Assessment of Oral Health-Care Needs for Patients under Palliative Care.

BACKGROUND: Patients under palliative care and their caregivers often ignore the dental treatment and oral hygiene needs as a result of which they face many day to day problems, which include difficulty in chewing, halitosis, and dry mouth eventually deteriorating the quality of life.
OBJECTIVE: The aim of this study is to understand the oral needs and oral health-related concerns of the patients under palliative care.
METHODOLOGY: A total of eight patients agreed to enroll in the study. A detailed interview with oral examination, including Sillness and Loe Plaque Index and Decayed Missing and Filled Teeth (dmft) Index, was recorded. Patients were also given the treatment needed if willing for the same.
RESULTS: In our study, we observed that the mean dmft scores of dentulous patients were 7.96 ± 3.35, and mean plaque score was 1.75 ± 2.12, which was significantly higher and further highlights the need for dental treatment.
CONCLUSION: The patients under palliative care have many oral problems such as dry mouth, difficulty in eating, halitosis which needs to be addressed; hence, dental health plays an important role in improving the quality of life of these patients. Copyright:

INTRODUCTION

As per the WHO, palliative consideration is the kind of specific clinical consideration that improves the personal satisfaction of patients and their families confronting the issue related with perilous sickness, through the anticipation and alleviation of enduring by methods for early ID and immaculate appraisal and therapy of agony and different issues.[1]

Six essential components of palliative care have been identified, namely (1) integrated teamwork, (2) management of pain and physical symptoms, (3) holistic care, (4) caring, compassionate, and skilled providers, (5) timely and responsive care, and (6) patient and family preparedness.[2] Apart from the above six components, early identification, effective communication with the patients, and their caregiver are also important in palliative care. Palliative care is more focused on improving the quality of life rather than treatment.[3]

End-of-life is the palliative care provided to people who are nearing death. Palliative care patients usually depend on caregivers to help them with the activities of daily living. It is observed that the patients under palliative care usually have poor oral hygiene.[34] This is true for patients with cognitive decline as well as for the patients in whom illness has taken the priority, also, it has been observed that patients and caregivers lack the awareness for oral health.[5] The helpless oral well-being causes oral diseases as well as lead to numerous dangerous well-being conditions such as bacteremia, cerebrum abscesses, endocarditis, and desire pneumonia.[6] Frequently, the criticalness of dental consideration is disregarded, and dental specialists are excluded from the palliative consideration teams.[7]

Oral health is an important aspect of general health and well-being. The scope of oral health is well beyond the healthy teeth. Insufficient oral hygiene can lead to a wide range of oral problems.[8] The elderly, care-dependent patients are more vulnerable to oral diseases, and they frequently have the high measures of plaque on their teeth as well as dental replacement surfaces, extreme gingival aggravation, periodontal illness, and dental caries is more commonly observed in this group. Patients under palliative care are most vulnerable in this group and usually have poor oral hygiene.[910] The significance of dental care is usually ignored in these patients, and dentists are not regularly included in the palliative care teams.[11]

Patients under palliative consideration are generally care subordinate older people, and they are helpless to an assortment of oral hindrances, including brokenness of the salivary organs, oromucosal contaminations, and trouble in gulping.

These individuals at the end of their life suffer from xerostomia, denture-related problems, fungal infections, and denture sores resulting from ill-fitting dentures affecting their mucosa. These conditions ability to chew and speak as well as their food choices, leading malnutrition. Poor oral health may also lead to other life-threatening health conditions such as bacteremia, brain abscesses, endo-carditis, and aspiration pneumonia. Finally and most importantly, it affects a person's quality of life leading to the array of other physiological and psychological problems.

Patients under palliative care even after having a vast majority of oral problems seldom get desired oral care services. This can be attributed to the seriousness of their medical conditions, medical care providers focusing on their general health paying less heed toward their oral health, high dental treatment costs, lack of knowledge of dental health importance, an absence of admittance to the dental consideration administrations, hesitance in the interest of dental specialist organizations to give care to these patients, and lack of specific dental preparing to treat these people.

The aim of this study is to understand the oral needs and oral health-related concerns of the patients under palliative care.

