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Oral and dental side effects of cancer treatment can be painful, interfere with function, and affect patients’ quality of life. Involvement of the dental team is important before, during and after treatment to manage the temporary, chronic or permanent consequences of treatment. The separation of medical and dental disciplines and insurance reimbursement models make it unnecessarily difficult to obtain medically necessary dental care. Nurses are on the front lines of care and are in a position to diagnose side effects of oral therapy, provide education and advocate for appropriate dental care.
Dental Care For Cancer Patients: Special Considerations
Cancer treatment can have serious, chronic or lifelong oral side effects. Getting timely, professional, and affordable dental care can be a challenge for anyone, especially those with limited resources or who rely on Medicaid to cover the cost of care. It can be difficult for cancer patients to find professionals who are knowledgeable, experienced, and willing to provide timely and necessary care within their capabilities. Standard health insurance (including Medicare) does not cover dental care, even if it is medically necessary. Medicaid dental coverage varies widely across the country. The oncology team is in a position to educate patients about the side effects of dentistry and help them navigate the complex world of dentistry.
Managing Patients Undergoing Cancer Therapy
Each of these conditions can cause pain and disability, as well as a change in appearance and quality of life. Patients diagnosed with head and neck cancer are particularly affected by these complications due to site of disease, surgery, tooth loss, and adjuvant treatments, including chemotherapy and radiation, which have significant adverse effects on teeth and surrounding structures (Turner, Mupparapu, & Akintoje, 2013).
Children are susceptible to the same oral side effects of treatment as adults. Children also face the risk of dental and cranial developmental abnormalities, especially those who undergo treatment before primary teeth form (Effinger et al., 2014; Padmini & Bai, 2014). Children aged 3-5 are susceptible to the most severe abnormalities (McBride, 2011). Developmental abnormalities may include enamel hyperplasia, microdevelopment, malformation of teeth and/or root structures, and possible senescence of primary or permanent teeth (Effinger et al., 2014; McBride, 2011).
Oral health and dental hygiene are often neglected before, during and after cancer treatment (Hartnett, 2015). Nurses are often on the front lines of care to help patients and their families navigate diagnosis, treatment and survival. They play an important role in educating patients about self-care and treatment options and referring patients to dentists who specialize in the care of this complex population.
Adults and children who have survived cancer, along with their family and caregivers, may not be aware of the unique oral health risks associated with their treatment. All members of the healthcare team, including dentists, should work together to provide education, support and appropriate treatment. The American Dental Association (2013) recommends at least annual visits for all individuals, with visits increasing based on individual risk. The recommended frequency of dental visits for cancer patients depends on the type of cancer, the patient’s condition, and the consequences of treatment (Epstein, Guneri, & Barasch, 2014). Tooth extractions are recommended every three to four months for those who have undergone head and neck radiation (Bruce, 2011).
Is Oral Surgery Covered By Medical Or Dental Insurance?
Cancer patients and survivors need the care of experienced, educated and engaged dentists; however, they are at high risk of unmet oral hygiene needs. Prevention, identification, and prediction of potential side effects of oral cancer therapy are important for newly diagnosed cancer patients and survivors. General dentists often lack the education, training, and experience necessary to manage these patients (Epstein et al., 2014). Certified dentists make up about 80% of all dentists currently working (Kaiser Family Foundation, 2017). Fewer than 5% of dental practices specialize in oncology, further hindering patients’ efforts to find the appropriate provider to manage their complex oral health needs (Kaiser Family Foundation, 2017). Residents in rural areas are particularly affected by the lack of dentists. Those using Medicaid may have to travel long distances to receive some oral care, regardless of specialty (Rural Health Information Hub, 2017; Skillman, Doescher, Mouradian, & Brunson, 2010).
