**2. Addressing oral care neglect in palliative care patients**

In dental school in the eighties, I was offered one course on geriatric-centered care that required the students to spend a couple days observing at a nearby nursing facility, going from room-to-room with an instructor. There was, as is typically the case, no functioning, physical dental clinic. Some patients were seen by us at bedside, but with little overhead lighting. We held flashlights for one another. We gave up rather quickly on those who were combative to any extent. Positioning was difficult in many patients who were less limber than others. Nonetheless, it wasn't these incongruencies with which I take issue, but rather the fact that so little time was afforded to us students to learn to treat these types of patients and that we felt as though the paltry care we were able to administer was likely of little benefit.

#### **2.1 Why oral care is vitally important in the terminal and dependent patient?**

Palliative care serves essentially to inhibit an existence of pain and suffering. [1] The World Health Organization (WHO) defines palliative care as: an approach that improve the quality of life of patients and their families facing the problems associated with life-threatening illness, for the prevention of a life of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. [2]

Dental care is a fundamental part in management of patients with advanced disease, and oral care must become ensconced in the total care palliative philosophy to best maintain life quality. [3] Sischo and Broder describe a quality of life that focuses on oral health as it relates to functional and emotional well-being, expectations and satisfaction with general care, and an overall sense of self. [4]

To be certain, poor oral health can negatively affect nutrition, comfort, and social issues. [5–10] Jobbins found Candidiasis in 85% of patients studied, which can cause burning and dry mouth [11], such that palliative care is often required. [12–14] These burning and discomforting circumstances can also lead to anorexia, difficulty swallowing, problematic respiration, and inhibited verbal communicative ability. [15] Additionally, in patients with poor oral hygiene, the "bonding" that occurs with family and friends and even professional care givers can be impeded in instances of oral neglect due to offensive halitosis, unattractive tooth loss and rampant decay, heavy plaque and bleeding gums. [16] To avoid these circumstances, it is vital that all attempts possible be made to assure that the patient feels fresh, welcomed by others, and retains dignity as much as is possible.

Further, periodontal disease is a very common problem among the elderly, being linked to 46% of American adults between the years of 2007 and 2012. [17] This disease of the tissues that hold the teeth in place can create systemic medical conditions such as aspiration pneumonia [18] as well as heart disease, diabetes, and cancer. [19] Periodontitis results in the release of inflammatory cytokines, growth

**67**

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient*

ranging from a depressed mental state to renal disease. [21]

compared to those individuals who have no symptoms whatsoever.

**2.2 Why care of the mouth and dentition is typically lacking in the** 

*Some see this demand for more meticulous oral care as being futile.*

for the prior-mentioned aspiration pneumonia. [18]

soothing dry and burning oral tissues?

factors, prostaglandins, and enzymes [20], and results in many ramifications,

Of even greater interest due to its relevance in more recent times, perhaps, is the fact that a 2020 study out of the University of Toronto has stated that there is evidence showing that patients with periodontal disease may be much more likely to have heightened issues with COVID-19. [22] This is likely because in patients with active and untreated periodontal infection, already-circulating neutrophils are more excitable and ready to attack in a rather hyper-vigilant nature after a second infection, such as a viral load, is introduced into the body. The authors explain further that this cascade of events creates a susceptibility towards damage within one's body from these "primed" infection fighting cells to destroy affected tissues and organs more readily, leading to more negative outcomes. [22] This may explain why some have far more hasty and deleterious pulmonary and renal issues from COVID-19 as

In my experience, another very real challenge with oral issues in the elderly and infirmed relative to COVID-19 has been that governmental limitations on visits to nursing homes and other such institutions has impeded my getting in to perform my monthly preventative screenings over the course of the past year. This may be more inconsequential for the patient who is alert and communicative and can request an emergency visit from or to a dental professional; however, in those patients who are suffering from pain without giving outward signs of such may have issues that can only be discoverable via an on-site oral examination. This oversight does not bode well in cases such as these, and it puts into play a storm of

