- Email: [email protected]
Educational issues in oral care
48
Seminars in Oncology Nursing, Vol 20, No 1 (February), 2004: pp 48-52
OBJECTIVE: To discuss the importance of patient, family, and health care professional education in enhancing oral care and adherence to treatment regimens.
DATA SOURCE: Textbooks, review articles, and research studies.
CONCLUSION: Oral complications of cancer therapy influence both patient outcomes and fiscal outcomes. Patient awareness of the importance of oral health improves adherence to the oral care standard. However, the lack of knowledge of health professionals is a barrier to implementing patient education and oral care standards.
IMPLICATIONS PRACTICE:
FOR
NURSING
Curriculum should incorporate oral assessment and oral hygiene. Training of oncology nurses must include assessment, prevention, and treatment of oral mucositis.
From The University of Texas M.D. Anderson Cancer Center, Houston, TX; the Department of Oral Diagnosis, School of Dental Medicine, University of Connecticut Health Center, Farmington, CT; and Healthquest, Minneapolis, MN. Betty T. Daniel, MS, RN, AOCN®: Clinical Nurse Specialist (Retired), The University of Texas M.D. Anderson Cancer Center, Houston, TX. Kathryn L. Damato, RDH, MS, CCRP: Clinical Instructor, Department of Oral Diagnosis, School of Dental Medicine, University of Connecticut Health Center, Farmington, CT. Judith (Judi) Johnson, PhD, RN, FAAN: Nurse Consultant, Healthquest, Minneapolis, MN. Address reprint requests to Betty T. Daniel, MS, RN, AOCN®, 1502 Enclave Pkwy, No. 205, Houston, TX 77077.
© 2004 Elsevier Inc. All rights reserved. 0749-2081/04/2001-0008$30.00/0 doi:10.1053/S0749-2081(03)00139-6
EDUCATIONAL ISSUES IN ORAL CARE BETTY T. DANIEL, KATHRYN L. DAMATO, JUDITH JOHNSON
O
AND
RAL AND gastrointestinal mucositis is recognized as a common complication of radiation and cancer drug therapy. Although management of gastrointestinal mucositis is not well documented in the literature, a plethora of research and clinical literature is available relating to prevention and treatment of oral mucositis. However, much of the research published showed that the majority of the studies have major design flaws, resulting in conflicting or insufficient evidence. Consequently, evidence-based practice recommendations are difficult if not impossible to make. However, the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology Mucositis Study supports the use of systematic oral care protocols that include patient education to reduce the severity of oral mucositis from chemotherapy or radiation therapy. The literature indicates that patient education on oral mucositis is not being initiated on a routine basis. Clinicians and practitioners, especially in the outpatient setting, rarely initiate interventions to prevent oral mucositis, and patients and caregivers are not receiving routine information for oral care.1 With the development of hematopoietic growth factors over the past decade that reduce treatment toxicities, fewer patients are hospitalized for treatment, thus increasing the volume and complexity of patients treated in ambulatory care settings.2 Lack of routine patient teaching about oral care represents an important gap in current health care systems, in that maintaining oral health throughout the cancer experience can reduce morbidity and in selected cases morbidity associated with cancer and its treatment. Lack of knowledge has been identified as one of the barriers to implementing oral care standards and educating patients and caregivers.1,3-8 With the trend for more outpatient treatment protocols, as noted above, and with current economic restraints, it is critical that patients and their families receive instructions for self-care using systematic institutionally developed oral care protocols that include oral assessment, oral hygiene procedures, and
EDUCATIONAL ISSUES IN ORAL CARE
symptoms to report to health care providers. In addition, it is essential that health care professionals, including oncology nurses, be knowledgeable in contemporary approaches for mucositis prevention and treatment. Thus, both patient as well as health professional educational models are of pivotal importance in cancer treatment settings. The purpose of this article is to discuss these patient, family, and health care professional educational models relative to enhancing oral care and adherence to treatment regimens. Emphasis is placed on the role of various health care professionals, such as nurses and dental hygienists. Suggestions for improving the foundational knowledge provided in basic nursing and other health professional education programs are also provided.
