The future of oral-systemic health: Dental hygienist breaks new ground treating pediatric cancer patients

Martinez began working at Phoenix Children's Hospital in 2019 through a program funded provided by Delta Dental of Arizona. Martinez works to lower infection rates, specifically in PIKK line infections of patients in the hospital's hematology/oncology unit. She also works in the hospital's pediatric intensive care unit and cardiovascular intensive care unit.

With the title of Oral Health Educator, Martinez has a full schedule teaching providers, nurses, clinical staff, patients, and parents about dental issues involved with cancer treatment. She rounds with clinical staff members, who consult Martinez in an effort to reduce oral side effects of chemotherapy, such as xerostomia and oral lesions.

Martinez has successfully lobbied to have an oral health tab added to all electronic charts for patients in hematology/oncology unit, and she continues to work to have the tab added hospital-wide. In addition, she was asked by a Phoenix Children's Hospital provider who partners with the Mayo Clinic to update protocols for mucosal barrier injury.

We had a chance to speak to Martinez about her observations, challenges, and successes over the past two years. We also spoke with the Delta Dental of Arizona team about the origins of this unique program.

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Interview with Katharine Martinez, RDH

DentistryIQ: Can you tell us about yourself and why were you interested in this unique position with Phoenix Children's Hospital?

Martinez: I always knew I wanted to help people, whether it be in education, nursing, public health, or dentistry. Choosing dentistry ultimately was an area that enticed me for my future. I respected the interpersonal, trusting relationships you build with patients as a hygienist. I valued the opportunity to help make a person healthier by way of the oral cavity. I knew that this was a field I would ultimately thrive in.

Upon graduation from dental hygiene school, I worked in different clinical settings that included pediatric, corporate, and private environments. I learned so much during my time in clinical practice, but I knew I was not ultimately fulfilled. I am a strong believer in always continuing to further your knowledge and skills. I knew eventually to achieve what I wanted, I would need to expand myself outside of the operatory, which spurred me to pursue a masters degree in public health. While in graduate school, I helped to develop oral health programs within public health departments, developed policies and procedures for home health special needs patients, and acted as an oral consultant for providers treating patients undergoing cancer therapy.

It turns out that this quote is true: “When all’s said and done, all roads lead to the same end. So it’s not so much which road you take, but how you take it.” All my paths led me to finding this role. This position as oral health educator was exactly what I had been looking for and what my educational paths were leading to. This role combines my love of dentistry, education, public health, and nursing into a rewarding position. I am so incredibly grateful and humbled that Phoenix Children’s Hospital and Delta Dental of Arizona saw something in me to be the one to pave the way for this role to exist.

DentistryIQ: Why is there such a great need for oral health care in the hosptial's hematology/oncology unit?

Martinez: There is an unbelievable need for oral health care across hospital settings. Where I see the greatest need for oral care exists in patients with central lines and those on ventilators. These patients are at the greatest risk of developing a hospital-acquired infection (HAI). Acquiring an HAI can be serious for patients who are immunocompromised. I spend a great deal of time with hematology/oncology patients. Cancer treatment lowers a patient’s immune response and inability to fight off infections. Side effects also wreak havoc on the oral cavity. Oral care is extremely important in this population, as it keeps bacteria levels low to avoid contaminating a patient’s central line.

Another major side effect of chemotherapy and radiation is mucosal barrier injury. Our mouths have a high cellular turnover rate, which makes chemotherapy/radiation break it down at a faster rate. Pediatric patients are unfortunately exposed to this more frequently. Preventing and managing this breakdown of the oral cavity is crucial to the patient’s treatment outcome and helps prevent central line-associated blood stream infections (CLABSIs).

DentistryIQ: Could you tell us some specifics about the kinds of clinical problems you see and the treatments you provide? Also, what do you feel have been the results of your presence there?

Martinez: I help decrease the chance of patients developing ventilator-associated pneumonia (VAP), nonventilated hospital-acquired pneumonia (NV-HAP), and central line–associated blood stream infections. Research shows through the use of educating on proper oral care, assessments, infection prevention, and products, there is a reduction in hospital acquired infections. Thanks to Delta Dental of Arizona, Phoenix Children’s Hospital is leading the way with its utilization of an oral health educator to prevent these.

There is a sense of gratitude among nurses and doctors for the expertise that I bring to the hospital. For many of these providers, their education only touched briefly upon the oral cavity, and they rely heavily on an otolaryngologist for help with conditions of the mouth. Now that my role exists, I help these providers navigate and educate patients on oral conditions. I work very closely with medical residents to educate them on performing assessments and how to classify a patient’s oral status. These residents will take that education with them to other hospitals and hopefully provide better overall care for their future patients.

DentistryIQ: Take us through a typical day. Do you make rounds similar to other hospital staff, and what are your interactions with patients and parents like?

Martinez: My workweek typically varies. Some days I see more patients and families, while other days I am in more committee meetings, general meetings, or trainings.I primarily work with the hematology/oncology unit, pediatric intensive care unit (PICU), and cardiovascular intensive care unit (CVICU).