Further, in my recent visits to the home of one particular hospice patient whose diagnosis was terminal, I was there strictly to offer emotional support to the spouse. I would simply bring groceries whenever requested by the husband, who only asked for goods to be delivered that his wife needed for sustenance. It was obvious that he was not only depressed from his wife's condition, but also from the restrictive isolation he was going through socially from COVID restrictions. It was just the two of them-alone-except for the care extended by the hospice facility. I would imagine that this, and the fact that he was wheelchair-bound, made life exceptionally burdensome

It is not uncommon to find apathy among professionals and their staff members

who view treatment at this level as being redundant, burdensome, unpleasant, and unfulfilling. [9] Others may feel that meticulous oral care may be "overdoing it" in these more intolerant and sickly cases. [23, 24] Thus, it is out of concern for the patients that they inadvertently neglect that oral component of care that they do not understand to be a necessary part of therapy. Still others do not like to have to restrain, force, or argue with many patients to clean their mouths or to remove their dentures, so the feat goes underperformed day after day. Plaque accumulations from both teeth and gingiva can get into the lungs and have been noted as the cause

A lack of supplies afforded to staff may also account for reasons of neglect. Are there toothbrushes, non-toxic toothpastes, denture storage cups and denture cleaning tablets available? Are there natural oils for caregivers to use for coating and

*Some see this demand for more meticulous oral care as absorbing precious staff time.*

*DOI: http://dx.doi.org/10.5772/intechopen.95606*

conflicting ethical principles.

for this couple and others like them.

**institutionalized infirmed**

#### *Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient DOI: http://dx.doi.org/10.5772/intechopen.95606*

factors, prostaglandins, and enzymes [20], and results in many ramifications, ranging from a depressed mental state to renal disease. [21]

Of even greater interest due to its relevance in more recent times, perhaps, is the fact that a 2020 study out of the University of Toronto has stated that there is evidence showing that patients with periodontal disease may be much more likely to have heightened issues with COVID-19. [22] This is likely because in patients with active and untreated periodontal infection, already-circulating neutrophils are more excitable and ready to attack in a rather hyper-vigilant nature after a second infection, such as a viral load, is introduced into the body. The authors explain further that this cascade of events creates a susceptibility towards damage within one's body from these "primed" infection fighting cells to destroy affected tissues and organs more readily, leading to more negative outcomes. [22] This may explain why some have far more hasty and deleterious pulmonary and renal issues from COVID-19 as compared to those individuals who have no symptoms whatsoever.

In my experience, another very real challenge with oral issues in the elderly and infirmed relative to COVID-19 has been that governmental limitations on visits to nursing homes and other such institutions has impeded my getting in to perform my monthly preventative screenings over the course of the past year. This may be more inconsequential for the patient who is alert and communicative and can request an emergency visit from or to a dental professional; however, in those patients who are suffering from pain without giving outward signs of such may have issues that can only be discoverable via an on-site oral examination. This oversight does not bode well in cases such as these, and it puts into play a storm of conflicting ethical principles.

Further, in my recent visits to the home of one particular hospice patient whose diagnosis was terminal, I was there strictly to offer emotional support to the spouse. I would simply bring groceries whenever requested by the husband, who only asked for goods to be delivered that his wife needed for sustenance. It was obvious that he was not only depressed from his wife's condition, but also from the restrictive isolation he was going through socially from COVID restrictions. It was just the two of them-alone-except for the care extended by the hospice facility. I would imagine that this, and the fact that he was wheelchair-bound, made life exceptionally burdensome for this couple and others like them.

## **2.2 Why care of the mouth and dentition is typically lacking in the institutionalized infirmed**

#### *Some see this demand for more meticulous oral care as being futile.*

It is not uncommon to find apathy among professionals and their staff members who view treatment at this level as being redundant, burdensome, unpleasant, and unfulfilling. [9] Others may feel that meticulous oral care may be "overdoing it" in these more intolerant and sickly cases. [23, 24] Thus, it is out of concern for the patients that they inadvertently neglect that oral component of care that they do not understand to be a necessary part of therapy. Still others do not like to have to restrain, force, or argue with many patients to clean their mouths or to remove their dentures, so the feat goes underperformed day after day. Plaque accumulations from both teeth and gingiva can get into the lungs and have been noted as the cause for the prior-mentioned aspiration pneumonia. [18]

A lack of supplies afforded to staff may also account for reasons of neglect. Are there toothbrushes, non-toxic toothpastes, denture storage cups and denture cleaning tablets available? Are there natural oils for caregivers to use for coating and soothing dry and burning oral tissues?

