Oral health assessment of newly diagnosed oncology patients—Who are we missing?

An estimated 1:500 children are diagnosed with cancer each year.1 When assessed on a global scale, there is a higher incidence of childhood cancer in countries of a high human development index (HDI), compared to that of a low development index (LDI).2 In the UK, all children are treated at designated specialist Principal Treatment Centres (PTC), including Royal Manchester Children's Hospital (RMCH), to standardise clinical care and follow-up.3 Approximately 120 new malignant disease diagnoses are seen per year at RMCH from across the region, all of whom require a range of treatment modalities including chemotherapy, radiotherapy, proton beam therapy, stem cell transplant and surgical management.4 The Royal College of Surgeons England has recommended that all children diagnosed with cancer should have access to dental care, including a full initial assessment with radiographs at time of diagnosis, before commencement of treatment.4 Paediatric dental units working with oncology centres should have a mechanism of notification for new patients.5 During oncology treatment, oral care can become neglected with changes in oral health routines, particularly for children undergoing inpatient treatments.6 Additional nutritional intake requirements and oral manifestations such as mucositis and opportunistic infections further impact oral health and increase caries risk. Poor oral health can adversely impact oncology treatment, increasing morbidity risk and length of inpatient hospital stays.3 Furthermore, long-term oral complications following curative cancer treatments may require specialist-led care for oral rehabilitation in future. Following an urgent general anaesthetic procedure for a child receiving cancer treatment with severe dental decay, it became apparent that not all newly diagnosed oncology patients at RMCH were referred for a baseline dental assessment at time of diagnosis. Analysis of the previous month highlighted multiple urgent ward visits for dental assessments for patients in pain who were unknown to the department and had not seen a dental practitioner for assessment prior to commencing cancer treatment. This highlighted a clinical need to improve dental care for this cohort, and thus provided stimulus for this quality improvement project which was conducted using the Plan-Do-Study Act (PDSA) model. This project aimed to evaluate the DHU referral pathway and oral health outcomes for children with new oncology diagnoses at RMCH. Retrospective case note analysis of newly diagnosed paediatric oncology patients occurred in referral order until a sample of 50 was met for the period of September 2019–July 2020 (Cycle 1). Patients who only required surgical management and no adjunct therapy (chemotherapy, radiotherapy, proton beam therapy or bone marrow transplant) were excluded. Repeat analysis occurred for the same time periods in subsequent years (Cycle 2:2 020–2021 and Cycle 3: 2 021–2022), following the implementation of changes in Cycle 1. Data were accessed via online electronic Trust records Chameleon™ (for Cycles 1 and 2) and newly implemented ‘HIVE’ by Epic™ (for Cycle 3). An encrypted standardised data collection form was used via Microsoft Excel (Microsoft® Corporation, Washington, USA). Data collected included: age at diagnosis, date of diagnosis, oncology diagnosis and treatment, date of dental referral and new patient assessment, dental attendance and treatment outcome. Only 42% (n = 21) of patients received dental referrals, demonstrating a need for improved communication with oncology wards (Table 1). One of the 21 patients who received a dental referral was already under the care of the DHU and so was excluded from data collection for Objective 2. The majority, 86% (n = 18), of patients referred received an appointment for dental assessment. The remaining 14% (n = 3) were triaged at time of referral, however, due to administrative processing were not provided an appointment. Discrepancies in referral of new diagnoses were observed between clinical teams managing children with haematological malignancies, solid tumours and neurological tumours (Table 1). Objective 2 showed no improvement from Cycle 1. This cycle was completed following implementation of a new electronic note keeping system across Manchester Foundation Trust (MFT), ‘HIVE’ from Epic™ and digital referral system. Of the 50 case notes reviewed, 10 were excluded due to a surgical only approach. Improvements were seen for Objective 1 for all oncology teams (Table 1). Improvements were made in each PDSA cycle for referral of children to the DHU at the point of cancer diagnosis, with an overall improvement of 48%. With 90% (n = 36) of children referred in Cycle 3, this improvement was felt to be supported by the integration of direct electronic referral into the new Trust wide electronic record system (Epic™). Previous cycles required an electronic document referral to be sent via email to the dental secretary, which provided a significant administration burden to the referrer and potential for missed patient referrals. Following the Cycle 2, we implemented a cross-checking system whereby the oncology team provide a digital list of newly diagnosed patients each month. This allows the DHU to check patients, identifying those who have been missed and highlight those who need referrals. We have since worked closely with the oncology team to promote the importance of oral health baseline prevention and assessment to improve oral health in this population. Cycle 1 was conducted during the initial COVID-19 pandemic, which influenced the number of referrals being triaged due to reduced capacity and availability of clinical staff. As a result, the proportion of referrals receiving a dental assessment was initially suboptimal. Further cycles demonstrate a proportionate increase in referrals being triaged and offered a dental assessment appointment, 90% (n = 26) and 94% (n = 34) retrospectively. Low numbers of children in each cycle result in a significant percentage change following relatively modest absolute changes. Subsequently, it is acknowledged that is will be challenging to obtain 100% compliance in the objectives set, although this presents best practice. Consistently over the 3-year project, approximately one in four children referred to the DHU had an active treatment need, with a third of these children requiring dental general anaesthetic. Often oral health teams are separate from PTCs, and further collaborative projects across medical disciplines can help to further integrate patient care putting the mouth back in the body. With increased referrals to the department from the oncology team, the DHU is working hard to ensure the Mini Mouth Care Matters initiative is being utilised effectively. The principles of Mini MCM will help reinforce oral health promotion across medical departments, ensuring a holistic approach to patients' care, and ensuring appropriate dental referral for baseline assessment when needed. Our department aims to expand oral health screening to other medical specialities.6 The RMCH Dental Team and Macmillan Team for their support and involvement with this quality improvement project.