St. Jude dentists protect patients’ smiles during and after treatment

Dental care in pediatric oncology has traditionally been restricted to surgical management: identifying a problem and treating it. But oral disease is a persistent condition that demands a chronic disease management philosophy, particularly given that many patients at St. Jude receive therapy for two years or more. We don't want patients to go that long without being seen by a dentist and receiving routine dental care. My goal as Chief of Dentistry at the St. Jude Dental Clinic is to bring as much individualized preventative care as possible to patients while they are here and set them up for success when they leave.

Before coming to St. Jude, I was the program director for pediatric dentistry at the University of Tennessee Health Science Center. We had a strong relationship with Le Bonheur Children’s Hospital, so I gained experience working with medically compromised patients and patients with special healthcare needs. For example, patients who receive a stem cell transplant may be immunosuppressed for an extended period. A dental abscess could become life-threatening because their immune systems are unable to contain and localize that infection.

Detection, prevention and communication for better oral health

To address this, we have three main goals we want to accomplish with patients. The first is a dental evaluation at the beginning of cancer therapy. This assessment is essential to treat any potential areas of dental infection that may compromise therapy. 

Step two is prevention, and this is more than just preventing cavities. We talk to parents about the importance of using the toothbrush to remove the bacteria that grow in plaque, an action that prevents bloodstream and line infections. We evaluate patients for xerostomia (dry mouth) because saliva is our most natural defense against dental decay, gingivitis, periodontal disease and mouth sores. We also look at soft tissues such as lips, cheeks, hard palate and tongue, to ensure they're healthy and without ulcers. For stem cell transplant survivors, we monitor for secondary cancers and graft-versus-host disease.

The final step is to communicate about how receiving treatment may impact a growing child’s developing teeth. For some patients, especially very young ones, cancer therapy can result in smaller teeth, thinner and shorter roots, or teeth not developing at all. This is most notable in patients receiving total body radiation, radiation to the head or neck, or treatment for neuroblastoma. We often won’t know the effects or severity until that child is older, so education on these risks is a vital part of our clinical visit for parents.

Oncologists see value of a clean bill of oral health

We are also actively involved in research to better understand how treatment affects long-term dental health in survivors of childhood cancer. By focusing on dental health among children treated with hematopoietic stem cell transplantation, we aim to pair clinical data from the dental evaluation with oral quality of life data to describe exactly what is happening with our transplantation patients and to identify barriers to getting dental care in their local communities after cancer care ends.  

One of the special things about doing such research at St. Jude is the buy-in we receive from all corners of the institution. Cancer survivor control groups, biostatisticians, oncologists and many others have reviewed this work and have been extremely open to learning about the current needs in oral health locally and nationally. Nurses and oncologists are excited about dentistry’s efforts and are embracing the role that dental health plays in overall outcomes. They understand the importance of referring patients to us and monitoring oral health.

Short- and long-term wellbeing are at the center of dental care

Along with clinician buy-in, we also strive to enhance the experience patients and families have during the treatment journey. Dentistry is done largely under local anesthetic, so we are asking a lot of children to maximize their coping skills to cooperate with us. The entire dental team, from our coordinator of operations to our lead dental assistant to each dentist on the team, strives to create a positive experience. We want our patients to become children who love going to the dentist so that they turn into adults who enjoy the dentist.

While we use common aids, such as storytelling, praise for cooperation and nitrous oxide, we wanted to partner with Child Life and offer an extra layer of support to those patients old enough to understand dental care. 

At St. Jude, we have our Paws at Play Facility Dog Program, and I immediately inquired about getting them involved while patients are receiving dental care. The dogs had to practice being in the room with all the noises that come with a dentist’s office, and we tried different ways to position the dogs beside the chair. By using a platform beside the dental chair, we now have a process for our therapy dogs to sit with a patient who might need some extra support.

Parents really appreciate having this option. For example, we organized for Snuggle, a playful, sweet therapy dog, to assist a patient who needed some dental work. Snuggle sat beside him, and he petted her throughout the treatment. At the end, his mom thanked us and told us he really loves it when he can have one of the dogs for a procedure. She said, “You guys just really get my son.”

To maximize the long-term well-being of St. Jude patients, we also help families re-establish dental care with local providers after treatment. We often hear that families cannot find a dentist to treat them, or children struggle with the transition, so we strive to find any opportunity to better communicate with these providers.

There are still many questions in supportive dental care for our patients in oncology that need to be answered. We are actively attempting to be the dental home for St. Jude patients – a place that offers comprehensive and continuous care throughout therapy – as opposed to looking at oral health as just fixing a single problem or two. Now, through our clinical work and ongoing research into outcomes and the barriers patients face after completing treatment, we are building a more complete oral health program designed with patient well-being at the center.