Palliative dental care is described by the World Health Organization (WHO) as an approach that improves the quality of life of patients and families facing the problems associated with life-threatening illnesses, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, spiritual. The active care of patients at end-stages of their diseases usually comprise the basis and principle of palliative care. So why should a dentist be a part of a palliative team? What role could they possibly play? While many people are oblivious to the extent of responsibility a dental surgeon holds especially while dealing with a terminally ill patient, they are actually a pivotal segment of the healing and caring process.
What is palliative care dentistry?
Palliative care dentistry deals with the management of patients with active, progressive, and far-advanced disease in whom the oral cavity has been heavily impacted and compromised by the primary disease or by its treatment process. Dental treatment may be strenuous most of the time, but with palliative care, it mainly focuses on improving the quality of life of the patient than being solely curative and progressive.
A palliative team consists of a multidisciplinary approach where the main role of all medical and dental professionals involved is to assure an affluent life for the patient during their difficult end times and to prevent and relieve the suffering as much as possible. In addition, routine dental care run many major postulations in the early identification, assessment, and treatment of pain and distress in all forms.
Oral conditions and the role of palliative dental care
Patients at the end of their lives may not have the best immune systems and thus may be highly susceptible to a wide range of oral complications, including pain, salivary dysfunction, dysphagia, and numerous oro-mucosal infections. Ironically, most acute and terminal conditions usually manifest symptoms in the mouth that can further indicate the severity and extent of the disease.
Maintaining proper oral hygiene is difficult in terminal patients which is why dental expression in palliative care plays such a big role in influencing a patient’s substance of life. Pain may also be another imperative factor that signifies the importance of dental professionals as part of an emergency palliative team.
Some of the oral manifestations encountered in palliative patients are:
- Mucositis and stomatitis
Mucositis is a critically painful condition characterized by the inflammation and ulceration of the mucous membranes in the mouth, pharynx (throat), and the digestive tract. It usually occurs as a result of toxic chemotherapy. Almost 80% of the people diagnosed with head and neck malignancies receiving radiotherapy and chemotherapy are prone to mucositis. Clinically, it presents as red or white lesions in the oral tissues, a pseudomembrane or layer formation, and ulceration in the initial stages. In the advanced stages, the disease may cause fibrosis of the connective tissues and a drastic deficit of veins (hypovascularity). Radiotherapy to the head and neck may also be associated with Grade 3 and 4 oral mucositis where the patient is unable to consume solid foods and liquids, thereby physically debilitating them.
What can the dentist do about it?
Palliative care treatments for mucositis primarily deal with pain relief. Topical anesthetics and mucosal coating agents such as xylocaine and dyclonine may be provided for comfort. The dentist may also prescribe various mouth rinses such as diphenhydramine hydrochloride (5%) and benzydamine that have anti-inflammatory and analgesic properties. These are reported to relieve radiation-induced stomatitis.
- Oral candidiasis
The incidence of candidiasis in palliative care has been estimated to be 70-85%. Candida albicans is a common infectious fungal organism and the infection candidiasis is its opportunistic by-product. It is characterized by creamy white patches on the inner cheeks, tongue, roof of the mouth, and throat with redness or soreness. Immunosuppression and chemotherapy are some of the common causes of candidiasis. However, in palliative care patients, candidiasis is primarily a result of xerostomia. Results of a study done of oral candidiasis in a cohort of cancer patients receiving specialist palliative care showed that 66% of the patients had microbiological evidence of oral candidiasis.
What can the dentist do about it?
Palliative care treatments for oral candidiasis corresponds to a prescription of analgesics, both topical and systemic. Topical agents such as nystatin suspension help restore oral health in the patient, eliminating fungal infections such as candidiasis. Angular cheilitis or the intense cracking seen at the corner of the mouths may be treated with a cream made up of 0.5% triamcinolone and 2% ketoconazole. Anti-fungal medications like such help the patient regain oral health.
Dry mouth or xerostomia is very common among older people. However, radiotherapy to treat cancers of the head and neck may also result in xerostomia due to the destruction of the salivary tissues within the treatment zone, says The Oral Cancer Foundation. This loss of lubrication and protective agents in the saliva makes the tissues more susceptible to trauma and invasion by the opportunistic pathogens, the common one being Candida albicans. In xerostomia, the saliva may be ropey and thick, potentially functioning with no good effect. Increased plaque retention, fissured tongue, and oral ulceration are considered some of the main problems regarding xerostomia.
What can the dentist do about it?
Palliative management of xerostomia includes preventive, symptomatic, and curative approaches. The dentist may prescribe mouthwashes composed of antacids, topical antifungal nystatin, and viscous anesthetic lidocaine in various formulations. In minor cases of xerostomia, oral care is done by the use of lozenges or sugarless gum that help stimulate saliva production. In extreme cases of radiotherapy-induced xerostomia, treatment may be indicated. Pilocarpine is the preferred drug of choice for long-term treatment.
Supportive or palliative care dentistry is focused on managing the symptoms and keeping the patients comfortable. A terminal patient with poor oral hygiene and aggravating oral symptoms may be treated by a dentist in a number of ways. In some cases, the dentist may suggest at-home remedies to provide the patient with some relief. Aggressive oral manifestations such as stomatitis or xerostomia may be treated adequately with a combination of home remedies and professional triage techniques, including medications. The mouth is an extremely important part of the body aiding in eating, communication, and expression. The ultimate goal of a palliative dentist is to keep the oral cavity free from as much trauma as possible and make the end-of-the-life experience (quality of life) as comfortable as possible.