Innovations in Dental Care Part A
The Head & Neck Cancer Innovations 2020 Video Series is brought to you by St Vincent’s Hospital Sydney & The Kinghorn Cancer Centre. In this episode we talk to special needs dentist and university lecturer Sharon Liberali about innovations in the dental treatment of head & neck cancer patients. For more information please visit our website or our You Tube channel. The podcast versions can be found on our SoundCloud channel.
Julie McCrossin, Head & Neck Cancer Survivor
A/Prof Sharon Liberali, Special Needs Dentist, Adelaide Dental Hospital
Hello, my name is Julie McCrossin. And I’m so pleased to welcome you to this video looking at innovations in dental care for people with head and neck cancer. And this is part of a series of videos looking at innovations in care, in all aspects of care, for people with head and neck cancer, as we seek to improve survival, but equally importantly, quality of life. I myself am a former head & neck cancer patient. I was treated seven years ago for cancer in my tonsils, tongue and throat with radiation and chemo and, like everybody else, I’ve had a few of my own dental issues.
Today we are coming to you from Sydney, on the land of the Gadigal people of the Eora nation and I’d like to pay my respects to elders past and present and to emerging leaders. And in Adelaide, where we’re about to meet a Special Needs Dentist broadcasting from the land of the Kaurna people. And I want I want to acknowledge that Aboriginal people and some Torres Strait Islander people are disproportionately affected by the head & neck cancers that we’re talking about.
This series of videos are hosted by St Vincent’s Hospital Sydney and The Kinghorn Cancer Centre. And we thank them so much for their support. So here we go to Adelaide and how excited I am to do so. Sharon, can you introduce yourself to our patients and clinical teams watching this? And just tell us in a nutshell what you do?
Thanks very much, Julie. So as you said, I’m a specialist in special needs dentistry. And that means that I provide oral health care and provide, I guess, information to my patients who have medical treatments, or are receiving medical care for either head neck cancer or any sort of medical treatment, like perhaps a transplant and things like that.
But I also take care of people that have intellectual, physical or psychiatric health issues as well. But I do a lot of head and neck cancer treatments.
And how did you get involved in head and neck cancer? What? What brought you to that area of work?
That’s a really good question, Julie. I think I, as a very younger dentist was interested in something different in dentistry. Just didn’t want to spend my time, you know, doing fillings and cleans and dentures. And I wanted to care for more vulnerable members of the community. So I got quite heavily involved in more intellectually disabled, provision of oral healthcare for that cohort of patients.
And then it sort of spread from there. So it was, sort of, I guess, an interest to do something to the parts of the community and care for the parts of the community that, you know, we’re sort of often missed out on, or neglected, and then it sort of grew from there.
Well, you can imagine how interested people are to hear what you’ve got to say, because many head & neck cancer patients rely tremendously on dentistry and dentists, and yet, don’t always get easy access. So I’ve got to ask you a lot of questions from we’ll move efficiently through it together. I want to start with your four key messages and get an overview of your thoughts on key issues for head and neck cancer patients. And then we’ll go into each of them in more depth.
Now, your first key message is that head and neck cancer patients need to be managed by a multidisciplinary team. For a brand new patient or family member watching this, what’s a multidisciplinary team and why is it so important that a dentist is part of it?
So a multidisciplinary team are basically all the healthcare workers that will be involved in your care. And for a patient that has a head & neck cancer, that’s going to be the group of surgeons that may be involved. And they may be the maxillofacial surgeons, the plastic surgeons, the ENT surgeons. It will be the oncologists involved, whether it’s the medical oncologists that provide the chemotherapy or the radiation oncologists.
It’s all the Allied Health people that support that care. The speech pathologists. The dietitians. Its the radiologists that interpret all the imaging you have done, whether it’s CT scans, or MRIs or PET scans. It’s people like Tracey, who we’re going to meet as well, that coordinate the care for us and is a point of contact for the patient and also for all the multidisciplinary team.
And it’s also then the dentists because, head & neck cancer, you can’t separate the oral cavity and the care of your oral health from that. So the benefit of a multidisciplinary team is that all those players know each other. All those players communicate with each other. And most importantly, everyone knows the intent of that patient’s treatment, and what’s going to be provided to that patient during the treatment and then in the longer term as well.