For the PICU and CVICU, I work with quality control nurses in performing rounding for health care–associated conditions. In the CVICU, I work with heart transplant patients and provide education. I am able to complete assessments and provide education. 

In the hematology/oncology unit, I work closely with the bone marrow transplant team, where I conduct oral assessment pretransplant for all solid organ and bone marrow transplant patients. I follow up with these patients during the course of their therapy. For solid tumor patients, I go in when providers would like me to assess and to help educate nurses and families.

I work on other various other projects as well. I currently sit on numerous committees in the hospital related to infection prevention. I have updated oral health products hospital-wide, policies and clinical skills for all neonatal intensive care unit, nonventilated, ventilated, and hematology/oncology/bone marrow transplant patients. I have revised standard operating procedures on oral care for bone marrow transplant patients for Phoenix Children's Hospital and the Mayo Clinic.

Moreover, I educate patients and providers in the outpatient clinics on oral care and provide insights to help with side effects of chemotherapy and radiation. I try to keep the education fun and to distract patients from the infusion they are receiving.

DentistryIQ: What is the most rewarding part of your work?

Martinez: My interactions with patients and families is by far the best aspect of my daily work. These patient families are going through some of life’s toughest challenges. Many times, they have been inpatient for weeks or months. I always go into the room and build trust with the child and family first and foremost. I listen to the families express their concerns, setbacks, and goals for their children. I listen to children talk about their activities outside of the hospital and learn about what they want to do when they are well enough to leave the hospital. I relate to these families on a personal level, and know how to best help them by having a better understanding of chldrens' ages and families' culture, dynamics, and behaviors. Taking the time to listen is one of the most crucial things a health provider can do. If you earn trust, people will be more inclined to listen and make use of education given.

DentistryIQ: What was it like integrating into a hospital setting? Did you come across challenges in trying to get your colleagues to see the importance of oral health, or were there logistical challenges that you had to overcome that you recall?

Martinez: I found that integrating into the hospital setting was easier than I expected. My dental hygiene and public health background set up the foundation for what I am doing at Phoenix Children’s Hospital. My public health background gave me the framework to carry out program planning, research, and evaluations. My dental hygiene background provided me education on how to assess, educate, work interpersonally with other medical professionals, discover and research products that can help with oral conditions, and the ability to have interpersonal relationships with patients/families.

One challenge I faced when coming into the hospital setting was understanding the medical terminology. Many acronyms that are second nature to nurses and doctors were a foreign language to me. I also found that learning the computer software was a challenge.

This position was set up from the very beginning with the chief nursing officer pushing it forward in the hospital. Thanks to the support from executive leadership, the transition and respect was there from the beginning. My colleagues at Phoenix Children's Hospital have been nothing but supportive and interested in learning more about oral health and ways to expand my role throughout the hospital.

The biggest challenge I faced was introducing myself to every provider in the hospital and discussing what my role was. Now that I have been here for more than a year and involved in many committees, everyone in the hospital knows who I am and what my position entails. I am staying very busy to say the least!

DentistryIQ: Are there any patients who you remember as greatly benefiting from your care?

There are so many patients who have made a lasting impact. Once I was asked by a patient’s provider if I could go into this patient’s room to assess the mouth and help give education to family and patient. I never know what I am walking into when I enter these patient rooms. Sometimes they are up in bed playing and laughing, sometimes they are crying inconsolably. This patient was in and out of consciousness due to severe pain in the mouth. When I first walked into the room and introduced myself, I locked eyes with this patient’s mother, who gave me the most helpless look and asked if there was anything I could do to help her child.

Upon assessment, the patient had sores all over the palate, tongue, cheeks, floor of mouth, and lips. The patient was unable to close her mouth due to severe pain, and she presented with excess saliva due to an inability to swallow. This is still the worst case of mucositis I have ever seen. My approach was as follows:

• I worked with this mother every day on how to provide oral care and how to not hurt the oral cavity any further.
• This patient was in full orthodontic braces, which exacerbated the mucositis. I discussed with mom when the patient would be physically able to have them removed and explained the reasoning as to why they needed to be removed.
• I looked at all oral prescription rinses being used and determined which ones were aggravating the mouth. I worked with providers to change the rinses and find alternatives to help soothe and protect the mouth from developing a central line infection.
• I showed mom how to keep her child's central line dressing dry from saliva and how to apply oral rinses in the mouth.
• I performed numerous amounts of research on products to help this child when she  underwent the second round of infusion treatment.
• I worked in a collaborative approach with the medical team to ensure the second infusion this patient underwent would not cause significant mucositis.

Going forward, this patient did not have as severe of mucositis when all combined efforts were achieved in the treatment plan. I followed this patient very closely to ensure a central line infection did not occur.

At the start of educating mom on how to perform oral care, there was one day that will always resonate with me. I walked into the room and the patient was up and alert. I walked over to her bedside and she took my arm and whispered very quietly, “Thank you for helping me. I am finally able to swallow.” I looked right in her eyes and said, “No, thank you for being so brave and never giving up.” I left the room with tears in my eyes. I knew at that moment that I was in the right place, and I was making a difference in these children’s lives.

