Monday 22nd September 2014
Mac Voice, the magazine for Macmillan professionals: Autumn 2014
Imogen Wood (pictured) is currently one of only two Macmillan Dental Therapists in the UK
Oxford University Hospitals currently holds the first two Macmillan Dental Therapist posts in the UK. The dental team is led by Mr Sandip Popat, Consultant in Restorative Dentistry, who fought hard to bring dental therapists into the team with help from Macmillan.
What is a dental therapist?
Dental therapists provide preventative and restorative dental care. This includes treating and managing gum disease and undertaking simple restorative procedures for teeth.
Before becoming a dental therapist, I undertook a three-year full time Bachelor of Science Degree in Oral Health Sciences at the University of Manchester and then a further year of training within Oxford and Wessex Deanery.
Why is dental health important for people having head and neck cancer treatment?
Radiotherapy to the head and neck region may damage the salivary glands, leaving people with a very dry mouth. This creates long-term speech and swallowing problems. It also leaves people with a high risk of dental decay and gum disease. Preventing dental disease is therefore essential in order to prevent infection.
If teeth need to be extracted in a site that has been exposed to radiation, the bone in this area may not heal, then become infected and die. This process is called osteoradionecrosis (ORN) of the jaw. This condition can be very painful and very difficult to treat.
Before people begin cancer treatment, Mr Popat assesses their dental health and formulates a dental treatment plan. This helps minimise complications at a later stage, especially if radiotherapy is likely. Plans are made to extract teeth that are heavily filled, decayed or diseased. This is first discussed with the person being treated so that they make a fully informed decision. Mr Popat has over 20 years of experience in this field and in creating this type of treatment plan. Any extractions required are undertaken well in advance or during the cancer surgery if possible.
People having this treatment are educated about the long term risks of radiotherapy to their dental health. We also stabilise and maintain their remaining teeth and gum health. They are given oral health advice that is tailored to them and their current phase of treatment. If they are in the middle of treatment, they may need a very soft toothbrush, neutral flavoured toothpaste and rinses to minimise irritation, for example. Long-term use of high fluoride toothpastes and rinses is usually recommended, due to the high decay risk.
This prevention phase greatly minimises the risk of complications and ultimately any risks of ORN.
Despite the preventative measures taken, radiation-associated dental decay is still common and is often made worse by people’s limited diets during and after the treatment. Tooth wear is another common problem. Some of this may pre-date the cancer diagnosis but some may be due to significant nausea and vomiting during chemotherapy, for example.
Because of these problems, the role of the Macmillan Dental Therapist can extend beyond ongoing oral hygiene care and preventative treatment. It is often necessary to build the teeth back up with tooth-coloured filling material. Improving the appearance of the teeth can also give the patient a boost in confidence and give them back their smile both physically and psychologically.
Once surgery sites have healed and the patient has recovered from any radiotherapy or chemotherapy, they will be seen again by Mr Popat who will facilitate the replacement of teeth. If part of the roof of the mouth (palate) was removed during surgery to remove a tumour, the person may require an obturator. This is an extended denture which ‘fills the gap’ left after surgery. An obturator can dramatically improve people’s speech and ability to swallow and eat. Once the person’s oral health has been stabilised, it is monitored and maintained with regular Macmillan Dental Therapist appointments, alongside periodic re-assessments with the Restorative Consultant.
Treating people who have undergone treatment for head and neck cancer is made much more challenging as many have great difficulty opening their mouths due to scar tissue. This makes access for dental care very limited. They often have difficulties swallowing. The diet advice we give, therefore, must take into account the importance of the person keeping up their weight when eating can be a struggle. It means striking a balance between limiting the risk of decay from sugars and ensuring the patient is taking on board enough calories.
Communication can sometimes be more difficult if the person has had a laryngectomy or if part of the roof of their mouth or tongue has been removed in surgery.
These are challenges that dental professionals within general dental practices are not commonly used to facing. Within the department we are able to provide the necessary time and care to work around these issues.
Having seen my own grandfather suffer from cancer of the salivary gland while I was growing up, this is an area very close to my heart. Raising the awareness of the importance of dental health in relation to head and neck cancers has become our team’s main campaign both within the Oxford University Hospitals and also more nationally. The feedback we have received from patients about this relatively new role has been outstanding.
The dental therapist service has been running nearly two years. During that time there has been a huge increase in people being seen for dental care alongside their cancer treatment. We hope that this service will continue to grow and improve.
Macmillan Dental Therapist
Blenheim Head & Neck Outpatients
Churchill Hospital, Oxford