the reader an insight into the dental hygienist's perspective of mouth care before, during and after treatment and then graduating the patient back into primary care. The treatment for each head and neck cancer patient is varied, therefore the process of healing post-surgery and therapy can be complicated. Balancing patient's expectations before and after diagnosis is a difficult task and may be impossible to predict, which makes this area of care complicated and involved for the dental hygienist.
CPD/Clinical Relevance: The diagnosis and treatment of head and neck cancer takes place in hospitals and involves a team of clinicians, including dental hygienists. Once patients treated for such cancers return to general dental practice, it is essential that general dental practitioners (GDPs) and their teams have a clear understanding of how they have been treated and how GDPs and their teams can contribute to the patients' aftercare.
Article
Incidence rates for head and neck cancer in the UK during 2015–2017 was highest in the 70–74 years age group and with an ageing population with comorbidities to consider, complications can occur.1 According to United Kingdom Oral Management in Cancer Care Group (UKOMiC), ‘Oral problems and damage can be temporary or permanent resulting in a significant health burden for the individual while making substantial demands on limited heath care resources’.2 Individual advice given by the dental hygienist and dental therapist is necessary for the patient, whilst being mindful of their psychological effects as well as their physiological effects.
As stated in the guidelines from the Royal College of Surgeons of England/British Society for Disability and Oral Health that suggest we should ‘…improve the quality of life for patients with malignant disease, who are receiving cancer therapy that has implications for oral comfort and function, by promoting consistent, evidence-based high standards of oral care through a co-ordinated team approach.’3
Initial considerations
Psychological impact
The psychology of patients throughout this journey is complex, so a patient's visit to a dental hygienist immediately after their multidisciplinary team (MDT) meeting needs to be carefully managed. Mouthcare immediately following diagnosis at this stage involves giving careful oral health advice only. Extractions will have been advised by the specialist for teeth with a poor prognosis and this can be overwhelming for some patients. Limiting information at this appointment to discuss bullet points of important oral hygiene advice may be all the patient can manage. It is best to be mindful not to overload the patient with information. At the initial dental hygienist's appointment, it is good practice to begin building a rapport with the patient whilst giving guidance and establishing the patient's own oral hygiene routine. A high fluoride toothpaste and fluoride mouthwash is prescribed, along with instructions for use in line with Public Health England (PHE).4 A patient's main concerns at this time can vary from organizing his/her finances, work-related problems or family issues, so oral health may not be a priority, especially if the patient is not a regular attender prior to treatment.
Information for carers
A patient may attend appointments with a partner, carer or supportive friend. This is an opportunity to offer practical support for the people who are involved in the patient's care. Charities and organizations can be signposted for support for the patient and his/her carers.5,6
Oral health advice
Oral health advice will include the type of toothbrush and frequency of brushing and, if necessary, suggesting changing from an electric toothbrush to a manual toothbrush or other softer options, if oral mucositis inhibits cleaning. There are versions of very soft filamented toothbrushes if brushing becomes very difficult. A patient's diet can be discussed at this point too. Our diet advice regimen for patients in secondary care about to embark on their cancer treatment is very different from diet advice for a patient in primary care. A patient will see a dietitian before they start their treatment and, although good dietary control is preferable, this will not always be possible, as the emphasis is upon ensuring oral comfort during therapy. Patients will be encouraged to eat a high sugar and fat diet before and during their treatment. This will help to rebalance the weight loss that commonly occurs during their treatment. Patients will commonly be supported with a percutaneous endoscopic gastrostomy (PEG). By working closely and collaborating with speech and language, therapists and dietitians, the patient's oral health can be supported. Good oral hygiene is encouraged, even when a patient is fed by other means.
Managing side-effects
Changes to the oral cavity and side-effects will have been explained to the patient prior to starting treatment, alongside supporting information from specialists. Side-effects of treatment can differ greatly between patients. A patient's medical history should be discussed and, if he/she smokes or drinks alcohol, encouragement should be given to get them to seek support for stopping smoking and lowering their alcohol intake.
Xerostomia
Xerostomia is a common long-term side-effect for radiotherapy patients and short-term side-effect for chemotherapy patients. Xerostomia significantly increases the risk of dental caries and gum disease, which will have been discussed by the specialists at the patient's initial visit. A hygienist appointment is another opportunity to have a discussion and raise awareness. In some cases, xerostomia may be present before commencing treatment owing to other medications; the patient may or may not be aware of this as xerostomia can be subjective. However, with head and neck cancer patients, this can affect their speech and swallowing and can be extreme. Severity of xerostomia may become more noticeable during treatment. This may improve slightly on completion but has the potential to be severe and long term for some patients.
The Challacombe scale of clinical oral dryness is a diagnostic tool that uses an additive scale to help clinicians record, quantify and monitor the extent of xerostomia present.7 Xerostomia and poor diet control during treatment causes rampant tooth decay so, following PHE guidelines for patients at high risk of caries, the prescription of a high fluoride toothpaste and fluoride mouthwash is prescribed.4 Dry mouth products are useful for long-term care, as are different options for toothbrush types should a patient struggle with cleaning due to soreness during treatment.
Dehydration
Dehydration is a common reason for xerostomia, so encouraging regular sips of water should be the initial recommendation along with reduction of caffeinated drinks. Ice chips or water spray bottles are other options. Saliva replacements, substitutes and stimulants are available, both on prescription and over the counter. Professionals also need to warn about the effects of acid erosion of tooth enamel from products that have a low pH, especially if the patient is dentate.
