How do you transition patients from curative but damaging treatment to survivorship? Dr Kim Gear, oral medicine specialist, wants to be the ambulance at the top of the cliff while Dr Neil Croucher, Clinical Director of Oral Health admits that funding and staffing for follow up dental care is limited and patients should go back to private dental care as soon as they are returned to function after treatment.
Dr Kim Gear
Today's meeting was about teeth, about the mouth, but also about survivorship in general for head and neckers. First speaker was Dr Kim Gear who is leaving Oral Health and running a new project through Ko Awatea* and ORL at Auckland City Hospital. She called in briefly to explain this new head and neck cancer initiative but I can give only a brief summary here. We hope to update you later.
Dr Gear's idea is to create a "survivorship hospital", not in one concrete location but as a network of services that will aim to keep head and neck cancer survivors healthy, especially in respect to their dental care.
She would like to see integration between different services. After a "cure", there is often a void. There are long term side effects and a psychological impact. We need to take a broader view of health where psychological and physical are seen more as one.
Follow up and screening are not always best in the hospital. A screening clinic with a broad, holistic view would be better.
What about funding for these services? Kim quoted Earnest Rutherford: "We didn't have the money so we had to think."
She mentioned the "olive effect". Take one olive off the first class passengers and spread the savings around. We can do the same thing in hospitals.
An example of smart spending is the treatment of osteoradionecreosis. $2.5 million a year is spent on this bone decay after radiotherapy. Hiring a hygienist to keep patients' mouths bug free seems expensive in the short term but in the long term would SAVE money. She recommends the Atul Gawande's book the Checklist Manifesto which outlines how we can carry out simple steps to cut through the complexity of the modern world.
Finally, it might be that we need to have private care with public funding. Meanwhile, because we need private care anyway, we need to come up with a list of dentists in the community (and perhaps hygienists) who have the skills and confidence to treat the radiotherapy-affected mouth. She suggests that we email all out members and ask for recommendations. Next month we can come up with a partial list of dentists.
AUT also has a programme where patients can receive free hygienist care from trainee practitioners.
Dr Neil Croucher
Our second speaker was Dr Neil Croucher, Clinical Director of Oral Health, based in Whangarei and speaking to us by phone from there. His voice came through the speakers loud and clear but he was only able to speak to us briefly.
Neil has two days a week in a clinical leadership role in Oral Health to deliver hospital dental care from government to population He used to be a hospital dentist specialising in special care and pediatric care. He is two and an half years into the role now and hopes to look back after five years to see an improvement in service delivery.
His first major improvement is in gaining a maxillo-facial surgeon with 7.5 of a full time role; in other words 7 1/2 sessions a week. Now their relationship with other clinicians, for example plastics, will be better. Secondly they have a new oral medicine specialist, newly trained, Hedley Clark.
They have appointed a new dental technician who can make a variety of prostheses for areas like the eyes and ears.
However rehabilitation for people like us is not sufficiently funded. Dentistry is the "forgotten son of medicine". We are entitled to only once episode of care after treatment to get us fit for the private service, not necessarily for the restoration of aesthetics.
implants are available but patients are asked to pay lab fees. Implants are not likely for HNC patients.
Head and neckers’ 20 year battle to get funded dental surveillance is ongoing. Kim’s project offers hope as does the Northern Regional Review of Head and Neck Cancer Services, the report from which is coming out in the next few weeks. In the review, patients were surveyed about their dental needs among a variety of other treatment factors.
Many thanks to Kim and Neil for making themselves available to talk to us.
* Ko Awatea is the innovation centre at CMDHB (Middlemore)