National Survey of Oncology Members ’ Knowledge , Education and Patient Management Regarding Oral Care in Cancer Therapy

INTRODUCTION Oral complications can be profound in patients undergoing cancer therapy, negatively impacting quality of life, and potentially postponing or disrupting treatment. While oncology team members seek to deliver optimal oral care, evidence-based management of oral complications and knowledge in the provision of oral care poses a challenge to attaining satisfactory reductions in complications such as oral mucositis, xerostomia and rampant dental caries. METHODS A cross-sectional, random sample (N=2,000) of members of the Oncology Nursing Society were surveyed via a Web-based questionnaire to identify knowledge of oral care, oral health management practices and factors influencing provision of oral care for patients being treated for cancer. Frequencies were calculated for demographic and categorical data. Education, years of experience, and comfort levels were measured and correlated to identified subscales of knowledge, management of oral complications, and use of evidence-based protocols for high-risk patients. RESULTS Over 75% of respondents reported some to little oral health content in their primary education. Significant correlations were found between the three subscales and the variables years of experience and comfort levels (p≤0.05). Use of evidence-based protocols and oral management increased with levels of oral healthcare education and years of experience (p≤0.05). CONCLUSION Results of this investigation suggest a need for the inclusion of more education in general nursing programs addressing oral healthcare of cancer patients, as well as continuing education for practicing oncology professionals. Additionally, findings support the inclusion of dental hygienists, oral health/disease prevention experts, as members of interdisciplinary teams caring for cancer patients. Received: 04/55/2013 Accepted: 09/18/2013 Published: 10/07/2013 © 2013 Tranmer et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & Oral Care in Cancer Therapy ORIGINAL RESEARCH 2(1):eP1049 | 2 Introduction Assessing knowledge of oral health and practice of evidence-based guidelines among oncology teams is crucial in oral management of oncology patients (Barker et al., 2005; McGuire, 2003; McGuire, Johnson, & Migliorati, 2006; Southern, 2007; Vissink et al., 2003). Annually, over one million Americans are diagnosed with cancer and 40% of patients receiving systemic chemotherapy develop oral problems (American Cancer Society, [ACS], 2013; National Cancer Institute, [NCI], 2013; National Institute of Dental and Craniofacial Research, [NIDCR], 2011). Patients undergoing cancer therapy are immediately at risk for shortand long-term oral complications when treatment begins (ACS, 2013; NIDCR, 2011). Oral complications can be profound, negatively impacting quality of life, and potentially postponing or disrupting cancer therapy (ACS, 2013; NIDCR, 2011). Shortand long-term complications associated with head and neck radiotherapy and/or systemic chemotherapies include oral mucositis, a painful inflammation and ulcerations in the oral tissue; xerostomia, severe dry mouth resulting from reduced or absent saliva flow; trimus, a condition limiting opening of jaw with painful muscle spasms; rampant dental caries, tooth decay that affects multiple teeth and progresses rapidly ; and osteoradionecrosis, a necrosis of the jaw bone following radiation (ACS, 2013; NCI, 2013; NIDCR, 2011; Trotti et al., 2003). Oral mucositis is a common complication among patients with cancer undergoing systemic chemotherapy and/or head and neck radiotherapy (Arora, Keerthilatha, Maiya, Vidysagar, & Rajeev, 2008; Stokman et al., 2006; Trotti et al., 2003). The Mucositis Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) and International Society for Oral Oncology (ISOO) published guidelines for care of mucositis based upon a systematic review of the literature (Keefe et al., 2007). These guidelines are similar to those found in other cancer resources, such as those published by NCI and NIDCR. A systematic review by Keefe et al. (2007) concluded, depending on severity, mucositis can cause serious complications to a patient’s ability to eat and maintain a healthy weight. The author also reported cancer treatment may be suspended or discontinued due to severity of mucositis (Keefe et al., 2007). Xerostomia is another common short-term complication resulting from systemic chemotherapy, head and neck radiation, medication, and/or illness. It results from reduction of salivary output (chemical composition) and flow from salivary glands (Al Nawas & Grötz, 2006). In a clinical trial by Papas, Russell, Singh, Kent, Triol & Winston (2007) dramatic reduction of saliva was noted within the first weeks of high-dose systemic cytotoxic agents or head and neck radiotherapy (Papas et al., 2007). Without regular oral Implications for Interprofessional Practice • Emphasizes the presence of specialized oncology members with knowledge and training in oral health, or utilizing an oral health liaison, as being crucial for the implementation of evidence-based oral management of oncology patients. • Describes a need to increase access to and use of current evidence-based guidelines and validated assessment tools for oral complications, as well as modalities for management of oral complications. • Provides published oral management guidelines to assist oncology professionals in the provision of standardized care for patients. • Stresses importance of knowledge of oral health throughout all phases of cancer therapy and the use of guidelines for oral care among oncology teams as critical to the overall management of these patients. H IP & ISSN 2159-1253 Health & Interprofessional Practice | commons.pacifi cu.edu/hip 1(5):eP1049 | 3 assessment and preventive measures, xerostomia can be directly related to rampant dental caries. If xerostomia is not managed eff ectively, teeth can be destroyed in a matter of months and can lead to osteoradionecrosis if not addressed properly. (ACS, 2013; NCI, 2013; NIDCR, 2011; Shiboski, Hodgson, Ship, & Schiødt, 2007).


