Impact of the absence of dental support on cancer patients during the COVID-19 pandemic

Purpose With the suspension of routine services due to the coronavirus disease-2019 (COVID-19) pandemic, a signicant number of the population has been presenting acute oral alterations without proper treatment. Through telecontact, this study aimed to identify individuals in treatment and had been treated for cancer who had their clinical dental care interrupted by the COVID-19 pandemic. Individuals with oncologic diseases were selected from a telephone list of a clinical research center specializing in the care of cancer patients. We included those who answered an online questionnaire about their general health status and oral problems when they were unable to access dental care during the pandemic. Statistical analysis was performed using Fisher and Chi-square tests. The signicance level was set at 5% (p<0.05).


Introduction
In early March 2020, the World Health Organization declared the outbreak of the disease coronavirus disease-2019 (COVID-19) as a pandemic. In an attempt to control it, social isolation was one of the main strategies proposed. Thus, the con nement of the population and the impact of the outbreak on healthcare systems have disrupted the routine care required by COVID-19-negative patients [1].
Dental practice involves a high risk of infection by the severe acute respiratory syndrome coronavirus 2 since the procedures performed require close approaches to the nasopharyngeal and oropharyngeal regions, which are directly linked to the pathophysiology of COVID-19. In addition, the frequent contact with saliva, blood, and other body uids of patients, handling of sharp instruments, and constant production of aerosols also increase the risk of infection [2]. Given all these factors, dental surgeons are the most vulnerable health professionals to disease infection [3,4].
As a preventive measure, most countries suspended elective dental care [5]. Brazil was no exception, and both the Federal Council of Dentistry and the National Health Surveillance Agency recommended limiting dental care to urgent and emergency cases [4,6]. With the suspension of routine services, a signi cant number of the population has presented with acute oral changes without proper treatment [7].
Oral health has a signi cant impact on the quality of life of immunosuppressed patients, such as organ and tissue transplant patients and those who are or have been under cancer treatments [3], since the dental support to these individuals mitigates the repercussions arising from the therapies for these diseases [8]. The suspension of clinical care and lack of dental care for these individuals may exacerbate the adverse effects of medical treatments, causing pain and discomfort in the mouth. Therefore, dental surgeons are increasingly seeking alternative approaches to provide supportive care to these groups of patients to reduce the impact of oral problems on their quality of life.
Teleconsultation is one of the tools used for distance care during the pandemic in various areas of health, using applications and social media [9]. While it facilitates communication and guidance between the professional and the patient, this practice has not yet been established by the regulatory authorities of dentistry. Therefore, through virtual/telephone contact, this study aimed to identify individuals under treatment and who had already been treated for some type of cancer who underwent dental treatment in 2019 and had their clinical care interrupted by the pandemic caused by COVID-19 in 2020.

Methods
Approval was obtained from the Human Research Ethics Committee of the Bauru School of Dentistry, University of São Paulo (CAAE: 39316520.2.0000.5417). The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Sample
This cross-sectional study was conducted in a clinical research center specializing in the care of systemically compromised individuals in the areas of oncology and organ and tissue transplantation. It included patients who underwent dental treatment in 2019 but did not receive care in 2020 due to the suspension of clinical dental care during the COVID-19 pandemic. Individuals over 18 years old who were able to communicate remotely by email or messaging applications were selected from the institution's updated phone list. Questionnaire A two-part online questionnaire was sent via Google Forms: (I) Sociodemographic and Health Data and (II) Structured Questionnaire, along with the informed consent form. The topics in the rst part of the questionnaire included sex, age, occupation, underlying disease (location), and type of systemic and/or antineoplastic treatment. The second part of the questionnaire was composed of previously established structured questions and questions about their overall oral problems when they had no access to dental care during the COVID-19 pandemic.