EDUCATION OF HEALTH CARE PROFESSIONALS
T
he basic curriculum of health care professionals contains little or no content relating to mucositis.8,9 Nursing curriculum includes oral care as an intervention. Textbooks on fundamentals of nursing include the procedure of oral hygiene for patients unable to manage their own care.10 Medical-surgical textbooks usually contain a chapter on cancer care, with a paragraph about the effects of chemotherapy and radiation therapy on the oral and gastrointestinal mucosa, and sometimes a table with eating “hints” during treatment. The authors of these texts agree that oral assessment should be provided, but rarely provide any guidelines for assessing the oral cavity.11,12 However, nursing specialty organizations provide more comprehensive guidelines, for instance, the Oncology Nursing Society includes the prevention and management of oral mucositis as a part of its certification examination.13 More detailed content is found in oncology nursing textbooks relating to the complications of therapy and interventions.14 Clinicians caring for cancer patients have these as resources, and also can avail themselves of continuing education offerings, such as conferences and seminars. Many cancer centers introduce the subject during orientation, and as a part of inservice training. Despite this, oral care protocols are not systematically implemented, and reliance on tradition continues.4 Academic and clinical dental professionals recognize that more substantive preparation is re-
49
quired for health professionals in the cancer setting. Sadler et al8 reported that the topics of cancer, cancer treatment, and treatment complications are under-represented in the curriculum of dental schools. With the rapid development of technology and novel treatment agents (see Peterson et al elsewhere in this issue), the coming decade will bring an increased demand for providers who are skilled in identification and management of oral manifestations of disease and in associated clinical sequelae.9 In anticipation of satisfying this demand, Miller et al9 suggested that dental schools significantly expand their oncology content in the curriculum. In addition, similar opportunities need to be included in continuing education programs for dental practitioners. The National Institute of Dental and Craniofacial Research’s National Oral Health Information Clearinghouse initiated a campaign in the late 1990s to educate oncology professionals and patients and families about oral complications of cancer treatment (http://www.nohic.nidcr.nih.gov). This campaign, based on consensus among cancer health care professionals that oral care (including dental evaluation and treatment) was essential for improving cancer patient outcomes and emphasized the importance of providing “medically necessary” dental care before, during, and after cancer treatment. Sadler et al8 suggested that this effort can be used to promote awareness that patients would benefit from a multidisciplinary team of nurses, physicians, dentists, and dental hygienists who are adequately prepared to manage these complications. Using cross-teaching, faculty from nursing and medical schools could contribute to the training of dentists and dental hygienist, and the dental faculty could participate in training physicians and nurses.9 Adequate oral health counseling requires knowledgeable health care professionals in every discipline that works with cancer patients. Academic faculty involved in teaching oncology professionals can take the lead in helping to ensure the curricula are expanded.
ROLE
H
OF
ONCOLOGY HEALTH CARE PROVIDERS
ealth care providers work as a team to provide the patient with the care necessary to prevent or minimize the effects of treatment on the mucosa. The physician is responsible for the diagnosis and treatment of disease. Once the cancer
50
DANIEL, DAMATO, AND JOHNSON
diagnosis is determined, depending on treatment setting, the oncologist and often the nurse present the patient with treatment options and possible side effects and complications of treatment, including the occurrence of mucositis. The team of patient and oncologist (and sometimes the nurse) together decide on the treatment plan. Ideally, there will be time for a referral to a dental oncologist or dentist familiar with the special needs of cancer patients for a pretreatment oral examination for all patients scheduled for head and neck surgery and associated radiotherapy or who will be receiving chemotherapy.15-17 “With a pretreatment oral evaluation, the dental team can identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease that could contribute to oral complications when cancer therapy begins.”18 The oncology and dental team should plan and communicate on an ongoing basis throughout the patient’s treatment and recovery. Patient and caregiver education is an important part of the pretreatment phase. The oncologist and oncology nurse initiate instructions regarding the treatment and management of treatment side effects and complications. Oncology nurses provide detailed instructions on specific oral care protocols. During the pretreatment dental evaluation, the dental team of dentist and hygienist also help educate the patient about the importance of adherence to an oral care protocol to protect the oral mucosa.18 During the treatment phase, the oncology team works together to provide regular oral assessments and any necessary care. The oncologist and oncology nurse perform routine oral assessments and emphasize the need to follow the daily oral care regimen. If mucositis does occur, the team shifts to treatment of the mucositis and management of symptoms. Any follow-up dental appointments are scheduled for times when the blood counts are at safe levels. If any oral surgery is required, the dental and oncology teams work together to monitor blood counts, to obtain blood work 24 hours before the procedure, and administer any prophylactic antibiotic treatment.18 After recovery from treatment, the team emphasizes the need to follow the normal dental care schedule. The oncology team should keep the dental clinicians informed of the hematologic status of the patient. For 6 months after radiation therapy, patients should be evaluated by the dental team every 4 to 8 weeks.18 Other patient pop-
ulations that develop mucositis should also be followed regularly after treatment.