Introduction
Assessing knowledge of oral health and practice of evidence-based guidelines among oncology teams is crucial in oral management of oncology patients (Barker et al., 2005;McGuire, 2003;McGuire, Johnson, & Migliorati, 2006;Southern, 2007;Vissink et al., 2003).Annually, over one million Americans are diagnosed with cancer and 40% of patients receiving systemic chemotherapy develop oral problems (American Cancer Society, [ACS], 2013; National Cancer Institute, [NCI], 2013; National Institute of Dental and Craniofacial Research, [NIDCR], 2011).Patients undergoing cancer therapy are immediately at risk for short-and long-term oral complications when treatment begins (ACS, 2013;NIDCR, 2011).Oral complications can be profound, negatively impacting quality of life, and potentially postponing or disrupting cancer therapy (ACS, 2013;NIDCR, 2011).Short-and long-term complications associated with head and neck radiotherapy and/or systemic chemotherapies include oral mucositis, a painful inflammation and ulcerations in the oral tissue; xerostomia, severe dry mouth resulting from reduced or absent saliva flow; trimus, a condition limiting opening of jaw with painful muscle spasms; rampant dental caries, tooth decay that affects multiple teeth and progresses rapidly ; and osteoradionecrosis, a necrosis of the jaw bone following radiation (ACS, 2013;NCI, 2013;NIDCR, 2011;Trotti et al., 2003).
Oral mucositis is a common complication among patients with cancer undergoing systemic chemotherapy and/or head and neck radiotherapy (Arora, Keerthilatha, Maiya, Vidysagar, & Rajeev, 2008;Stokman et al., 2006;Trotti et al., 2003).The Mucositis Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) and International Society for Oral Oncology (ISOO) published guidelines for care of mucositis based upon a systematic review of the literature (Keefe et al., 2007).These guidelines are similar to those found in other cancer resources, such as those published by NCI and NIDCR.A systematic review by Keefe et al. (2007) concluded, depending on severity, mucositis can cause serious complications to a patient's ability to eat and maintain a healthy weight.The author also reported cancer treatment may be suspended or discontinued due to severity of mucositis (Keefe et al., 2007).
Xerostomia is another common short-term complication resulting from systemic chemotherapy, head and neck radiation, medication, and/or illness.It results from reduction of salivary output (chemical composition) and flow from salivary glands (Al Nawas & Grötz, 2006).In a clinical trial by Papas, Russell, Singh, Kent, Triol & Winston (2007) dramatic reduction of saliva was noted within the first weeks of high-dose systemic cytotoxic agents or head and neck radiotherapy (Papas et al., 2007).Without regular oral