Despite the obvious benefits of regular dental checkups and treatment, many Americans face significant barriers to obtaining medically necessary care. Reasons for this are multiple and may include access to service providers, lack of insurance or funds to pay for care, transportation, work or family responsibilities, and educational and cultural influences (Epstein et al., 2014; Freeman, 1999). Financial issues related to cancer treatment can be significant due to co-payments, high deductibles, transportation costs and even accommodation for those who have to travel long distances for care (Kent et al., 2013). Many families face additional difficulties, such as loss of income or childcare costs. These people are more likely to delay or skip needed health care (Kent et al., 2013).
The Patient Protection and Affordable Care Act (ACA) defines pediatric dental care as an essential health benefit (Centers for Medicare and Medicaid Services [CMS], 2017), and dental care must be available to children under the age of 18; however, families are not required to purchase this coverage (CMS, 2013). Dental care for adults is not considered an essential health benefit, and health insurance plans are not required to provide coverage, although dental insurance can be purchased as a stand-alone plan (CMS, 2013). The Children’s Health Insurance Program is a federal grant program established in 1997 that helps states provide publicly funded coverage for uninsured children who are not eligible for Medicaid. Funding for this program has been extended through September 30, 2017 (Georgetown University Health Policy Institute Center for Children and Families, 2017). Given the current political situation, it is uncertain whether this program will be funded at the time of publication.
One of the hallmarks of the ACA was the expansion of Medicaid, which provided dental care to people who otherwise couldn’t afford it, although coverage varies by state. The nation remains divided on the merits of Medicaid expansion and other aspects of the ACA. In May 2017, the US House of Representatives passed the American Health Care Act by four votes (Congress.gov, n.d.). This bill would reduce the number of people on Medicaid, limit funding, and allow states to waive essential health benefits (Reusch, 2017). All of these factors are likely to affect health insurance for children and adults. It is uncertain whether the ACA has been fully repealed and replaced (Congress.gov, n.d.). Nevertheless, at a time when health care costs are tight, dental payments are unlikely to increase (see Figure 1).
Dental Treatment Planning And Management For The Mouth Cancer Patient.
Dental coverage for adults through Medicaid varies by state (see Table 1). Many states offer limited or comprehensive coverage, and a few states only offer emergency services (Hinton & Paradise, 2016). Some do not offer any dental benefits. Nationally, only about 38% of dentists accept Medicaid (Hinton & Paradise, 2016). Even those who accept Medicaid patients can limit the number of patients they see in the program. Many private dentists do not accept Medicaid clients due to very low reimbursement rates for dental services and complex billing procedures.
One of the biggest risk factors for cancer is advanced age. The median age at cancer diagnosis is 66 years (Krabbameinsstofnun, 2015). Medicare is the major third-party payer for cancer treatment in the United States. The Medicare Act was signed into law in 1965 and has remained largely unchanged since then. Includes general dental exclusions and does not include routine oral exams, screenings, cleanings, restorative services, dentures or extractions. There are limited exceptions to exclusions, but the conditions for coverage are complex and confusing. A notable exception is the inclusion of dental extracts awaiting radiotherapy for jaw tumors (CMS, 2013). In this case, the cost of a dental evaluation is paid if the patient needs an extraction. Because dentists primarily deal with dental billing codes (not medical diagnosis codes), most people do not understand how to bill for this type of care.
Access to care is less of an issue for those with private dental insurance or the financial means to pay for dental care. However, employer-provided dental insurance typically covers only $1,000 to $1,500 per year. This amount has remained largely unchanged since dental insurance was first offered 30 years ago (Vestal, 2015). Considering that the average cost of a root canal is $1,000 (Burns, Vujičić, & Blatz, 2016), $1,500 is a modest amount for any individual who requires significant dental restoration during cancer treatment.
Collectively, Americans spend approximately $2.75 billion annually on cosmetic dentistry to obtain or maintain a beautiful smile with 32 teeth (Rabinovitz, 2017). In a surreal parallel, one million of the working poor lack dental insurance and are ineligible for public insurance, finding themselves on the wrong side of America’s dental divide.