PATIENT
AND
CAREGIVER ROLES
T
he oncology patient and caregiver have the monumental task of learning new and frightening facts and skills during the pretreatment phase following a cancer diagnosis. Many patients have poor oral hygiene habits that must be changed. Toth et al15 noted that “the status of the oral cavity in the cancer patient is no different from that found in the general population: poorly maintained dentition, moderate to advanced periodontal disease, ill-fitting denture prostheses, and related soft-tissue pathologies associated with tobacco and alcohol use and nutritional and/or general hygiene neglect.” Thus, the patient must become aware of the importance oral care and learn new skills to maintain a healthy oral cavity to prevent or minimized oral mucositis. If the patient is able to perform the skills needed, the caregiver role is to assure that the patient has the necessary supplies to perform oral care, to be a positive influence, to encourage adherence to the protocol, and to assure that the patient keeps scheduled oncology and dental appointments. If the patient is unable to perform the skills necessary, the caregiver role shifts to that of assistant or actual care provider. Thus, the caregiver plays an essential role and must be included in the educational sessions.
USING PRINCIPLES OF ADULT LEARNING PROVIDE ORAL CARE INSTRUCTIONS
T
TO
eaching about oral care as a supportive measure for the prevention and treatment of mucositis can be challenging. Consider the fact that newly diagnosed cancer patients retain less than 20% of the information they receive at the time of diagnosis.8 Patients are easily overwhelmed and may be consumed with fear and anxiety from learning of their diagnosis. These individuals quickly find themselves in information overload. They are expected to learn about the cancer, listen to treatment options, and make life-altering decisions. As if that is not enough, once the patient has decided on treatment, the nurse requests that the patient listen to yet another piece of important information: symptoms and their management. Included in this list is the prevention and treatment of mucositis, which requires that
EDUCATIONAL ISSUES IN ORAL CARE
51
TABLE 1. Key Concepts Related to Adult Learning What Motivates Adults to Learn Needs promote the desire to learn: Adults identify their own learning needs. Once the patient understands “the relationship between oral health and the development of oral complications and how that can affect the course of treatment,” the patient will be motivated to learn and care for his or her mouth during and after treatment.19 Stimulation maintains attention: Provide a variety of learning materials, vary the methods for delivering the instructions, include opportunities for questions and responses from the learner, and use humor and enthusiasm for the topic. Competence builds confidence: Use return demonstrations, provide feedback, and affirm the learner’s competence and performance.
Attitudes influence behavior: Promote the learner’s personal control of the context of learning. Make learning goals as clear as possible, and create a climate that communicates acceptance and support. Reinforcement enhances learning: Show the learner that success is attributable to his or her own ability and effort. Stress the impact or consequences of the learning. Give praise and rewards when appropriate.
the patient take action even before beginning the first phases of treatment. Taking this into consideration, the nurse should schedule ample time for presenting oral health information, take the opportunity to repeat the message during future visits, and always try to have the primary caregiver present to help the patient remember important points, provide support, and learn the necessary knowledge and skills to assist as needed.8 Critical to teaching at this stressful time is to remember that less is more. Therefore, the educator (nurse or other provider) should keep it simple, stress only the most essential points, set realistic objectives, and focus on the desired behaviors and skills. If presented with the chance to learn and the conditions are right, the adult will want to learn. To effectively educate adult learners, health care professionals must apply key concepts related to adult learning. Table 1 identifies points that are vital to what motivates adults to learn, and each is accompanied by examples of a specific teaching activity.19
Teaching Activity During initial discussions of the side effects of therapy, include the impact of oral complications both on the patient and on the course of treatment.