The best feeling in the world was when this patient left the hospital cancer-free. The mom called me a few months later and sent pictures showing her child with a huge smiling face and enjoying the beach. This is the best news a health-care provider can ever hope for.

DentistryIQ: The oral-systemic connection is an ongoing conversation in dentistry. What has your experience at Phoenix Children's Hospital taught you in this area?

Martinez: The oral-systemic connection is a huge piece of the puzzle that all health-care providers need to better understand. This experience has opened my eyes to the reality that as a dental provider, I need to be better educated on the entire body for doctors and nurses on oral health, and vice versa. With the amount of research correlating poor oral health to systemic issues in the body, we need to advocate better care for our patients. As dental providers, we need to be considered part of the interdisciplinary team. We are just as valuable as speech-language pathologists, occupational therapists, and physical therapists.

With continued ongoing research on the oral-systemic connection, it is only a matter of time before we will be part of the interdisciplinary team in every medical setting. I look forward to helping expand our roles as dental providers into these settings.

DentistryIQ: You were asked to review and update oral health protocols for the hospital. That sounds like an incredible opportunity. Can you tell us more about how you approached that challenge?

Martinez: Phoenix Children's Hospital and the Mayo Clinic (Arizona, Minnesota, and Florida) are partners in their Bone Marrow Transplant Program. I was asked by a Phoenix Children’s Hospital bone marrow transplant provider to look over and edit the oral care section for prevention and management of mucosal barrier injury that is currently used by all sites. These guidelines and procedures are set in place to help guide providers on what to do to help prevent or manage oral injury issues. I am honored that they approached me to use my expertise and experience to ensure a thorough set of guidelines were being followed and utilized for these patients.

DentistryIQ: What has this opportunity meant for you personally? Also, for dental hygienists looking to pursue alternative career paths, what would you tell them?

Martinez: This position has been life changing. I have a newfound love of dentistry in a high-demand setting. Being able to do what I am passionate about and that also makes a difference has been transformative. These children make my outlook on life so much brighter and give me an overwhelming sense of gratitude.

For all RDHs who have a calling for something outside the dental operatory, I would say, "Take the time to find what excites and motivates you." If you find that something you are passionate in, the sky’s the limit. Take the time to network; work hard at building your resume (even if it is pro-bono work); never stop educating yourself; and the biggest things—for me—would be to find something that makes you a better person and to never stop believing in yourself.

Interview with Delta Dental of Arizona

DentistryIQ: Tell us a little bit about the origins of this program. How did you identify the need and work with Phoenix Children's Hospital to make this happen?

Delta Dental of Arizona: This program came about in an effort by Delta Dental of Arizona (DDAZ) to integrate oral health and education into medical health care for children. DDAZ funds a number of medical-dental integration programs at federally qualified health centers across the state. Phoenix Children’s Hospital is the first organization that people in Phoenix turn to for getting the best medical care for their children, so we felt it would be a strong organization to work with to expand the concept. There were initial discussions between Phoenix Children’s Hospital and DDAZ on whether a dental operatory in the hospital would be useful, and these discussions slowly morphed into “here’s what we really need” discussions. As a result, the Oral Health Educator position was born.

DentistryIQ: How long will the program be funded?

DDAZ: The program is funded through 2021 with ongoing discussions to continue funding based on positive outcomes. Based on the interim reporting, we are confident this program will be continued for the foreseeable future.

DentistryIQ: What has the feedback been from the hospital as to the results of Martinez's work?

DDAZ: Katharine was absolutely the best person for the job. She is an RDH and has a masters degree in public health, but what truly makes her perfect for the job is her personality. She is a patient and helpful influence, whether working with children, parents, clinicians, or providers—it’s no small feat dealing with such a wide variety of constituents.

DentistryIQ: Are there similar programs planned for other states?

DDAZ: We have spoken to a number of hospitals who are interested in starting a similar program, but we aren't aware of any other programs that operate this way. We know other systems have oral health protocols, but are not sure of the specific staffing models.

DentistryIQ: How does this program fit into Delta Dental of Arizona's overall mission?

DDAZ: Delta Dental of Arizona’s mission is to improve lives by promoting optimal oral health. I don’t think we could have hit the nail on the head any better than we did with this program. We are working with Phoenix Children's Hospital to not only reach children and specifically improve their clinical outcomes, but educate providers and clinicians too.

Editor's note: Interviews have been edited for length and clarity.

Related:

• Oral-systemic section of DentistryIQ

From RDH magazine:

• Dentistry, data, and population health: Why dental hygienists matter
• A link between Alzheimer’s disease and oral inflammation: The dental hygienist’s role
• Oral medicine: Linking medicine and pathology

Zachary Kulsrud is the editorial director for Endeavor Business Media's dental group, publishers of Dental Economics, DentistryIQ, Perio-Implant Advisory, and RDH magazine.