Data analysis
A database covering the patients' responses was tabulated using Microsoft O ce Excel 2016 (Microsoft Corporation, Redmond, WA, USA) spreadsheets. Statistical analysis of the obtained data was performed using the Fisher test in IBM SPSS V21 Software (IBM; Armonk, New York, United States) and the Chisquare test in Jamovi Project 2020 (Version 1.2) and R Core Team 2019 (Version 3.6) software. Frequency tables with percentages and graphs were used to verify the possible associations between the variables evaluated. The signi cance level was set at 5% (p<0.05).

Results
A total of 280 patients with a history of oncologic disease were recruited through the Clinical Research Center's phone book. Of these, it was possible to establish contact remotely with the 151 individuals who agreed to participate in the online survey. Of them, 104 answered the questionnaire through the Google Form platform. The other 129 individuals did not participate in the survey for the following reasons: 42 had died during the pandemic; eight were minors; 19 did not answer the calls after several attempts; nine answered, but the number did not correspond to the individual; 33 phone numbers were unable to receive calls or were outside the coverage area; 15 did not agree to participate in the survey; and three individuals were bedridden/inpatients. Tables 1, 2, and 3 present the sociodemographic and health data, general structured questions previously established for this research on the general health status of the individuals, and the data on the oral problems related to those undergoing treatment for cancer compared to previously treated patients who had dental treatment in 2019 but did not receive care during the COVID-19 pandemic.
Of the 104 individuals, 64 (61.5%) had no complaints regarding their general health. In addition, eight (7.7%) patients had a con rmed diagnosis of COVID-19, with mild symptoms in six patients (5.8%) and severe symptoms in two (1.9%). Regarding general health, 57 (54.8%) had a worsened status due to a lack of dental care. Questioned about the di culty in performing daily activities caused by problems in the teeth and/or mouth, 74 (71.1%) did not experience any di culties. In contrast, 51 (49.0%) patients sought dental care during the pandemic, and 30 (58.8%) of these were still undergoing oncologic treatment. A total of 42 (40.4%) individuals postponed their treatments other than dental care; however, 93 (89.4%) did not decrease the frequency of tooth brushing during the pandemic and social isolation. In addition, 94 (90.4%) individuals did not receive any type of supervision or monitoring via telephone during the pandemic, and of these, 56 (53.8%) were still on oncology treatment ( Table 2).
Regarding the oral problems of individuals who were left without dental care during the COVID-19 pandemic, there was no statistically signi cant difference (p=NS) between those who were and were not being treated for cancer. Regarding oral problems that arose during the pandemic in the 104 cancer survivors, the most commonly reported was dental pain when eating hot or cold food or drinks (59, 57.0%), followed by muscle pain (56, 53.8%), and di culty when chewing (53, 51.0%). In contrast, the least reported were the presence of purulent secretion (31,29.8%), spontaneous gingival bleeding (33, 29.8%), and spontaneous dental pain (37, 35.6%) ( Table 3). However, even though these were reported by the individuals, the rates of oral problems did not show statistical signi cance (p=NS).