When talking about good oral care/hygiene use pictures, videotapes, printed material, samples of oral hygiene products, and encourage questions.
Have patients demonstrate how they floss and/or brush their teeth, and how they examine their mouths. This allows correction of mistakes while acknowledging their competence. Inquire about the patient’s preferences for learning. Does he or she learn by reading, seeing, doing? If possible, include al of the following: videotapes, printed material, and demonstration/return demonstration, as appropriate. During the teaching session, be very positive. Take time during patient visits to assess the oral cavity and while doing that, reinforce the steps in the oral care protocol, and emphasize the importance of adherence. Offer praise for adhering to the protocol.
Incorporating these key concepts into instructional sessions will not only enhance learning but should also increase adherence to the oral care protocol. Such protocols are important in maintaining good oral care and helping improve outcomes.17,18,20,21
CONCLUSIONS, IMPLICATIONS, RECOMMENDATIONS
E
AND
ducation of health professionals often does not include oral health, and patient education can be overlooked during the rush to start treatment as soon as possible. If information is provided to the patient, very little is retained because of stress and being overwhelmed, and thus the patient does not adhere to the instructions. Several strategies are recommended to deal with this broad set of issues. First, schools of health professions need to strengthen their curricula by including additional content of cancer, cancer treatment, oral health,
52
DANIEL, DAMATO, AND JOHNSON
and oral care at appropriate points in the curriculum. Medical and nursing schools should include faculty from dental schools as adjunct faculty to teach these topics if possible. Similarly, faculty from medical and nursing schools should be adjunct faculty at dental schools. This cross-teaching would allow each profession to share expertise and knowledge, and create a heightened awareness of the importance of oral health in cancer patients. Second, patient education is critical. When patients understand the importance of oral health they are more likely to adhere to an oral care protocol. The oncology and dental teams are responsible for patient education, but nurses spend more time with the patients and should consistently reinforce the institution’s oral care standard. Patient education materials such as that published by the National Oral Health Clearing-
house should be available for teaching. It is equally important to include family caregivers in these educational efforts, in recognition of the key role they may plan in patient care. Outcome assessment of these educational interventions is critically important. Such efforts should include assessing both how the curricular revisions change clinical practice among health professionals, as well as how the new interventions improve the patient and caregiver well-being over time. In conclusion, there have been exciting advances in understanding the impact of current molecular pathogenesis on mucositis in cancer patients relative to targeted interventions. It is more important than ever that contemporary educational models are designed and implemented for the oncology team as well as patient and caregivers.
REFERENCES 1. Larson PJ, Miaskowski C, MacPhail L, et al. The PROSELF Mouth Aware Program: an effective approach for reducing chemotherapy induced mucositis. Cancer Nurs 1998;21: 263-268. 2. Bociek RG, Armitage JO. Hematopoietic growth factors. CA Cancer J Clin 1996;46:131-133. 3. Miller R, Rubinstein L. Oral health care for hospitalized patients: the nurses’ role. J Nurs Educ 1987;26:362-365. 4. Adams R. Qualified nurses lack adequate knowledge related of oral health, resulting in inadequate oral care of patient on medical wards. J Adv Nurs 1996;24:552-560. 5. McGuire D. Barriers and strategies in implementation of oral care standards for cancer patients. Support Care Cancer 2003;11:435-441. 6. Lee L, White V, Ball J, et al. An audit of oral care practice and staff knowledge in hospital palliative care. Int J Palliat Nurs 2001;7:395-400. 7. Freer SK. Use of an oral assessment tool to improve practice. Prof Nurse 2000;15:635-637. 8. Sadler GR, Oberle-Edwards L, Farooqi A, et al. Oral sequelae of chemotherapy: an important teaching opportunity for oncology health care providers and their patients. Support Care Cancer 2000;8:209-214. 9. Miller CS, Epstein JB, Hall EH, et al. Changing oral care needs in the United States: the continuing need for oral medicine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:34-44. 10. Elkin MK, Perry AG, Potter PA. Nursing Interventions and Clinical Skills. St Louis, MO: Mosby: 2000.