*Some see this demand for more meticulous oral care as absorbing precious staff time.*

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

**2. Addressing oral care neglect in palliative care patients**

problems, physical, psychosocial, and spiritual. [2]

team, but rather as a volunteer.

surmountable.

are sorely lacking. In an effort to improve the standards of oral management in the dependent and incapable, I would urge all medical institutions to mandate that a dentist be on staff, and that minimum standards programs be instituted as are appropriate, yet this is seldom the case. Even in a local faith-based hospice for which I am the gratis dental consultant, I am not listed as a member of the staff

There are multiple obstacles to be overcome to correct these inadequacies, but with compassion, candor, and competency these challenges are indeed

In dental school in the eighties, I was offered one course on geriatric-centered care that required the students to spend a couple days observing at a nearby nursing facility, going from room-to-room with an instructor. There was, as is typically the case, no functioning, physical dental clinic. Some patients were seen by us at bedside, but with little overhead lighting. We held flashlights for one another. We gave up rather quickly on those who were combative to any extent. Positioning was difficult in many patients who were less limber than others. Nonetheless, it wasn't these incongruencies with which I take issue, but rather the fact that so little time was afforded to us students to learn to treat these types of patients and that we felt as though the paltry care we were able to administer was likely of little benefit.

**2.1 Why oral care is vitally important in the terminal and dependent patient?**

Palliative care serves essentially to inhibit an existence of pain and suffering. [1] The World Health Organization (WHO) defines palliative care as: an approach that improve the quality of life of patients and their families facing the problems associated with life-threatening illness, for the prevention of a life of suffering by means of early identification and impeccable assessment and treatment of pain and other

Dental care is a fundamental part in management of patients with advanced disease, and oral care must become ensconced in the total care palliative philosophy to best maintain life quality. [3] Sischo and Broder describe a quality of life that focuses on oral health as it relates to functional and emotional well-being, expecta-

To be certain, poor oral health can negatively affect nutrition, comfort, and social issues. [5–10] Jobbins found Candidiasis in 85% of patients studied, which can cause burning and dry mouth [11], such that palliative care is often required. [12–14] These burning and discomforting circumstances can also lead to anorexia, difficulty swallowing, problematic respiration, and inhibited verbal communicative ability. [15] Additionally, in patients with poor oral hygiene, the "bonding" that occurs with family and friends and even professional care givers can be impeded in instances of oral neglect due to offensive halitosis, unattractive tooth loss and rampant decay, heavy plaque and bleeding gums. [16] To avoid these circumstances, it is vital that all attempts possible be made to assure that the patient feels fresh,

Further, periodontal disease is a very common problem among the elderly, being linked to 46% of American adults between the years of 2007 and 2012. [17] This disease of the tissues that hold the teeth in place can create systemic medical conditions such as aspiration pneumonia [18] as well as heart disease, diabetes, and cancer. [19] Periodontitis results in the release of inflammatory cytokines, growth

tions and satisfaction with general care, and an overall sense of self. [4]

welcomed by others, and retains dignity as much as is possible.

**66**

And the institution in which I work, it seems that all employees are for the most part already so busy that I cannot see how time could be allotted to attend to patients' mouths with regularity, except to develop a very efficient method that is part of the daily protocol. Such a plan has yet to be established in the vast majority of institutions as far as I am able to tell.

For example, is there adequate lighting, and if not, can an institution afford to have one staff member hold a light while another performs hygiene … and is this to be done daily, twice daily, or more? Should headlamps be purchased for each caregiver? Further, manipulating patients into positions that afford one better oral visibility in attempting bedside care can be physically taxing to those staff delegated to this function.

Certainly, since many auxiliary staff are not trained in dental schools, as are healthcare professionals, to become conditioned to working in another person's oral cavity, it can be daunting to some who must become so closely approximated to the mouth and have to deal with the unpleasantries of the smells and sights of plaque, halitosis, periodontal disease and the like.