Discussion
The majority of our study population were women, and breast cancer was the most prevalent, in line with the estimates and projections of this cancer both in the southeastern region of Brazil and globally [10,11]. Chemotherapy was the most prevalent treatment in both groups of patients. For the 52 (50%) who were still undergoing antineoplastic treatment, the need for monitoring by a specialized dental service to mitigate the acute complications of this treatment is highlighted [12]. Similarly, patients who are undergoing head and neck radiotherapy with the likely demand for the acute effects of radiotherapy [13] and even those who have already received this therapeutic modality need constant monitoring to avoid or treat the late manifestations of radiotherapy treatment [14].
Globally, numerous governments have mobilized their forces to mitigate COVID-19, making the enforcement of non-pharmacological interventions, such as keeping the population at home and closing non-essential services, indispensable. Furthermore, it can be observed that these large-scale measures were effective in reducing the spread of the virus [15], given that only eight individuals in the study tested positive for the disease. On the other hand, some public dental care services had to be closed, causing a decrease in pediatric dentistry services, prosthetic rehabilitation treatments [16], and oral pathology and medicine services [17,18].
With social isolation and the modernization of the workforce, some individuals experienced reductions in their income, which possibly aggravated the negative effects on oral health. The majority of those under antineoplastic treatment were retired (52%). Among those who have completed therapy, most were currently active in their professions (43%). Diet and oral hygiene were adapted to the new reality, along with other behavioral changes, such as smoking and loss of access to dental services [19]. In this sense, it is known that in times of epidemics, people experience the fear of becoming infected with the virus/disease, resulting in anxiety, stress, and depression [20]. Thus, despite their demands for dental care, the population remains in social isolation [21]. This could explain why only 49.0% of the sample (51 patients) sought dental care services in almost one year of the pandemic, even if 59 patients (56.7%) reported feeling "tooth pain when eating hot or cold food and/or drinks." The COVID-19 pandemic led to increased rates of anxiety (31.9%) and depression (33.7%) in the normoreactive population [22]. On the other hand, in patients undergoing cancer treatment, trait and state of anxiety were found in 59.1% and 48.4%, respectively [23]. In view of this, another aggravating factor generated by stress is periodontal disease, which was referred to as "teeth softening" in the questionnaire applied. The changes in the patients' supporting tissues may have made them ag this issue. The frequency of periodontal disease in individuals exposed to stress was 15-36% higher than that in healthy individuals [24]. Therefore, in our sample, 48 individuals (46.1%) reported "teeth softening, " which could suggest some complications of periodontal nature.
Similarly, both temporomandibular dysfunction and bruxism (sleep or wakefulness) can be caused by psychosocial factors, such as anxiety, stress, depression, and catastrophizing, which are commonly present in cancer patients [25][26][27][28]. This could justify why more than half of the sample reported "di culty when chewing" and "muscle pain in the jaw area when waking up." Moreover, it has already been discussed in the literature that patients experienced an intensi cation of bruxism and temporomandibular dysfunction symptoms during the pandemic [29].
The accessibility of the Internet and the development of new technologies may favor the use of tools for remote care during the pandemic, such as telesupport in dentistry. This is relevant to society given the changes in the provision of health services [30]. From this perspective, when the team in this study came into contact with individuals, they directly experienced an innovative experience from the perspective of assistance. Most individuals, including those in antineoplastic treatment and those who have already been treated, reported not having received any type of supervision or dental monitoring via telephone or virtually (telesupport) before being contacted by our team, highlighting the novelty of the teleconsultation tool in society [31].
One study reported that the patients' quality of life and emotional functioning were not affected during the COVID-19 pandemic [32], in contrast to the ndings of another previous study [33]. This may be because the patients felt safe while the whole population practiced social distancing, which corroborates our nding that the "quality of life related to general health" did not change during the pandemic for most of the individuals in treatment and those already treated. This was not due to the absence of oral complaints but because of the proximity of family members during the lockdown. Being a high-risk group, this proximity emotionally helped most of these individuals feel better during the pandemic, maintaining a better quality of life. This is important since it occurred even in the absence of dental support; however, the quality of life for a few individuals in treatment and for some who had already been treated was worse, showing COVID-19's impact on this group of patients who are battling cancer.
It has already been discussed in the literature that lack of regular dental visits and poor oral hygiene were associated with worse survival in cancer patients [34]. It was emphasized that in this study, both groups of patients had already received instructions and recommendations on the importance of oral hygiene since their rst face-to-face visit before the pandemic began. The team of professionals specializing in the care of cancer patients educated the individuals about the importance of routinely performing oral care. Although we are still facing one of the biggest health crises in the world during this study, the result of all this dedication was evident when we saw that most of the interviewed individuals did not reduce their frequency of brushing during this period.
A limitation of this study was that it was not possible to establish telephone contact with all the individuals initially listed since most of them had died due to the progression of the underlying diseases during the pandemic, which required social isolation. Future research is needed to explore the main oral complaints in pediatric oncology patients and in individuals with other systemic diseases.