Implications for Interprofessional Practice
• Emphasizes the presence of specialized oncology members with knowledge and training in oral health, or utilizing an oral health liaison, as being crucial for the implementation of evidence-based oral management of oncology patients.
• Describes a need to increase access to and use of current evidence-based guidelines and validated assessment tools for oral complications, as well as modalities for management of oral complications.
• Provides published oral management guidelines to assist oncology professionals in the provision of standardized care for patients.
• Stresses importance of knowledge of oral health throughout all phases of cancer therapy and the use of guidelines for oral care among oncology teams as critical to the overall management of these patients., 2013;NCI, 2013;NIDCR, 2011;Shiboski, Hodgson, Ship, & Schiødt, 2007).

Literature Review
Oral health professionals have been identifi ed in the literature as a valuable component to the oncology team (ACS, 2013;NCI, 2013;NIDCR, 2011).Th eir expertise in oral disease and health promotion can provide needed oral health evaluation prior to cancer therapy by addressing existing oral health issues which could impact cancer therapy, as well as through assessment/ treatment of oral complications (for example, see Figure 1) associated during and aft er completion of cancer therapy (ACS, 2013;Barker et al., 2005;Keefe et al., 2007;McGuire, 2003;McGuire, Johnson, & Migliorati 2006;NCI, 2013;NIDCR, 2011;Öhrn & Sjödėn, 2003;Southern, 2007;Vissink et al., 2003).Th e role of the oral health professional may positively aff ect treatment outcomes for patients with various cancers, whether through direct patient care or educating oncology teams on evidence-based practices.Multidisciplinary approaches that include dental professionals have not been integrated into this population's total care (ACS, 2013;Barker et al., 2005;Keefe et al., 2007;McGuire, 2003;McGuire, Johnson, & Migliorati 2006;NCI, 2013;NIDCR, 2011;Öhrn & Sjödėn, 2003;Southern, 2007;Vissink et al., 2003).
In each phase of cancer therapy, patients need oral assessment, oral self-care education, and preventive therapy measures.Frequent oral assessments using evidence-based indices are recommended throughout cancer therapy (Keefe et al., 2007;NCI, 2013 2003).
Investigators in Sweden, The Netherlands, and the United States have conducted surveys among oncology staff to evaluate oral health knowledge level and patient management protocols related to oral complications of patients undergoing cancer therapy (Barker et al., 2005;McGuire, 2003;McGuire et al., 2006;Öhrn, Wahlin, & Sjödén, 2001;Öhrn, & Sjödén, 2003;Southern, 2007).Findings of research evaluating oncology nurses' knowledge of oral health indicated both professional nursing programs and continuing education (CE) courses needed to either add or extend their didactic/ clinical content regarding oral health assessment and therapeutic strategies associated with cancer care (Öhrn, Wahlin, & Sjödén, 2001;Öhrn, & Sjödén, 2003;Southern, 2007).These educational experiences and introduction of evidence-based protocols are needed to keep professionals informed of current information and effective interventions to manage common oral complications (Barker et al., 2005;McGuire, 2003;McGuire et al., 2006;Öhrn, Wahlin, & Sjödén, 2001;Öhrn, & Sjödén, 2003;Southern, 2007).
A survey of nurses involved with cancer care in Ireland showed nearly half of respondents had received some educational content on oral healthcare/patient management during their primary nursing education.A large portion of respondents (43%), however, reported no education during their primary training regarding oral care related to cytotoxic agents or radiation therapy (Southern, 2007).In addition, Southern (2007) found nurses self-rated their knowledge about saliva substitutes, oral health status, and signs and symptoms of oral complications as poorest (no knowledge) on a 5-point Likert scale.
Three key principles regarding provision of oral care during cancer therapy have been identified for oncology teams: "1) recognizing oral care is medically necessary in patients with cancer; 2) collaborating with members of other healthcare disciplines; and 3) engaging in evidence-based practice to the fullest extent possible" (McGuire 2003, p.438)