*Some see this demand for more meticulous oral care as reimbursing too little for the amount of time it takes to accomplish needed tasks.*

In most cases, and perhaps even in most countries, the reimbursement fees for oral care whether for maintenance or restorative procedures in these aged and infirmed is little more than paltry. Typically, in the United States, Medicare and Medicaid funding for oral conditions is only available where medical illnesses are secondary to dental injury or disease, such as with an abscess that brings many to an emergency room. One problem with neglecting regular exams in the aged infirmed is that many individuals cannot describe their pain or even indicate that there is any discomfort whatsoever, and these infections may ultimately prove to be an undocumented cause of death.

For those patients who can verbally communicate that they are uncomfortable and have pain, it is imperative that the caregiver check for allergies and other medications being given to the patient that may not be compatible with a particular pain medication being considered for therapy. One also must be cognizant of the fact that pain medications may make these already frail patients more likely to fall or become disoriented and more confused than is normally the case. Further, it is certainly advisable to use the lowest dose and least number of pills possible for managing patient pain, and to avoid opioids, if at all possible, by using alternating doses of nonsteroidal inflammatory drugs with acetaminophen where tolerated. [25]

Distress experienced during injections may also be reduced by use of a controlled flow anesthesia system [26], and in some cases very loose teeth may be extractable with the use of a xylocaine viscous gel or topical anesthetic so as to avoid the stress of dental injections to accomplish the necessary treatment.

#### **2.3 Moving forward to best meet the oral care needs of institutionalized patients requiring palliation**

With so many questions, there seem to be very few answers in addressing this severe shortfall in caring for the oral soft tissues and dentition in this vulnerable population. But we must start somewhere, and that begins with shunning apathy and embracing the awareness that there is much ground to be gained if those who can make a difference will work towards eldercare dental equity. This starts most particularly with dentists, their staff, hospice and long-term care institutions, as well as their staff managers, physicians, nurses, and aides, all working in tandem

**69**

dying. [29]

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient*

for planning, implementing, and assessing dental programs within each health-

Dentists must first evaluate the institutional setting in mind for enhancing change of oral care practices. Then, the dentist should consider those capabilities for stepping up oral care to levels that are reasonably within reach. After meeting with the staff administrator, and possibly even the medical staff as well, the two entities should then discuss how to implement the envisioned changes, taking into

For example, they should together decide if conditions exist for their patients to be evaluated yearly, biannually, or perhaps even monthly, which time frame will depend on the total number of individuals within the institution and the availability of staff as resources to help organize the entire patient "recall system". Thus, if the dental team can perform an oral exam or screening on 15 patients in one day, and the dentist is able to work for that entity one day a week, approximately 60 patients could be evaluated and their treatment plans customized/altered as need be each month. If, then, there are 180 patients in the facility, all could be covered within a three -month time frame, and this institution might well have each patient seen quarterly. However, were the dentist to only work once a month, then the patients

Of course, deflecting apathy starts with proper training, and this begins through advocacy education within the dental school itself. Schools are urged to develop a dental curriculum for "justice", placing a heavier emphasis on basic dental care for those with mental health and physical disabilities, geriatric dentistry, and nursing home oral health care. [27] Students should know that lower-paying positions and charitable services should be considered where need is significant, even if done on a limited basis. Rozas et al. speak of the "wide gap in knowledge regarding effective methods" specific to oral care in patients with dementia. [28] Oftentimes, a school can make a significant impact in a local healthcare community by sending its students to such sites on rotations, follow-

So that care can carry on properly once the dental staff is gone for the time being, the dentist must teach caregivers to make time for patients overall needs, as is practical within the scope of their environs. This program must have the goal of helping the staff implement a long-lasting oral maintenance program as efficiently and fiscally responsibly as is possible, customized to each individual patient's needs. Ellershaw and Ward are proponents of having in the curricula of all healthcare professionals those necessary educational objectives relating to the oral care in the

