Financial and socio-economic factors influencing pre- and post-cancer
therapy oral care
Derek K. Smith
Emily H. Castellanos
Barbara A. Murphy
Received: 22 September 2017 /Accepted: 25 December 2017 / Published online: 25 January 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
Purpose The primary objective of this study is to evaluate how attendance at dental visits may change as cancer patients move
through pre-diagnosis, diagnosis, and into survivorship.
Methods The Health and Retirement Study consists of longitudinal survey data collected biannually detailing financial and
health information in subjects over 51 years old. We assessed a subset of 4195 patients who received a new cancer diagnosis
during the study period. The odds of reporting a dental visit were examined using a mixed effects logistic regression model. A
propensity score weighted analysis of the association between dental attendance and survival was also undertaken.
Results The odds of attending a dental visit were substantially lower in the peri-diagnosis period OR = 0.784 (0.700, 0.876) and
the post-diagnosis period OR = 0.734 (0.655, 0.823) compared to pre-diagnosis. This effect persisted in patients who survived for
at least 2 years indicating that the decline in oral health visits was not due to low expected survival. After propensity score
weighting, patients who attended a dental visit in the peri-diagnosis period demonstrated a reduced hazard of all-cause mortality
HR = 0.825 (0.681, 0.979) compared with those with no attendance.
Conclusions Dental attendance decreases by a statistically and clinically significant amount both during and after cancer therapy
despite guideline recommendations encouraging dental referral and monitoring for many types of cancer therapy. Attendance at
dental appointments during cancer therapy is associated with improved survival, which is likely due to a combination of direct
and indirect effects.
Keywords Pre-treatment dental evaluation
Health and retirement study
Oral care utilization
The negative effects of cancer therapy on oral health have a
significant impact on general health and quality of life [1–6].
Multiple cancer therapies, including chemotherapy,
bisphosphonates, head and neck radiation, stem cell transplant
therapies, and targeted therapies, can all lead to substantial
oral complications [7–11]. Based on current guidelines, pa-
tients should be referred for oral evaluation prior to initiation
of cancer treatment [11–16]. The oral evaluation affords the
cancer team the opportunity to identify and address dental
problems before initiation of treatment, thus potentially
preventing acute and long term oral health complications. In
addition, cancer patients also require close follow-up care dur-
ing and after their treatments have concluded to ensure ade-
quate preventive measures and to monitor for acute and late
oral health toxicities.
A number of factors contribute to poor adherence to oral
health guideline. Not all patients with a cancer diagnosis re-
ceive appropriate pre-treatment assessment of dental health. In
addition, patients often fail to comply with routine follow-up
care. More importantly, patients with clinically evident oral
complications requiring dental evaluation may decline to seek
appropriate care. Finally, patients found to have oral health
complications may not comply with recommended treatment
regimens. The degree to which the above problems exist in the
cancer patient population has not been well defined.
Furthermore, the barriers to oral health care have yet to be
* Derek K. Smith
Departments of Biostatistics and Oral Maxillofacial Surgery,
Vanderbilt University Medical Center, 2525 West End Ave, Ste
11000, Nashville, TN 37203, USA
Department of Oncology, Vanderbilt University Medical Center,
Nashville, TN 37221, USA
Supportive Care in Cancer (2018) 26:2143–2148