Discussion
Oral health professionals are not standard members of oncology teams, although their expertise in oral disease and health promotion could positively affect oral health of patients prior to cancer therapy, standardization of oral assessment tools, and evidence-based oral health management (Barker et al., 2005;McGuire, 2003;McGuire, Johnson, & Migliorati, 2006) Studies have indicated the importance of knowledge of oral health in all phases of cancer therapy and use of guidelines for oral care among oncology teams as being critical to the overall management of these patients (Keefe et al., 2007;NCI, 2013;NIDCR, 2011).Sound educational training in oral care protocols can provide an important foundation for total care (Barker et al., 2005;McGuire, 2003;McGuire, Johnson, & Migliorati, 2006;Southern, 2007;Vissink et al., 2003).Respondents reported their primary professional education provided minimal content regarding oral health.Furthermore, our findings indicate oral complications, specifically with cytotoxic drugs and radiation therapy, were minimally addressed in general professional programs; however, extensive content regarding oral health within specialized oncology education was reported by nearly half of responding oncology professionals, and an additional forty percent reported some content.
Published oral management guidelines, knowledge of oral care, and use of validated assessment tools can assist in the provision of standardized care for oncology patients (McGuire, 2003;NCI, 2013;NIDCR, 2011).The majority of respondents in this study reported oral assessment indices were useful, and most were using the World Health Organization Oral Mucositis Index (WHO OMI) for assessment of mucositis.Although not specifically addressed in this study, Southern (2007) reported a lack of training on how to use oral assessment tools in primary professional education.Twenty percent of respondents in this study were not using any form of oral assessment index to aid in the identification and management of oral complications.(Harris, 2008), CE for oncology nurses should include evidence-based oral assessment guides to help prevent, document, and/or manage oral complications from cancer treatment.See Table 6 (following page) for evidence-based recommendations for referral and oral management in cancer therapy.The inclusion of an oral health professional in an oncology team could provide direct patient care and educate other oncology team members on evidence-based guidelines and management of oral complications (Barker et al., 2005;McGuire, 2003;McGuire, Johnson, & Migliorati, 2006;Southern, 2007;Vissink et al., 2003).
Significant, direct associations were identified between management of oral complications and years of experience in oncology.This study's results show a direct association between respondents' self-reported knowledge of oral care recommendations/ management and years of practice in an oncology setting.Although updates of oral care protocols through CE may be valuable for educating oncology healthcare professionals who have minimal specialized oncology training, research has shown it has not necessarily changed implementation of those protocols into practice (Bloom, 2005;Robertson & Jochelson, 2006).It is not surprising to see significant correlations between increased experience and incorporation of management protocols for oral complications; still over half of respondents were seldom to never assisting patients with their oral care.

Before Cancer Treatment
To treat existing oral disease.

During Cancer Treatment
For treatment of pain or tooth infection (high-risk for oral complications).

After Cancer Treatment
To educate and manage long-term complications: have decreased significantly over the past few decades.These authors also assert that the representativeness of the sample is much more critical than the low response rate (Colbert, Diaz-Guzman, Myers, & Arroliga, 2013) The response rate found in this study, though far from ideal, may reflect this trend or may reflect a lower response rate sometimes found with online surveys of medical professionals (8.7%; Aitken, Power, & Dwyer, 2008) and surveys seeking information about an organization/team (18.8%;Baruch & Holtom, 2008).While results of this study are not generalizable to the population of oncology nursing professionals, they do support results from earlier research studies related to nurses' knowledge, education, and practices regarding oral care management of oncology patients.Despite previously established internal reliability and content validity of the survey constructed by Southern (2007), analyses of responses from this study using the original instrument showed nine items that were either unclear or had no theoretically correct response.Should the original instrument be used in future studies, these items would need revision.