Some facilities may be able to set up an actual fully functional dental clinic complete with an air compressor, suction, reclining chair, overhead light, and amenities necessary to carry out cleanings and basic restorative procedures. They may be able to cleanse each patient's mouth after all meals. However, other entities may be unable to do little more than remove a patient's dentures nightly and soak them in a cleansing bath, hand a toothbrush and toothpaste to those capable of at least some semblance of self-care, and to attempt to clean the mouths of the remaining patients who are totally dependent for their personal hygiene. At least this would likely be an improvement over prior facility practices, and that is a start

In all frankness, it is extremely rare for a nursing home, hospital or hospice to have a dedicated dental office, while it is much more common that there is absolutely no dental care afforded to patients by staff. In my experience, if a denture comes in and out easily, the cognizant patient is likely left to manage this at his or

*DOI: http://dx.doi.org/10.5772/intechopen.95606*

consideration the limitations the institution has therein.

within the facility may only receive an annual evaluation.

ing proper planning and protocol education.

in the intended and right direction.

care setting.

#### *Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient DOI: http://dx.doi.org/10.5772/intechopen.95606*

for planning, implementing, and assessing dental programs within each healthcare setting.

Dentists must first evaluate the institutional setting in mind for enhancing change of oral care practices. Then, the dentist should consider those capabilities for stepping up oral care to levels that are reasonably within reach. After meeting with the staff administrator, and possibly even the medical staff as well, the two entities should then discuss how to implement the envisioned changes, taking into consideration the limitations the institution has therein.

For example, they should together decide if conditions exist for their patients to be evaluated yearly, biannually, or perhaps even monthly, which time frame will depend on the total number of individuals within the institution and the availability of staff as resources to help organize the entire patient "recall system". Thus, if the dental team can perform an oral exam or screening on 15 patients in one day, and the dentist is able to work for that entity one day a week, approximately 60 patients could be evaluated and their treatment plans customized/altered as need be each month. If, then, there are 180 patients in the facility, all could be covered within a three -month time frame, and this institution might well have each patient seen quarterly. However, were the dentist to only work once a month, then the patients within the facility may only receive an annual evaluation.

Of course, deflecting apathy starts with proper training, and this begins through advocacy education within the dental school itself. Schools are urged to develop a dental curriculum for "justice", placing a heavier emphasis on basic dental care for those with mental health and physical disabilities, geriatric dentistry, and nursing home oral health care. [27] Students should know that lower-paying positions and charitable services should be considered where need is significant, even if done on a limited basis. Rozas et al. speak of the "wide gap in knowledge regarding effective methods" specific to oral care in patients with dementia. [28] Oftentimes, a school can make a significant impact in a local healthcare community by sending its students to such sites on rotations, following proper planning and protocol education.

So that care can carry on properly once the dental staff is gone for the time being, the dentist must teach caregivers to make time for patients overall needs, as is practical within the scope of their environs. This program must have the goal of helping the staff implement a long-lasting oral maintenance program as efficiently and fiscally responsibly as is possible, customized to each individual patient's needs. Ellershaw and Ward are proponents of having in the curricula of all healthcare professionals those necessary educational objectives relating to the oral care in the dying. [29]

Some facilities may be able to set up an actual fully functional dental clinic complete with an air compressor, suction, reclining chair, overhead light, and amenities necessary to carry out cleanings and basic restorative procedures. They may be able to cleanse each patient's mouth after all meals. However, other entities may be unable to do little more than remove a patient's dentures nightly and soak them in a cleansing bath, hand a toothbrush and toothpaste to those capable of at least some semblance of self-care, and to attempt to clean the mouths of the remaining patients who are totally dependent for their personal hygiene. At least this would likely be an improvement over prior facility practices, and that is a start in the intended and right direction.

In all frankness, it is extremely rare for a nursing home, hospital or hospice to have a dedicated dental office, while it is much more common that there is absolutely no dental care afforded to patients by staff. In my experience, if a denture comes in and out easily, the cognizant patient is likely left to manage this at his or

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

of institutions as far as I am able to tell.

halitosis, periodontal disease and the like.