11. Harkness GA, Dincher JR. Medical-Surgical Nursing: Total Patient Care. St Louis, MO: Mosby: 1999. 12. Williams LS, Hopper PD. Understanding Medical-Surgical Nursing. Philadelphia, PA: Davis Company: 1999. 13. Itano J, Taoka KNCore Curriculum for Oncology Nursing. Ed 3. Philadelphia, PA: Saunders: 1998. 14. Beck SL. Mucositis. In: Yarbro CH, Frogge MH, Goodman M, eds. Cancer Symptom Management. Ed 3. Sudbury, MA: 1999;328-343. 15. Toth BB, Chambers MS, Fleming TJ, et al. Minimizing oral complications of cancer treatment. Oncology 1995;9:851-858. 16. Madeya ML. Oral complications from cancer therapy: Part 2 - nursing implications for assessment and treatment. Oncol Nurs Forum 1996;23:808-819. 17. National Oral Health Information Clearinghouse: Oral complications of cancer treatment: what the oncology team can do. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health: 2002. 18. National Oral Health Information Clearinghouse: Oral complications of cancer treatment: what the oral health team can do. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health: 2002. 19. Manne DS. Patient understanding is key to success. ONS News 2003;18:6. 20. Yeager KA, Webster J, Crain M, et al. Implementation of an oral care standard for leukemia and transplantation patients. Cancer Nurs 2000;23:40-47. 21. Barker GJ. Current practices in the oral management of the patient undergoing chemotherapy or bone marrow transplantation. Support Care Cancer 1999;7:17-20.
Seminars in Oncology Nursing, Vol 20, No 1 (February), 2004: pp 48-52
OBJECTIVE: To discuss the importance of patient, family, and health care professional education in enhancing oral care and adherence to treatment regimens.
DATA SOURCE: Textbooks, review articles, and research studies.
CONCLUSION: Oral complications of cancer therapy influence both patient outcomes and fiscal outcomes. Patient awareness of the importance of oral health improves adherence to the oral care standard. However, the lack of knowledge of health professionals is a barrier to implementing patient education and oral care standards.
IMPLICATIONS PRACTICE:
FOR
NURSING
Curriculum should incorporate oral assessment and oral hygiene. Training of oncology nurses must include assessment, prevention, and treatment of oral mucositis.
From The University of Texas M.D. Anderson Cancer Center, Houston, TX; the Department of Oral Diagnosis, School of Dental Medicine, University of Connecticut Health Center, Farmington, CT; and Healthquest, Minneapolis, MN. Betty T. Daniel, MS, RN, AOCN®: Clinical Nurse Specialist (Retired), The University of Texas M.D. Anderson Cancer Center, Houston, TX. Kathryn L. Damato, RDH, MS, CCRP: Clinical Instructor, Department of Oral Diagnosis, School of Dental Medicine, University of Connecticut Health Center, Farmington, CT. Judith (Judi) Johnson, PhD, RN, FAAN: Nurse Consultant, Healthquest, Minneapolis, MN. Address reprint requests to Betty T. Daniel, MS, RN, AOCN®, 1502 Enclave Pkwy, No. 205, Houston, TX 77077.
