Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing serious illness. Palliative care aims to relieve suffering in all stages of the disease and is not limited to end of life care. A major tenet of palliative care is early identification, assessment, and treatment of pain and other sources of physical, psychological, emotional, and spiritual distress. Depending on the specific problem or complication, specialists, including dentists, may function as essential members of the interdisciplinary team.
Patients at the end of life are susceptible to a range of oral complications, including pain, salivary gland dysfunction, dysphagia, and oromucosal infections. Swallowing disorders may lead to aspiration pneumonia, which can directly contribute to mortality. This topic provides an overview of the importance of oral health in patients at the end of life and the diagnosis and management of common oral complications. A more extensive discussion of swallowing disorders in palliative care patients is provided elsewhere, as is mucositis/stomatitis related to cancer treatment.
Patients who are receiving treatment for cancer or other serious illnesses may experience unpleasant or painful oral side effects. These side effects may increase patients’ anxiety at an already difficult time. Dentists and dental hygienists try to manage oral effects to help keep patients from experiencing unnecessary pain or stress.
Many oral health problems can affect patients with serious illnesses, and dental palliative care may be offered to help offset them. Constant dry mouth, for example, may occur as a side effect of the radiation therapy or chemotherapy used to treat cancer, explains The Oral Cancer Foundation (OCF). Many other treatments and some medications may lead to dry mouth. There are more than 400 common drugs that can cause constant dry mouth, reports the OCF.
Sores and inflammation inside the mouth are a common side effect of chemotherapy, affecting up to 40 percent of patients. This side effect, known as mucositis, can interfere with eating, swallowing, and talking.
People with compromised immune systems, including cancer patients or people with HIV, may develop candidiasis, or a yeast infection in the mouth. People with this infection may experience burning or itching in their mouths, or they may have trouble swallowing. These symptoms can make eating and drinking difficult, which puts patients at risk for malnutrition and dehydration.
Anyone can get cavities, but people with serious illnesses may be more susceptible to tooth decay. For example, people who are receiving radiation therapy may develop rampant tooth decay known as radiation caries. These cavities could lead to toothaches or even tooth abscesses.
WHY ORAL HEALTH MATTERS IN END OF LIFE CAREThe oral cavity is often the first site of manifestation of treatment-related side effects in terminally ill patients, or it may be compromised by the direct and indirect effects of progressive, advanced disease. Oral health is essential for carrying out activities of daily living such as communication, eating, speaking, and swallowing. The oral complications that can arise in terminally ill patients can impact the quality of life (QOL) and contribute to functional decline and failure to thrive. Oral health care is therefore an integral component of palliative care, with the goals of preventing oral complications, maintaining the adequate oral function, and optimizing QOL and comfort.
Oral health impacts a person’s dignity as well as oral function:
●Dignity and respect –While easily overlooked, a patient’s concerns with facial and oral esthetics may relate to his or her desire to die with dignity and respect. As oral health is often neglected at the end of life, usual oral hygiene practices may be forgotten or eliminated, and this can contribute to gingivitis and/or periodontitis, caries development, tooth loss, and halitosis. This can impact self-esteem. Additionally, family and friends may avoid contact with their loved ones due to halitosis, worsening the patient’s isolation and depression.
Supportive care is focused on managing symptoms and keeping patients comfortable. Appropriate procedures will vary from one patient to another based on their symptoms. A dentist can recommend an appropriate dental care plan after examining a patient and talking with their doctors or health care team.
In some cases, dentists may suggest home remedies that may provide patients with some relief. For patients with mucositis, these suggestions may include drinking more water or eating a bland, soft diet. Patients with dry mouth may be advised to sip water throughout the day or use an over-the-counter saliva substitute.
Dentists may also recommend prescription medications if necessary. Pain medications may be useful for patients with mucositis, for example, and anti-fungal medications may help resolve cases of oral thrush.
Dental restorations such as fillings or crowns may be required for patients who have developed cavities. In cases of advanced decay where an abscess has formed, the tooth may need to be removed.
Palliative dental care can help relieve the oral side effects of a serious disease, allowing patients to eat, drink, and speak as comfortably as possible. If your loved one has a serious illness and is undergoing treatment, talk to their dentist about managing oral symptoms.
Q. Is there anything wrong with reporting palliative treatment (D9110) instead of D3221 (pulpal debridement) when performing
an open and broach on an emergency patient?
A. According to CDT 2011-2012 (p. 155), the CDT Companion (p. 95), and The Endodontists’ Guide to CDT (p. 28), an emergency open and broach procedure to relieve pain should be reported as pulpal debridement (D3221), which involves the removal of acutely inflamed pulp tissue.
D9110 was developed for reporting the relief of pain and typically does not have a therapeutic component. An open and broach commit a patient to have a root canal or an extraction, so there is a therapeutic component, which is why it is best coded as D3221. However, please note that the CDT description for D9110 does not specifically preclude it from being used to report an open and drain.
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Dr. Seif received an award in Aesthetic Dentistry and an Advanced Standing Achievement Certificate and held a position as a part-time clinical instructor.
Dr. Seif has more than 15 years of experience as a dentist and has obtained two dental degrees. Dr. Seif earned his first degree in dentistry in Syria in 1998 and practiced general dentistry until coming to the US to advance his education by earning a second dental degree from Loma Linda University School of Dentistry, a world-renown dental institute. While at Loma Linda, Dr. Seif received an award in Aesthetic Dentistry and an Advanced Standing Achievement Certificate and held a position as a part-time clinical instructor.
Dr. Seif’s compassion and friendly nature is evident to his patients. He believes that every individual should be treated in a kind, caring and respectful manner. Dr. Seif is dedicated to life-long learning and enjoys participating in post-graduate courses that enable him to provide his patients and community with the excellent dental care he believes every person deserves.
Moving from the Dallas-Fort Worth area in 2014, Dr. Seif now calls Baytown his home. Along with cooking, friends, family and his dog, Sophie, he enjoys southern culture. He is enthralled by the friendliness and hospitality he finds in Texas, saying, “This is exactly the kind of community I want to live and practice in!”