And my understanding is that another key message from you Sharon is that, not only should there be a dentist in the multidisciplinary team, but that dentist should have training and experience in head and neck cancer. Why do you believe that’s best practice?
It’s not something we are routinely taught about as an undergraduate. In the care of patients who are diagnosed with head neck cancer, you need to understand the implications of the surgery on oral health. You need to understand the implications of the chemotherapy and or the radiotherapy on oral health, both at the time that treatment is provided and in the longer term.
You need to be able to liaise with those teams around what the implications of their treatments will be on oral health, and also what you need to do to make the patient dentily fit to receive those treatments.
And then you need to be able to understand the impacts of those treatments, both in the short term when the patient is actually receiving the treatment, but in the longer term. Because ultimately, as you said, people survive from head & neck cancer. So what do those treatments look like, in terms of oral healthcare, two years, five years, 10 years, 20 years down the track?
And understanding that when you’re planning for it, that you’re thinking about those longer-term ramifications for that patient as well.
We’ll have dentists watching this, as well as families, patients and other clinicians of all kinds. The Australian Dental Association, do they offer special training or information on the management of the head & neck cancer patient? Can you just tell us that briefly, please?
The Australian Dental Association is the, I guess, the voice of dentistry in Australia, but the training they provide is continuing professional development. The education of specialists in training for dentistry actually occurs within the university bodies.
So there are two main dental specialties that are trained to assist in the care of people that have had head & neck cancer. And they are people like me, specialists in special needs dentistry, where we are not only trained to provide and understand medical treatments on our oral health and on the provision of dental treatments, but also in the in the range of people that I talked about before: the medically complex, the intellectually, physically and psychiatrically.
So we’re actually trained to do that through the university system and then can go onto get other additional qualifications through our college, our College of Dental Surgeons. The other cohort of specialists in dentistry that are trained to do this are oral medicine specialists. And so they’re trained to do that manage oral healthcare in terms of medications. They don’t tend to necessarily provide clinical dentistry.
So they’re, they can, I guess, assist in a diagnosis. They can assist in the healthcare, or oral healthcare, through the oncology treatments, but they don’t tend to get involved in the longer term care. And they certainly don’t tend to be wet-finger dentists like me, that will go in and do fillings and do cleans and extractions and things like that. So the training is actually very much through a specialty training program through a university.
But there is obviously continued professional development that we, as specialists, give to the profession as well. So that’s part of my role that I educate the general dentists around understanding their patients that you know, will go back to them at some point, in understanding what they can and can’t do safely for that patient. What the risks are. How they maintain oral health into the longer term.
So in a nutshell, if a dentist is watching this and wants to do the right thing and upskill themselves, do they contact the Australian Dental Association say, hey, let’s do some training? What what’s the message?
So there’s two opportunity, there’s probably three opportunities. So one is to contact, if you have a patient and you’ve and they’ve been diagnosed and they’ve had their treatment, one of the things you can do is actually contact the surgeon. But the surgeon should be able to know who was the dentist as part of that multidisciplinary team. So that dentist can go and directly liaise with that specialist that was involved in that patient’s care.
Now, one of the things I do in South Australia here is that, when I see these patients on referral from one of them, from the medical team, or the multidisciplinary team, I will write a referral back to that general, that patient’s general dentist saying, “This is what the patient had done. This is what we need to worry about. These are the issues for you.” And there’s been a means of communication. That patient’s dentist knows who it was that looked after them. So that’s one side of it.
There is continuing professional development on that. The Australian Dental Association Federal Body has a CPD or Continuing Professional Development Portal. There’s plenty of stuff on there about head neck cancer, Human Papillomavirus and things like that.
People like myself are also called to give presentations on that. And so the Australian Dental Association has a conference every two years. There will be at least one presentation on cancers in general. And certainly next year, I go to Sydney and I’m involved in the conference and doing exactly that. So there is often that as well.
And then the other thing that happens is people like me are also involved in training as well. So I do undergraduate training. I teach the postgraduate specialist program. The thing is Julie that we are a relatively new specialty and, as you said, in the past head and neck cancer was very much about smoking and alcohol exposure.
We’re seeing a different type of cancer come through. The treatments have been de-escalated for the HPV cancers. And that means we need to be able to have that ongoing training.