© 2004 Elsevier Inc. All rights reserved. 0749-2081/04/2001-0008$30.00/0 doi:10.1053/S0749-2081(03)00139-6
EDUCATIONAL ISSUES IN ORAL CARE BETTY T. DANIEL, KATHRYN L. DAMATO, JUDITH JOHNSON
O
AND
RAL AND gastrointestinal mucositis is recognized as a common complication of radiation and cancer drug therapy. Although management of gastrointestinal mucositis is not well documented in the literature, a plethora of research and clinical literature is available relating to prevention and treatment of oral mucositis. However, much of the research published showed that the majority of the studies have major design flaws, resulting in conflicting or insufficient evidence. Consequently, evidence-based practice recommendations are difficult if not impossible to make. However, the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology Mucositis Study supports the use of systematic oral care protocols that include patient education to reduce the severity of oral mucositis from chemotherapy or radiation therapy. The literature indicates that patient education on oral mucositis is not being initiated on a routine basis. Clinicians and practitioners, especially in the outpatient setting, rarely initiate interventions to prevent oral mucositis, and patients and caregivers are not receiving routine information for oral care.1 With the development of hematopoietic growth factors over the past decade that reduce treatment toxicities, fewer patients are hospitalized for treatment, thus increasing the volume and complexity of patients treated in ambulatory care settings.2 Lack of routine patient teaching about oral care represents an important gap in current health care systems, in that maintaining oral health throughout the cancer experience can reduce morbidity and in selected cases morbidity associated with cancer and its treatment. Lack of knowledge has been identified as one of the barriers to implementing oral care standards and educating patients and caregivers.1,3-8 With the trend for more outpatient treatment protocols, as noted above, and with current economic restraints, it is critical that patients and their families receive instructions for self-care using systematic institutionally developed oral care protocols that include oral assessment, oral hygiene procedures, and
EDUCATIONAL ISSUES IN ORAL CARE
symptoms to report to health care providers. In addition, it is essential that health care professionals, including oncology nurses, be knowledgeable in contemporary approaches for mucositis prevention and treatment. Thus, both patient as well as health professional educational models are of pivotal importance in cancer treatment settings. The purpose of this article is to discuss these patient, family, and health care professional educational models relative to enhancing oral care and adherence to treatment regimens. Emphasis is placed on the role of various health care professionals, such as nurses and dental hygienists. Suggestions for improving the foundational knowledge provided in basic nursing and other health professional education programs are also provided.
EDUCATION OF HEALTH CARE PROFESSIONALS
T
he basic curriculum of health care professionals contains little or no content relating to mucositis.8,9 Nursing curriculum includes oral care as an intervention. Textbooks on fundamentals of nursing include the procedure of oral hygiene for patients unable to manage their own care.10 Medical-surgical textbooks usually contain a chapter on cancer care, with a paragraph about the effects of chemotherapy and radiation therapy on the oral and gastrointestinal mucosa, and sometimes a table with eating “hints” during treatment. The authors of these texts agree that oral assessment should be provided, but rarely provide any guidelines for assessing the oral cavity.11,12 However, nursing specialty organizations provide more comprehensive guidelines, for instance, the Oncology Nursing Society includes the prevention and management of oral mucositis as a part of its certification examination.13 More detailed content is found in oncology nursing textbooks relating to the complications of therapy and interventions.14 Clinicians caring for cancer patients have these as resources, and also can avail themselves of continuing education offerings, such as conferences and seminars. Many cancer centers introduce the subject during orientation, and as a part of inservice training. Despite this, oral care protocols are not systematically implemented, and reliance on tradition continues.4 Academic and clinical dental professionals recognize that more substantive preparation is re-
49
quired for health professionals in the cancer setting. Sadler et al8 reported that the topics of cancer, cancer treatment, and treatment complications are under-represented in the curriculum of dental schools. With the rapid development of technology and novel treatment agents (see Peterson et al elsewhere in this issue), the coming decade will bring an increased demand for providers who are skilled in identification and management of oral manifestations of disease and in associated clinical sequelae.9 In anticipation of satisfying this demand, Miller et al9 suggested that dental schools significantly expand their oncology content in the curriculum. In addition, similar opportunities need to be included in continuing education programs for dental practitioners. The National Institute of Dental and Craniofacial Research’s National Oral Health Information Clearinghouse initiated a campaign in the late 1990s to educate oncology professionals and patients and families about oral complications of cancer treatment (http://www.nohic.nidcr.nih.gov). This campaign, based on consensus among cancer health care professionals that oral care (including dental evaluation and treatment) was essential for improving cancer patient outcomes and emphasized the importance of providing “medically necessary” dental care before, during, and after cancer treatment. Sadler et al8 suggested that this effort can be used to promote awareness that patients would benefit from a multidisciplinary team of nurses, physicians, dentists, and dental hygienists who are adequately prepared to manage these complications. Using cross-teaching, faculty from nursing and medical schools could contribute to the training of dentists and dental hygienist, and the dental faculty could participate in training physicians and nurses.9 Adequate oral health counseling requires knowledgeable health care professionals in every discipline that works with cancer patients. Academic faculty involved in teaching oncology professionals can take the lead in helping to ensure the curricula are expanded.