*amount of time it takes to accomplish needed tasks.*

to this function.

mented cause of death.

tolerated. [25]

**requiring palliation**

And the institution in which I work, it seems that all employees are for the most part already so busy that I cannot see how time could be allotted to attend to patients' mouths with regularity, except to develop a very efficient method that is part of the daily protocol. Such a plan has yet to be established in the vast majority

For example, is there adequate lighting, and if not, can an institution afford to have one staff member hold a light while another performs hygiene … and is this to be done daily, twice daily, or more? Should headlamps be purchased for each caregiver? Further, manipulating patients into positions that afford one better oral visibility in attempting bedside care can be physically taxing to those staff delegated

Certainly, since many auxiliary staff are not trained in dental schools, as are healthcare professionals, to become conditioned to working in another person's oral cavity, it can be daunting to some who must become so closely approximated to the mouth and have to deal with the unpleasantries of the smells and sights of plaque,

*Some see this demand for more meticulous oral care as reimbursing too little for the* 

For those patients who can verbally communicate that they are uncomfortable

and have pain, it is imperative that the caregiver check for allergies and other medications being given to the patient that may not be compatible with a particular pain medication being considered for therapy. One also must be cognizant of the fact that pain medications may make these already frail patients more likely to fall or become disoriented and more confused than is normally the case. Further, it is certainly advisable to use the lowest dose and least number of pills possible for managing patient pain, and to avoid opioids, if at all possible, by using alternating doses of nonsteroidal inflammatory drugs with acetaminophen where

Distress experienced during injections may also be reduced by use of a controlled flow anesthesia system [26], and in some cases very loose teeth may be extractable with the use of a xylocaine viscous gel or topical anesthetic so as to avoid

**2.3 Moving forward to best meet the oral care needs of institutionalized patients** 

With so many questions, there seem to be very few answers in addressing this severe shortfall in caring for the oral soft tissues and dentition in this vulnerable population. But we must start somewhere, and that begins with shunning apathy and embracing the awareness that there is much ground to be gained if those who can make a difference will work towards eldercare dental equity. This starts most particularly with dentists, their staff, hospice and long-term care institutions, as well as their staff managers, physicians, nurses, and aides, all working in tandem

the stress of dental injections to accomplish the necessary treatment.

In most cases, and perhaps even in most countries, the reimbursement fees for oral care whether for maintenance or restorative procedures in these aged and infirmed is little more than paltry. Typically, in the United States, Medicare and Medicaid funding for oral conditions is only available where medical illnesses are secondary to dental injury or disease, such as with an abscess that brings many to an emergency room. One problem with neglecting regular exams in the aged infirmed is that many individuals cannot describe their pain or even indicate that there is any discomfort whatsoever, and these infections may ultimately prove to be an undocu-

**68**

her discretion. In cases where the patient is demented, combative, or has a denture that is difficult to remove, or one that is causing sore areas, the denture is removed and put into a drawer or storage cup.

Moreover, without patients' being monitored for loose teeth, oral cancers, and large areas of decay, some teeth shop exfoliate during meal time, going without notice, while other patients experience pain that they cannot communicate vocally or otherwise. It is for patients such as these, as well as for those who still yearn for their regular oral hygiene protocol, that we owe our attention and service, compassion and soothing touch.

For those patients who can verbally communicate that they are uncomfortable and have pain, it is imperative that the caregiver check for allergies and other medications being given to the patient that may not be compatible with a particular pain medication being considered for therapy. One also must be cognizant of the fact that pain medications may make these already frail patients more likely to fall, become disoriented, or more confused than is normally the case. Further, it is certainly advisable to use the lowest dose and least number of pills possible for managing patient pain, and to avoid opioids, if at all possible, by using alternating doses of nonsteroidal inflammatory drugs with acetaminophen where tolerated. [25]

Distress experienced during injections may also be reduced by use of a controlled flow anesthesia system [26], and in some cases very loose teeth may be extractable with the use of a xylocaine viscous gel or topical anesthetic so as to avoid the stress of dental injections to accomplish the necessary treatment.

#### **2.4 Suggested directives for oral palliative care management**

In order to avoid oral discomfort in patients as much as is possible, the following protocol is recommended as a guide, especially for circumstances in which patients are unable to properly communicate. It is offered in a format that can be duplicated for institutional use.