So one of the things I did in South Australia was just develop a network in the public sector and trained up about 25 dentists around the state. So we had a means to step down within the public system. And I’ve sort of done the same thing in the private practice that I look after, Health Partners, We’ve got three locations around the city and I have dentists in each of those locations that can look after my patients ongoing as well. So that’s something that’s being, I guess, similarly done in other states and territories as well.
Look, thank you so much, because that’s a wonderful description of what should be happening all over Australia. So let’s return now, if I may, to the nitty gritty for patients who are watching here. Your next important message is that, once a patient has been diagnosed with a head and neck cancer, that they should see a dentist as part of the multidisciplinary team at least 14 days before they begin their radiation therapy.
Just in a nutshell, why is it important at least 14 days before and what should be happening at that point?
Ideally, the dentists involved in the multidisciplinary team, they should know at the point of diagnosis. And they should know, once the diagnosis is made, how that patient’s going to be managed. If they’re going to have surgery alone. If they’re going to have surgery and radiotherapy. If they are going to have all three modalities, in terms of surgery, radiotherapy and chemo, or just radiation and chemotherapy.
If the dentist can be involved and understand what the treatment plan is, and there is treatment that needs to be done to make that patient dentally fit, ideally it should happen as soon as possible. The reason I say at least 14 days before starting radiotherapy, is that if we need to extract teeth, we need at a minimum 14 days to enable that healing to occur before the radiation starts.
And I would not like to see dental treatment being the cause of someone’s radiation being deferred, because they need to have teeth taken out.
And the complexity in Australia is that you know, not everyone sees a dentist every six months. The way that our dental system works is that it’s essentially privately funded. So many people don’t go to the dentist for a long time. And then when they get this diagnosis, they’re sort of all caught up in the medical treatments. They don’t necessarily realize how important dentistry is.
And so, I don’t like to be the cause to say to someone will, we need to take, as I’ve got a patient happening this morning, 10 teeth out and we have to hold back your radiation to enable the healing to occur before the radiation starts.
Sharon I’m very mindful that some of the people watching us to have this conversation will be very experienced in head and neck cancers, either as patients or as clinicians, and they fully understand why something like 10 extractions, prior to radiation treatment occurring, may be necessary.
But of course, we may have someone watching this has only just had a diagnosis, and they may be a little bit startled by that. So, if I may go to the question of why is it so important that any extractions, or major dental needs, are met before radiation therapy treatment begins for a head and neck cancer patient.
Even though as we all know once you get this cancer diagnosis, the system is trying to treat you as quickly as possible. But they do want to clear up any dental problems first, as concisely as you can. Why is that essential?
Because one of the long term impacts of radiation is that it changes the blood supply, particularly to the lower jaw, and particularly to the back area of the lower jaw, where your molar teeth are. And that change to that blood supply gets reduced more with time, not less. So it’s not a problem that goes away as time passes. It’s actually a problem that becomes greater.
So the problem, after radiation, is that the bone changes, and the radiation causes damage as well to the big parotid glands that sit here that produce most of the saliva in your mouth. Now that combination is a little bit of a diabolical combination, because it means that, with time, your mouth is dryer after radiation. Your decay risk increases as a result of the change to the saliva, both the amount and the and the quality.
It means you’re more likely to have decay. And if you get decay, it’s a slightly different sort of decay. It progressive very rapidly, and then you may need an extraction.
And unfortunately, if that extraction is in the area where you’ve had the radiation, and the bone is affected from the radiation, it means that if I was to do that extraction without preventative measures in place, that bone doesn’t have the capacity to heal. So the impact of the radiation to the bone is really only a problem if your dentist needs to take your tooth out.
And that happens from about three to six months after radiation finishes, and is like a lifelong risk. That’s a lifelong ring life-long risk in all areas of your mouth, but the worst and highest risk is in the back area of the lower jaw.
So the tissues that the radiation effects and effects during the treatment are the salivary glands, the taste buds, the tissues of the mouth, and people get ulcers and things like that. And so they’re the main effects during radiation and so people get a lot of ulcers during the course of their treatment normally. Their taste goes. Their saliva goes, so the ability to eat is compromised.
After about six or eight weeks that slowly starts to improve and their taste comes back and the tissues of their mouth come back. But the ongoing impacts of the radiation to the saliva are lifelong. They get better. They do improve. And certainly the newer techniques that the radiation oncologists are using to avoid that big parotid salivary gland, to de-escalate the treatments in terms of the human papillomavirus cancers, have made a big difference in the quality of people’s saliva and the quantity afterwards.