ROLE
H
OF
ONCOLOGY HEALTH CARE PROVIDERS
ealth care providers work as a team to provide the patient with the care necessary to prevent or minimize the effects of treatment on the mucosa. The physician is responsible for the diagnosis and treatment of disease. Once the cancer
50
DANIEL, DAMATO, AND JOHNSON
diagnosis is determined, depending on treatment setting, the oncologist and often the nurse present the patient with treatment options and possible side effects and complications of treatment, including the occurrence of mucositis. The team of patient and oncologist (and sometimes the nurse) together decide on the treatment plan. Ideally, there will be time for a referral to a dental oncologist or dentist familiar with the special needs of cancer patients for a pretreatment oral examination for all patients scheduled for head and neck surgery and associated radiotherapy or who will be receiving chemotherapy.15-17 “With a pretreatment oral evaluation, the dental team can identify and treat problems such as infection, fractured teeth or restorations, or periodontal disease that could contribute to oral complications when cancer therapy begins.”18 The oncology and dental team should plan and communicate on an ongoing basis throughout the patient’s treatment and recovery. Patient and caregiver education is an important part of the pretreatment phase. The oncologist and oncology nurse initiate instructions regarding the treatment and management of treatment side effects and complications. Oncology nurses provide detailed instructions on specific oral care protocols. During the pretreatment dental evaluation, the dental team of dentist and hygienist also help educate the patient about the importance of adherence to an oral care protocol to protect the oral mucosa.18 During the treatment phase, the oncology team works together to provide regular oral assessments and any necessary care. The oncologist and oncology nurse perform routine oral assessments and emphasize the need to follow the daily oral care regimen. If mucositis does occur, the team shifts to treatment of the mucositis and management of symptoms. Any follow-up dental appointments are scheduled for times when the blood counts are at safe levels. If any oral surgery is required, the dental and oncology teams work together to monitor blood counts, to obtain blood work 24 hours before the procedure, and administer any prophylactic antibiotic treatment.18 After recovery from treatment, the team emphasizes the need to follow the normal dental care schedule. The oncology team should keep the dental clinicians informed of the hematologic status of the patient. For 6 months after radiation therapy, patients should be evaluated by the dental team every 4 to 8 weeks.18 Other patient pop-
ulations that develop mucositis should also be followed regularly after treatment.
PATIENT
AND
CAREGIVER ROLES
T
he oncology patient and caregiver have the monumental task of learning new and frightening facts and skills during the pretreatment phase following a cancer diagnosis. Many patients have poor oral hygiene habits that must be changed. Toth et al15 noted that “the status of the oral cavity in the cancer patient is no different from that found in the general population: poorly maintained dentition, moderate to advanced periodontal disease, ill-fitting denture prostheses, and related soft-tissue pathologies associated with tobacco and alcohol use and nutritional and/or general hygiene neglect.” Thus, the patient must become aware of the importance oral care and learn new skills to maintain a healthy oral cavity to prevent or minimized oral mucositis. If the patient is able to perform the skills needed, the caregiver role is to assure that the patient has the necessary supplies to perform oral care, to be a positive influence, to encourage adherence to the protocol, and to assure that the patient keeps scheduled oncology and dental appointments. If the patient is unable to perform the skills necessary, the caregiver role shifts to that of assistant or actual care provider. Thus, the caregiver plays an essential role and must be included in the educational sessions.
USING PRINCIPLES OF ADULT LEARNING PROVIDE ORAL CARE INSTRUCTIONS
T
TO
eaching about oral care as a supportive measure for the prevention and treatment of mucositis can be challenging. Consider the fact that newly diagnosed cancer patients retain less than 20% of the information they receive at the time of diagnosis.8 Patients are easily overwhelmed and may be consumed with fear and anxiety from learning of their diagnosis. These individuals quickly find themselves in information overload. They are expected to learn about the cancer, listen to treatment options, and make life-altering decisions. As if that is not enough, once the patient has decided on treatment, the nurse requests that the patient listen to yet another piece of important information: symptoms and their management. Included in this list is the prevention and treatment of mucositis, which requires that
EDUCATIONAL ISSUES IN ORAL CARE
51
TABLE 1. Key Concepts Related to Adult Learning What Motivates Adults to Learn Needs promote the desire to learn: Adults identify their own learning needs. Once the patient understands “the relationship between oral health and the development of oral complications and how that can affect the course of treatment,” the patient will be motivated to learn and care for his or her mouth during and after treatment.19 Stimulation maintains attention: Provide a variety of learning materials, vary the methods for delivering the instructions, include opportunities for questions and responses from the learner, and use humor and enthusiasm for the topic. Competence builds confidence: Use return demonstrations, provide feedback, and affirm the learner’s competence and performance.
