Getting patients to the dentist may not seem like an oncology nurse navigator’s duty, but that’s exactly the task assigned to Colleen Palay, BSN, RN, oncology nurse navigator at the Seidman Cancer Center at University Hospitals Case Medical Center, Cleveland, OH.
At the 2016 Oncology Nursing Society Annual Congress, Ms Palay described her role in caring for head and neck cancer patients, for whom dental care is an essential component of treatment.
“I deal with patients needing dental care on a regular basis. It can be very challenging,” she said.
In some rare and fortunate instances, the head and neck surgery department and dental oncology clinic are located in the same building, or even the same floor. But even large cancer centers must often rely on local dental schools and community dentists to provide services to head and neck cancer patients.
In these cases, she said, “You run into problems getting patients connected with dentistry soon enough. Ideally, the patient should be evaluated by a dentist prior to the initiation of treatment, soon after diagnosis.”
“Timing is very important,” she said. “If you get the patient to the dentist early enough, they can often save some teeth.”
Goals of Prompt Dental Care
The goals are to obtain a dental evaluation of the patient prior to the initiation of treatment; to educate patients and their families about the potential side effects of treatment, especially radiotherapy; and to teach proper dental hygiene for lifelong care after treatment is completed.
Collaboration among the nurse, dentist, and surgeon can make a difference in function after treatment. “Working together, we can help prevent things like crowning of a tooth beforehand, only to have the surgeon extract it,” she pointed out.
Dentists should understand the patient’s diagnosis, treatment plan, and potential risks and side effects as well as the patient’s comorbidities and medication use. The dentist will fully evaluate the patient’s oral cavity, remove sources of irritation, compromised teeth, and take measures that may prevent problems later. The dental team, along with nurses, will later monitor for signs of infection and educate the patient about the care of dentures, the use of fluoride and mouthwashes, and the proper brushing techniques.
Eating, swallowing, and speaking may be affected after treatment for head and neck cancer. The patient’s appearance may be altered, which can produce distress. Those who lose teeth may experience job discrimination. And there are clearly financial implications, she said.
Finding Dental Providers
“The financial issue is a big driver of frustration for both patients and providers,” Ms Palay said. “Patients without dental insurance or other financial means have a hard time finding providers and obtaining necessary care.”
Local dentists and academics at dental schools can sometimes be persuaded to see patients who lack the ability to pay. The American Dental Association may also help navigators identify dentists willing to provide pro bono care.
“If you find a dentist willing and able to care for your patients, see if a cancer center will contract with that dentist to help with evaluation and treatment,” she suggested.
Federally qualified “safety net dental clinics” are another resource for low-income patients, but waiting lists can be long. “I have tried calling, and it’s sometimes a 3-week wait unless the patient just goes and sits and waits for care,” she said.
Insurance Often Insufficient
Ms Palay emphasized that most dental work is not covered under health insurance. “For some reason the mouth is excluded from the rest of the body for the sake of insurance coverage,” she commented.
Medicare does not reimburse for preventive procedures done in preparation for the treatment of head and neck cancer, but it does pay for a limited number of services:
- Dental evaluations and extractions in preparation for radiotherapy; Medicare does not pay for the same evaluation if teeth are not pulled
- Hyperbaric oxygen therapy
- Debridement and mandibular reconstruction for osteoradionecrosis
- Treatment of acute side effects associated with treatment for lymphoma and leukemia (such as mucositis)
Medicaid pays for some dental services as well, but they are mostly for uncomplicated, preventive care and primarily in children.
Maureen Sullivan, DDS, Chief of the Department of Dentistry, Division of Oral Oncology and Maxillofacial Prosthetics at Erie County Medical Center, Buffalo, NY, further commented on the reimbursement issue in the session on dental oncology.
As a dentist who treats head and neck cancer patients, she said she does not request reimbursement for extractions prior to radiotherapy. “My goal is to have the insurer pay for reconstruction and prosthetics,” she said. While extraction may seem medically necessary, clinical guidelines do not consider it so. To submit for reimbursement for anything not authorized, she added, “is risky business…if a dentist is audited by a governing body, he or she will lose.”