But the problem is there still are significant changes to both those things, quality and quantity. And if you don’t have good quality and quantity of saliva in your mouth, the health of your mouth, not only the teeth, but also the tissues is compromised. Your risks around the different bacteria growing, the bacteria that cause periodontal disease and decay, increase. Risks around oral thrush in your mouth increase. And it’s that ongoing, increased risk of decay that becomes the biggest issue for us as dentists to manage.
So one of the things I do, is I do a saliva analysis for my patients that three months, six months and 12 months. And that guides the preventive program that I then recommend to my patients, I put them on a closer review schedule. So they come and see me every three months, in that 12 month period post-radiation, rather than a six monthly checkup. And then give that information back to their dentists to say, this patient’s got ongoing problems with saliva, you need to see them every four months. I explain to the patient why ongoing dental care is important to avoid those decay risks and extraction risks and the problem with the jawbone etc.
A couple of times you’ve mentioned the de-escalation of treatment for the HPV patient and you’ve also mentioned improvement In radiation. With the improvements, I think there we have better targeting and less damage to surrounding tissue, is that a fair summary?
Yes and three dimensional too. So you know, before 2000, it was the same radiation dose all the way through. Whereas now, they can really target where the cancer is and reduce the dose in the tissues around as much as well. And that has made a huge difference as well.
But for me, if I know a patient has got Human Papillomavirus head and neck cancer, if I know that they don’t have a heavy smoking or alcohol history, I know the prognosis of the patient is going to be very good. And then I know that, I don’t need to be, I need to spend a lot of time with that patient educating them around understanding to maintain their oral health.
I need to be careful about the teeth I keep behind and don’t take out . And I don’t want people to think that, you know, dentists are jumping in there and extracting a lot of teeth. We certainly are not.
But if I know a patient’s got a Human Papillomavirus cancer, and they are likely to live 10 – 15 – 20 years because the response of the medical treatments will be so good. I have to look at those teeth and think, I need to, and their dentist needs to, keep those teeth healthy for 20 years because their radiation dose has been the same. So that changes my treat treatment planning, my thinking how I educate the patient, etc.
I’m keen to come to Tracey Nichols, our nurse, but just before I do, I’m going to ask you two more areas. A number of people have sent in questions, because they knew I was going to be interviewing a dentist. And people will be watching this who have been one year, two years, four years, five years out. They’re still having problems with dry mouth.
Some people talk about this ropey thick saliva for quite long periods of time, not just acute. Another gentleman has said, my teeth have become very discolored. Is there anything I can do about that?
So in a nutshell, people can have quite…not all, but some…quite long term dental and oral impacts. And that means they need ongoing access to a dentist. What are some of the access issues because, as you’ve referred to earlier, when we created Medicare in Australia…so this publicly-funded medical system… we didn’t include the most of the mouth. We didn’t include dentistry.
So how many people have ongoing access to public dentistry? And how many people are reliant on private dentistry? Which must be very difficult to afford for some people?
It is and it’s one of the biggest complexities that I have to think about when I’m referring my patients back, because I can’t continue to look after, you know, all the patients that have had head and neck cancer. And my colleagues are the same.
Look, I think one of the issues is, as you as you pointed out, the access to public dentistry is limited to people that are pension-card holders or healthcare-card holders.
I think, Julie, the sad reality is that some people, particularly those who’ve had very extensive cancers that have had chemotherapy and radiotherapy, end up going becoming public patients for a number of reasons. They might not be able to go back to work afterwards. And so they end up remaining with us.
Some of the patients I continue to see because their complexity of their oral health after their treatment, particularly if they’ve had, you know, both sides of their mouth and all of their throat radiated, and they’ve had chemotherapy as well. They have ongoing issues. And those issues are beyond the scope of a general dentist.
So I might have a shared-care arrangement where they see their general dentist, but I continue to guide that general dentist ongoing. And some of those patients, even in South Australia, I can see those patients who are private patients on an ongoing basis.
They get billed as private patients, even though they’re being seen in the public system, but I’m not providing dental treatment. I’m providing, I guess, assistance in treatment planning for the general dentist. And there are some people as you said, that go into the private sector. And, you know, they’re fortunate enough to have private health insurance and that covers them.