Attitudes influence behavior: Promote the learner’s personal control of the context of learning. Make learning goals as clear as possible, and create a climate that communicates acceptance and support. Reinforcement enhances learning: Show the learner that success is attributable to his or her own ability and effort. Stress the impact or consequences of the learning. Give praise and rewards when appropriate.
the patient take action even before beginning the first phases of treatment. Taking this into consideration, the nurse should schedule ample time for presenting oral health information, take the opportunity to repeat the message during future visits, and always try to have the primary caregiver present to help the patient remember important points, provide support, and learn the necessary knowledge and skills to assist as needed.8 Critical to teaching at this stressful time is to remember that less is more. Therefore, the educator (nurse or other provider) should keep it simple, stress only the most essential points, set realistic objectives, and focus on the desired behaviors and skills. If presented with the chance to learn and the conditions are right, the adult will want to learn. To effectively educate adult learners, health care professionals must apply key concepts related to adult learning. Table 1 identifies points that are vital to what motivates adults to learn, and each is accompanied by examples of a specific teaching activity.19
Teaching Activity During initial discussions of the side effects of therapy, include the impact of oral complications both on the patient and on the course of treatment.
When talking about good oral care/hygiene use pictures, videotapes, printed material, samples of oral hygiene products, and encourage questions.
Have patients demonstrate how they floss and/or brush their teeth, and how they examine their mouths. This allows correction of mistakes while acknowledging their competence. Inquire about the patient’s preferences for learning. Does he or she learn by reading, seeing, doing? If possible, include al of the following: videotapes, printed material, and demonstration/return demonstration, as appropriate. During the teaching session, be very positive. Take time during patient visits to assess the oral cavity and while doing that, reinforce the steps in the oral care protocol, and emphasize the importance of adherence. Offer praise for adhering to the protocol.
Incorporating these key concepts into instructional sessions will not only enhance learning but should also increase adherence to the oral care protocol. Such protocols are important in maintaining good oral care and helping improve outcomes.17,18,20,21
CONCLUSIONS, IMPLICATIONS, RECOMMENDATIONS
E
AND
ducation of health professionals often does not include oral health, and patient education can be overlooked during the rush to start treatment as soon as possible. If information is provided to the patient, very little is retained because of stress and being overwhelmed, and thus the patient does not adhere to the instructions. Several strategies are recommended to deal with this broad set of issues. First, schools of health professions need to strengthen their curricula by including additional content of cancer, cancer treatment, oral health,
52
DANIEL, DAMATO, AND JOHNSON
and oral care at appropriate points in the curriculum. Medical and nursing schools should include faculty from dental schools as adjunct faculty to teach these topics if possible. Similarly, faculty from medical and nursing schools should be adjunct faculty at dental schools. This cross-teaching would allow each profession to share expertise and knowledge, and create a heightened awareness of the importance of oral health in cancer patients. Second, patient education is critical. When patients understand the importance of oral health they are more likely to adhere to an oral care protocol. The oncology and dental teams are responsible for patient education, but nurses spend more time with the patients and should consistently reinforce the institution’s oral care standard. Patient education materials such as that published by the National Oral Health Clearing-
house should be available for teaching. It is equally important to include family caregivers in these educational efforts, in recognition of the key role they may plan in patient care. Outcome assessment of these educational interventions is critically important. Such efforts should include assessing both how the curricular revisions change clinical practice among health professionals, as well as how the new interventions improve the patient and caregiver well-being over time. In conclusion, there have been exciting advances in understanding the impact of current molecular pathogenesis on mucositis in cancer patients relative to targeted interventions. It is more important than ever that contemporary educational models are designed and implemented for the oncology team as well as patient and caregivers.
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