Oral mucositis (OM)
At the Oncology Forum meeting 2019, the problem of OM was highlighted by one of the speakers. Sonia Hoy, Clinical Nurse Specialist, described OM like ‘a severe burning of your mouth multiple times caused with pizza’. OM is a common side-effect of chemotherapy or radiotherapy. Symptoms usually start 5–10 days after chemotherapy or 14 days after radiotherapy. OM related to chemotherapy can resolve within a few days after completion of treatment, but OM related to radiotherapy typically lasts much longer. Clinically, sequelae of OM include significant pain, dysphagia, dehydration, dysgeusia, anorexia, significant weight loss, and increased susceptibility to secondary and systemic infections.8
Trismus
Trismus can occur after more invasive treatment. Referral to a physiotherapist for help and support can limit this side-effect and a jaw-opening device used regularly can help. Long-lasting effect of trismus can affect the ability to access tooth cleaning for the patient and the professional. Adaptations to toothbrushes may help with limited opening and oral irrigators may be an option to consider.
Viral and fungal infections
These are a common occurrence with immunosuppressed patients and the oncology team will consider the medication regimen appropriate for the patient.
Protheses
If the patient has had radical surgery, a denture or obturator may be fitted. Cleaning these prostheses is very important to help control food from stagnating and biofilm removal. With the complexities of oral surgery and implants placed for fixed or removable prostheses becoming more commonplace, supporting the patient with aftercare becomes even more crucial. Support from the dental hygienist is vital with educating the patient on how to keep appliances clean.
Dental caries and periodontal disease
These oral diseases are devastating for patients being treated for head and neck cancer if not strictly controlled. With the often life-changing problems of xerostomia, dental caries and periodontal disease are exacerbated and very difficult to control, because of difficulties of access and tricky post-operative soft and hard tissue configurations. Maintenance and prevention are vitally important for the long-term oral health of head and neck cancer patients. According to Cancer Research UK, ‘Each year more than a fifth (22%) of all new head and neck cancer cases in the UK are diagnosed in people aged 75 and over (2015–2017)’.1 Root caries is a major concern when caring for this group of patients and may be increased by dexterity issues, xerostomia and comorbidities. Restorations placed can be difficult to maintain and the aim is to prevent extractions, especially for head and neck cancer patients who have had radiotherapy treatment.
Osteoradionecrosis
It is important to be watchful for the occurrence of osteoradionecrosis (ORN) and to warn the patient that, should they have any symptoms, to attend for a review. Regular reviews with the patient's dental team are important to monitor oral health, as some areas may be difficult for a patient to see directly. A decision about how this will be treated will be discussed with the specialist.
Dysgeusia
With the difficulties of OM and xerostomia, patients will commonly use a PEG for nutrition. Once side-effects subside after completion of treatment, and patients can eat rather than use their PEG, they will often report a loss or altered sense of taste. The return of taste can occur slowly, but may not return at all. A metallic taste is not uncommon during treatment. This will often affect patients psychologically and reduce their desire to eat. Nutrition is vital for patients' ongoing health and a dietitian can offer support, with suggestions and alternatives the patient may prefer.
Dysphagia
The International Dysphagia Diet Standardization Initiative (IDDSI) created and published a framework adopted by the British Dietetic Association in 2019. This framework was created to standardize the description of the consistency of foods for people diagnosed with dysphagia. A patient will often report a difficulty with certain foods and this framework contains definitions for texture-modified foods and thickened liquids and comprises dysphagia levels (0–7), to categorize both food and fluid. This framework can be a support for healthcare professionals and the patient when they are struggling with food texture, taste or xerostomia. A dietitian can provide support with this and specialized cookbooks are available for patients to help expand their alternatives.
Fatigue
This is a common side-effect and patients will often report problems with fatigue, as this can affect them physically, mentally and emotionally. The Spoons Theory is an interesting visual representation of energy and how to be mindful of mental and physical energy.9
During treatment and post-operative care
During radiotherapy treatment, on average 6 weeks, a patient may not be seen in the outpatient's department. The next appointment will take place after radiotherapy, chemotherapy or surgical treatment. This appointment is a good opportunity to support the patient and discuss any concerns they have. Many patients will report fatigue and, although exhausted and shocked by their experience, will be considering the next stage in their journey. For a dental hygienist, this appointment will be for discussing the importance of good oral hygiene and, as far as possible, impressing the importance of good diet control for the future. A prescription for applying a high fluoride varnish and high fluoride toothpaste is an important part of the treatment plan going forwards. Saliva substitutes, lubricants and stimulants are available for the patient to try in order to cope with the long-term effects of xerostomia. The patient can ask the specialist for support with this. Many products are available on prescription or over the counter, and the patient will be keen to try those with different flavours, ingredients and viscosity.
Long-term maintenance plan
The frequency of appointments and how long the patient is seen in secondary care will very much depend on the complexities of the patient's treatments, including post-treatment psychological effects. This is even more important at this stage and should be monitored by all who are involved in the patient's care and any concerns raised should be passed to the patient's specialists or clinical nurse specialist immediately.
Continuation of the patient's routine dental care after discharge back to primary care is planned with the patient and his/her specialists for any ongoing regular examinations, with the aim to make the transition as smooth as possible. Unfortunately, a patient may not have been a regular dental attender prior to starting treatment, so the dental hygienist and outpatients' team should encourage the patient to ‘register’ with a general dental practice as soon as possible.
Conclusions
The dental hygienist's role in a head and neck cancer patient's journey is to provide support, education and advice for the patient on appropriate products and techniques to keep his/her risk for dental problems in the future as low as possible.
As a professional team member working in head and neck cancer care, it is a challenging and varied role that will stretch you as a dental hygienist, but it is a role that can really change lives.