METHODOLOGY

The present study was conducted at the tertiary care center on seriously ill adults, with limited life expectancy and who are under palliative care were included in the study. Our study is a blend of quantitative, descriptive, and quantitative approach. In the descriptive qualitative approach, we interviewed the subjects with open-ended questions accepting descriptive answers and also any free inputs if they want, these interviews were recorded. For quantitative approach, subjects were asked to answer questions with definitive answers, and also, clinical examination was also done along with that, Sillness and Loe plaque Index[12] and decayed missing and filled teeth (dmft) index were recorded.

Inclusion and exclusion criteria

Patients suffering from advanced, incurable disease, receiving palliative care that can undergo 20 min oral care procedure and interview and above 18 years were included in the study. Patients suffering from head and neck cancer and those requiring antibiotic prophylaxis before oral procedure were excluded from the study.

A total of eight patients agreed to enroll in the study. A detailed interview with oral examination, including Sillness and Loe Plaque Index[12] and dmft index were recorded. Patients were also given the treatment needed if willing for the same. Any other requirement asked by the patients was also noted. In our study, we observed that the mean dmft scores of dentulous patients were 7.96 ± 3.35, and mean plaque score was 1.75 ± 2.12, which was significantly higher and further highlights the need for dental treatment. The patients under palliative care have many oral problems such as dry mouth, difficulty in eating, halitosis which needs to be addressed; hence, dental health plays an important role in improving the quality of life of these patients.

Data were analyzed using the SPSS 21.0 Armonk [2012]. Descriptive statistics, Kruskal–Wallis, and Mann–Whitney tests were used. Level of significance was set at P ≤ 0.05.

RESULTS

Quantitative study results

A total of eight patients were enrolled in the study, out of them, 6 were male and 2 were female. The average age of the patients was 64 with youngest 36 years and oldest 92 years old [Table 1].

Table 1

Demographic data of the patient

n=8	Mean age	Sex (male/female)
8	64 (36-92)	6/2

All the patients were interviewed by same interviewer, and a detailed dental history was taken on the preappointed day. Table 2 summarizes the answers to the interviewed questions.

Table 2

Oral hygiene practices and oral diseases as per the interview

Criteria	n (%)
Patients having difficulty in eating	6 (75)
Appetite loss	7 (87.5)
Edentulous without dentures	1 (12.5)
Edentulous with dentures	1 (12.5)
Dry mouth	5 (62.5)
Halitosis	6 (75)
Brushing on own	6 (75)
Oral hygiene practices brushing once a day	5 (62.6)
Twice a day	1 (12.5)
More than two times a day	0
Brushing with assistance	1 (12.5)

To access the current dental and periodontal condition and need for further treatment, dmft and plaque index were recorded by Community probe for treatment index (CPTIN) probe and a PMT set on the bed side of the patient. Table 3 summarizes the scores. The mean dmft score for 6 dentulous patients was 7.96 ± 3.35, and the mean plaque score was 1.75 ± 2.12 which was significantly higher and indicated the need for periodontal therapy.

Table 3

Mean plaque and decayed missing and filled teeth scores

	Mean score±SD	P
dmft scores	7.96±3.35	0.20
Plaque index	1.75±2.12	0.01

Mann–Whitney U-test. SD: Standard deviation, dmft: Decayed Missing and Filled Teeth

Table 4 shows the relationship between plaque and mean dmft scores, which came out to be significant with P value 0.00.

Table 4

Relationship between plaque index and mean dmft scores

Plaque index					P
	0.0	0.1-0.9	1.0-1.9	2.0-3.0
dmft	-	5.62±3.36	6.44±3.38	7.76±4.46	0.00

Kruskal–Wallis test, plaque index 0.0=excellent, 0.1-0.9=good, 1.0-1.9=fair, 2.0-3.0=poor. dmft: Decayed Missing and Filled Teeth