Conclusions
This investigation recognizes and supports the existing literature which describes a need to increase access to and use of current evidence-based guidelines and validated assessment tools for oral complications, as well as modalities for management of oral complications.This study also emphasizes the presence of specialized oncology members with knowledge and training in oral health or an oral health liaison as being crucial for the implementation of evidence-based oral management of oncology patients.It also sets the groundwork for the inclusion of licensed dental hygienists as members of oncology care teams.By the nature and content of dental hygiene education, licensed dental hygienists are already trained to assist, collaborate, and provide education in oral care for patients undergoing cancer therapy.Additional research is needed to examine whether increased knowledge and education of oral health among oncology teams positively impacts oncology patient outcomes.Furthermore, future studies could examine how technology or interactive CE courses might positively impact standardization of protocols among oral management of cancer therapy.
Southern (2007)dy was designed to evaluate oncology team members': (a) education in and knowledge of oral disease/oral complications associated with cancer care based on didactic study within their professional or continued education; (b) patient management practices of oral complications during cancer care; (c) comfort level performing oral care for patients with cancer; and (d) knowledge/education, comfort levels, and oral management of complications based on demographic characteristics.MethodsA Web-based survey was used to assess knowledge and educational levels regarding oral care, management practices related to oncology care for oral complications, and other influences affecting oral care of cancer patients by oncology nurses.The survey instrument used, National Survey of Oncology Teams' Knowledge and Education about Oral Care in Cancer, was developed and validated in Ireland bySouthern (2007).The instrument was reviewed for this study by an oncology nurse in the U.S.A. for applicability of responses, and minor modifications were made in verbiage for American English and regional professional terminology.The revised questionnaire was pilot tested by a small convenience sample (N=8) of two oncology nurses and six registered dental hygienists (RDH).The coded questionnaire contained 44 items related to oral health knowledge and education, evidencebased management of oral complications, evidence-ISSN 2159-1253 Health & Interprofessional Practice | commons.pacificu.edu/hip2(1):eP1049|5Followingapproval by the University's Institutional Review Board (IRB), an invitation link to the survey was sent via e-mail directly from the ONS online database.The link directed respondents to a Web-based survey site where informed consent and the survey instrument (questionnaire) were available.Two follow-up emails were sent to non-respondents.compare the subscale scores between those with and without oncology training.Exploratory factor analysis was performed to identify underlying subscales (such as knowledge of oral care) within the instrument.In addition to factor analysis, Cronbach's alpha was calculated to determine internal reliability of items within the three The second construct, evidence-based management of oral complications, was significantly associated with education regarding cytotoxic agents and radiation (r=0.286;n=104; p=0.003); however, no Oral Care in Cancer Therapy ORIGINAL RESEARCH 2(1):eP1049 | 6 & ISSN 2159-1253 Health & Interprofessional Practice | commons.pacificu.edu/hip2(1):eP1049 | 7

Table 3
Frequencies and Percentages of Responses within 3 Identified Constructs

Table 4
Years in Oncology in Oral Care of Cancer Patients Correlated to Knowledge of Oral Care, Management of Oral Complications and High-risk Patients

Table 5
Validated Oral Assessment Tools

World Health Organization (WHO) • Oral Mucositis Assessment Scale (OMAS)
Primary indicators of mucositis were the degrees of ulceration and redness measured in specific sites in the mouth.Secondary indicators included oral pain, difficulty swallowing, and the ability to eat as assessed by the patient.

Table 5 (
below) presents an overview of validated oral assessment tools.These findings emphasize, while oncology team members are aware of assessment protocol recommendations, there may be a need for standardized courses or specialized training on how to implement evidence-based oral care practices into oncology settings.According to the ONS mucositis PEP group

Table 6
Evidence-based Recommendations for Referral and Oral Management in Cancer Therapy

risk inpatient and outpatient oral assessment is needed. Clinical Guidelines by Multi-National Association of Supportive Care in Cancer (MASCC/ISOO) Referral to Oral Health Professionals Oral Management in Cancer Therapy
Both high-risk and outpatient oral assessment is needed:• To evaluate mucositis for severity & pain level.H IP & Oral Care in Cancer Therapy ORIGINAL RESEARCH 2(1):eP1049 | 12