It’s that group of people that often don’t have private health insurance. They don’t meet the public qualifications or the requirements set to get access to public care. And dentistry is not cheap. But I often will say to those patients, you must maintain your oral health. You must maintain your oral hygiene you know, brushing your teeth twice daily. You must go and see a dentist every three, four to six months.
And if by doing all those things, you’re outlaying for, you know, a checkup, a clean, an X-ray, and you’re preventing a problem, that money is well spent. Because you know, you just need one filling, and that will be more than covering the costs of, you know, those preventative measures.
But that is part of the education process also for the patient at the time of diagnosis. So when I talk to them, I will say you know, you will have ongoing problems with that thick ropey saliva you talked about Julie. I’ll give you the measures by which you can manage that. But the most important thing is you’re going to have to look after your teeth ongoing, because if you don’t, they’re going to deteriorate.
And so sometimes the treatment planning will be that I’ll have to be more aggressive because the patient will say, “I’ve never looked after my teeth, I don’t go to the dentist, I don’t want to go to the dentist after this”. Just take them just take x number of teeth out.” So that that’s part of that informed-consent discussion to educate the patient to understand what they’re buying into, if we’re going to try and save their teeth now,
I’ll simply say that, before each of each of us die, we must do everything we can to advocate for the inclusion of the mouth in Medicare for the head and neck cancer patient. I think there is a powerful case. for that. I mean that really deeply from the heart because, even as a privately insured person, the gap between what you get back and what you pay is quite significant.
And for those people without insurance and who don’t qualify for public dentistry, it’s a really serious issue, but I’ll leave it there if I may.
One last question. We haven’t mentioned fluoride. I’m using a special toothpaste that has extra fluoride. I had fluoride trays early on. Just in a nutshell, what should people be asking their dentist about in relation to fluoride?
I talk to you a little bit about the saliva analysis that we do to work out the quality and quantity changes. And the need for enhanced fluoride or enhanced oral-hygiene measures – and that includes products like Tooth Mousse, which have bio-available calcium and phosphate and that’s what our teeth are made out of, calcium and phosphate – is determined by how your saliva has changed.
So for some people that have might have a small radiation field, lower dose, just one side, if I dd the saliva test, the saliva test might come back that it has reduced, but it hasn’t reduced enough to show significant damage longer term to their teeth, particularly if they see their dentist every six months and brush their teeth twice a day.
Other patients, and you talked about your experience, that you know, have had radiation on both sides, had chemotherapy as well – because the chemotherapy does do some have some effects on the salivary glands – if I do this saliva test, not only has the quantity reduced by more than 50%, but the quality has as well. And so then I’m going to give them preventive products to use and that would include the higher level of fluoride that you talked about, or in different forms.
So usually, I find it’s easier to give people a high dose of fluoride in a toothpaste form because they are more likely to do it because it’s a routine of their day. And so you’re probably using a product that has 5000 parts per million of fluoride. Yep, because our normal toothpaste has about 1000 parts per million. And that just allows you to absorb more fluoride and make it more resistant to decay. Some of my patients that have really low saliva and I’ve already got them on the high fluoride, we don’t want to give them too much fluoride. So I’ll give them this Tooth Mousse to apply on their teeth in the night time.
Because one of the factors that limits fluoride absorption is how much calcium and phosphate you’ve got. So you can get a saturation of fluoride where it won’t absorb anymore. So I’ll give them the calcium and phosphate for the teeth to absorb that. Because that is actually the key role of saliva for teeth. Saliva acts as a reservoir of calcium and phosphate.
And if your teeth start to demineralize, the calcium and phosphate comes out. If you have good saliva, it can be reabsorbed. But if you’ve had radiation and you don’t have that pool of saliva, you don’t have that reservoir to draw upon. So the Tooth Mousse is the reservoir. So the saliva testing is dictating what preventive program the patient needs. We don’t have a one size fits all.
Sharon Liberali I could talk to you about teeth all day. But our time is up and I just I seriously want to thank you on behalf of all the head and neck cancer patients and families who will benefit from this detailed discussion about something so important to their health and well-being and quality of life. And I just really want to thank you for being part of it. I know Tracy Nicholls is in the background, and so we’ll talk to her. But thank you so much for talking to us here for these videos on improving the quality of life for head and neck cancer patients from a dental point of view. Thank you.