Palliative care: breaking oral health barriers

David Casey looks at the impact of limited resources and education in Ireland for oral health and palliative care on patients

There is a special needs area in oral health that is untouched in Ireland today: palliative care. A palliative approach improves the quality of life of patients and their families facing problems associated with a life-threatening illness.

This is done through the prevention and relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems, whether physical, psychosocial and spiritual (World Health Organisation, 2002).

In this article, we look at the limited number of resources and education available in Ireland today for oral health and palliative care, and the impact this has had on patients’ general health and overall wellbeing.
I will also outline my palliative care programme, which examines the challenges faced at end-of-life care.

I will discuss how these challenges are overcome, how they can be prevented and how to manage the symptoms through hygiene intervention and education.

Rising numbers

Pain and symptom management are often some of the main objectives of palliative care. The National Cancer Registry has predicted that the number of cancers diagnosed in Ireland will almost double between 1998 and 2020. Cancer accounted for 29% of deaths in 2010, according to the Central Statistics Office (Figure 1).

The majority of people that are admitted to palliative care or hospice service are living with advanced cancer-related problems, though their number also includes people with motor neurone disease, multiple sclerosis, and autoimmune deficiency syndrome.

In St James Hospital Dublin in 2011 25,168 in-house patients were treated. Of that figure, 948 patients were palliative care referrals between St James and Our Ladies Hospice Harold’s Cross.

Figure 1: Causes of death in 2010 (Central Statistics Office)

Minimising pain

Palliative care falls into a special needs group – these are people who, through no fault of their own, have a higher risk of developing dental disease or find it difficult to manage oral health procedures.

Oral health issues that are experienced at the end stages of life include:

• Dysphasia (difficulty in swallowing)
• Nutrition and taste problems
• Xerostomia (main issue to provide oral assistance)
• Thick mucus
• Thrush
• Difficulty speaking
• Denture-related issues
• Nausea and vomiting
• Mucositis (severe ulcerations brought on by oncology treatment)
• Stomatitis.

Palliative oral care focuses on strategies for maintaining the quality of life and mouth comfort. As oral lesions are indicators of disease progression, the oral cavity can be a window to overall health. Early clinical diagnosis of the oral lesions or conditions in palliative patients should be done and appropriate actions must be instituted to minimise pain and suffering by giving the symptomatic relief. Oral problems are common complications of cancer treatments, and are highly prevalent in palliative care patients. General health and comfort are linked closely with oral health in the terminal stages of an illness, and 89% of people in a hospice setting or attending palliative care treatment will have at least one if not many oral health care symptoms.

Care and comfort

Implementing palliative oral care into a hospice, hospital or other in-patient setting is not without its challenges.

I ran a voluntary programme in a local hospice over a two-year period with healthcare and nursing staff, where our primary focus was keeping patients pain-free and providing them with the best possible comfort. The programme was built around an interactive workshop with oral health stations targeting key issues such as diet and nutrition, pain-free living, comfort, and ensuring mouths were moist and clear from dental plaque, calculus or food debris.

The hospice included a training room, where a preventive dental training table/zone was set up and a presentation on palliative care and oral health was provided as a source of advice and training in a non-clinical area.

The programme ran for a one-and-half-hour session every two weeks.
An oral care health assessment tool was put together that used a ‘traffic light’ system as a guiding method of recording all data (Chalmers et al, 2004). This was designed for nurses and carers on the wards to record the data when oral hygiene procedures were carried out, or whether patients refused and had any oral problems.

Each oral health tool worked in a ‘number score’ system in relation to the overall health of the oral cavity at that time of day. An oral health box was given to every patient along with hygiene aids.

Future considerations

This voluntary programme has made it clear to me that palliative care and oral health has no dedicated oral health promotion staff in Ireland, and that there are little resources available to change this.

But the programme had a positive impact, showing increased knowledge among staff after training, and an audit of case notes showing sustained improvement in patient’s oral comfort after the training.

Different challenges must be overcome to keep patients free of pain and infection. Education and intervention are necessary to break the barriers of oral health and palliative care, making individuals feel more comfortable and giving them a better quality of life.

For a full list of references, please email carlotta@irishdentist.ie.

David Casey RDN holds a national certificate in biology and a specialist in oral health with health promotion qualifications. He has completed courses in radiography and the Society for the Advancement of Anaesthesia in Dentistry (SAAD) conscious sedation and palliative care. In June 2014, Dave was awarded the Annual Special Care Dental Professional Award from the Irish Society for Disability and Oral Health. He was also a finalist in the 2015 Irish Dentistry Awards. Dave currently works for Decare Dental Ireland as a dental professional.