Qualitative descriptive study results

For qualitative and descriptive study in our interview, we asked about the importance of oral health from the subjects. the meaning of oral health was understood well by all the participant, but their answers significantly reflected their illness status and the past dental history, experience and the oral health-related challenges they are facing in the current scenario. All the patients were unhappy with their current oral health status but with varied degree. Older patients were less concerned about the oral health as compared to the young ones. Younger patients were more concerned about bad breadth but for older ones able to chew food comfortably were more important. While interviewing we can see that there was clear divide in young/middle aged and old patients, former group routinely utilized dental care while the other group sought dental care only when it was deemed necessary. One out of two edentulous patients was having dentures, but it was ill fitting although he never asked for the repair of the denture earlier but when we offered relining he was happily willing and told us about the difficulty he was facing in eating due to that ill-fitting denture. The other edentulous patient told us that he got dentures made once, but they were not comfortable, so he prefers being without them and he was not even willing to get a new pair made for himself. The youngest patient was the one with best oral health and showed more concern about it, he was the only one who used to brush twice daily. One of these patients was with some cognitive disability and needed help to maintain oral hygiene, but despite that he was quite concerned about his oral health and was willing to undertake the required dental treatment.

Five out of eight patients complained about dry mouth, and they all were well informed by their medical practitioner that it is one of the side effects of the treatment. They were trying to keep them hydrated by regularly sipping water and have accepted that this was an inevitable and untreatable side effect of the treatment.

Most of the study participants were overwhelmed by their current medical condition which needed multiple medical appointments. They preferred not to consult anyone if the problem was not very serious in nature; hence, the dental health concerns were pushed for later most of the times. We also found that there were many misconceptions in the patients. For most of their dental/oral problems (such as discoloration of teeth, chipping of enamel, candidiasis etc., which were mostly dental/oral problems unrelated to their medical condition) they felt their ongoing treatment responsible and hence never thought of consulting a dentist.

DISCUSSION

According to the WHO, palliative care is the type of specialized medical care that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems.

Oral care needs often take the backseat concerning the patients under palliative care. In developing countries such as India, there is much less awareness for oral care and least in the patients under palliative care; hence, this study was done to emphasize the need for oral care in terminally ill patients. With the help of questionnaire, we accessed the needs of patients and with the help of indices taken we tried to ascertain their current oral condition. The literature that focus on the oral health statuses of individuals receiving palliative care patients is scanty.[1314]

Six out of eight patients in our study had difficulty in eating. Out of which, 5 were attributed to the dry mouth, and the remaining one was edentulous without dentures. One patient was having loose dentures and dry mouth both.

This shows that there was confusion between their oral well-being statuses and saw oral consideration needs. Numerous examinations have announced that patients experience issues with feel, agony, depressions, and trouble with biting are bound to see dental consideration needs and use dental consideration administrations (366–370), but in the scenario of this study, this lack of perception of need for dental care is attributed to their terminal nature of disease and to some extent on financial burden due to expensive palliative care.

In our study, we observed that the mean dmft scores of dentulous patients were 7.96 ± 3.35 which emphasizes the need for dental treatment. The mean plaque score was 1.75 ± 2.12 which was significantly higher and further highlights the need for periodontal treatment.

Six out of eight patients complained of difficult in eating which was largely due to dry mouth and to some extent due to dental condition. Out of two edentulous patients, one was having ill-fitting dentures and complained of sore mouth due to them. The dentures examined needed relining. The other edentulous patient was without dentures and showed no interest for getting new dentures made.

Six out of eight patients complained of halitosis which is attributed to higher plaque scores and dry mouth.

Most of the patients perform oral hygiene practices once a day independently only one patient needed assistance in brushing teeth, which was provided by nurse once every day.

Hence, our study emphasis the need of regular dental check-ups and inclusion of a dental surgeon in the palliative care team as the patients under palliative care have many oral problems like dry mouth, difficulty in eating, and halitosis, although they never complained of pain as they were all under medication for pain.

CONCLUSION

Patients under palliative care and their caregivers often ignore the dental treatment and oral hygiene needs as a result of which they face many day to day problems, which include difficulty in chewing, halitosis, dry mouth eventually deteriorating the quality of life. Hence, our study emphasis the regular need for dental check-ups and inclusion of dental surgeon in the palliative care team. In our study, we observed that the mean dmft and plaque scores of these patients were high and needed attention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.