Institutional recommendations for oral health standard of care when possible/ practical per patient are:

Patient/Caregiver Concerns

Offer oral hygiene a minimum of once every 8 hours while in the acute care or long-term care or home.


Professional Caregiver/Registered Nurse Concerns:


**71**

region

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient*

• Provide or refer for access to dental services as appropriate.

• Brown areas/dark staining/holes on or in the teeth

• Unusual-looking tissues of any type from any oral source

• Concerns of the patient of any type from any oral source

• Hypothyroidism, autoimmune disease, and sarcoidosis

• Use of drugs, such as anti-muscarinics, opioids, diuretics

• Injury to the salivary glands or buccal mucosa

• Mouth breathing, or unhumidified oxygen

When appropriate, the hospice staff will consult with either the patient's dentist

If the mouth is felt to be dry, one must treat the underlining cause as is appropriate. Not all xerostomia is secondary to a decrease in salivation or

• A history of surgery, chemotherapy, or radiotherapy to the head and neck

*2.4.1 Commonly identified problems reported by aides and family to the hospice* 

The following oral issues should be reported to the appropriate staff:

*DOI: http://dx.doi.org/10.5772/intechopen.95606*

Institutional Concerns:

*staff*

• Broken teeth

• Loose teeth

• Bleeding gums

• Red or white patches

of record or the in-house dentist.

*2.4.2 Xerostomia (dry mouth)*

Other causes include:

• Anxiety and depression

• Swelling

• Sores

• Lumps

dehydration.

• Monitor staff performance.

• Provide oral care and dental care education to patients and families.

*Why Are We Missing the Teeth? Addressing Oral Care Neglect in the Palliative Patient DOI: http://dx.doi.org/10.5772/intechopen.95606*

Institutional Concerns:

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

and put into a drawer or storage cup.

soothing touch.

for institutional use.

practical per patient are:

long-term care or home.

the oral cavity.

Patient/Caregiver Concerns

follow-up dental services

her discretion. In cases where the patient is demented, combative, or has a denture that is difficult to remove, or one that is causing sore areas, the denture is removed

Moreover, without patients' being monitored for loose teeth, oral cancers, and large areas of decay, some teeth shop exfoliate during meal time, going without notice, while other patients experience pain that they cannot communicate vocally or otherwise. It is for patients such as these, as well as for those who still yearn for their regular oral hygiene protocol, that we owe our attention and service, compassion and

For those patients who can verbally communicate that they are uncomfortable and have pain, it is imperative that the caregiver check for allergies and other medications being given to the patient that may not be compatible with a particular pain medication being considered for therapy. One also must be cognizant of the fact that pain medications may make these already frail patients more likely to fall, become disoriented, or more confused than is normally the case. Further, it is certainly advisable to use the lowest dose and least number of pills possible for managing patient pain, and to avoid opioids, if at all possible, by using alternating doses of

nonsteroidal inflammatory drugs with acetaminophen where tolerated. [25] Distress experienced during injections may also be reduced by use of a controlled flow anesthesia system [26], and in some cases very loose teeth may be extractable with the use of a xylocaine viscous gel or topical anesthetic so as to avoid

In order to avoid oral discomfort in patients as much as is possible, the following protocol is recommended as a guide, especially for circumstances in which patients are unable to properly communicate. It is offered in a format that can be duplicated

Institutional recommendations for oral health standard of care when possible/

Offer oral hygiene a minimum of once every 8 hours while in the acute care or

• Refer patients and families to dental services for urgent follow-up treatment.

• General assessment or evaluation of the oral cavity on admission performed at

• Notify physician and dentist of any abnormalities causing distress present in

• Observe for aspiration precautions and compliance while providing care.

• Provide oral care and dental care education to patients and families.

• Educate patients and families on the importance of good oral hygiene and

the stress of dental injections to accomplish the necessary treatment.

**2.4 Suggested directives for oral palliative care management**

Professional Caregiver/Registered Nurse Concerns:

least daily and if possible, during every shift.

• Assess what each patient can do independently.

**70**


The following oral issues should be reported to the appropriate staff:


When appropriate, the hospice staff will consult with either the patient's dentist of record or the in-house dentist.
