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Prosthodontics

Authors: Dr. Himanshu Aeran, Dr. Amrinder Singh Tuli, Dr. Avantika Tuli

Abstract

Palliative care dentistry was defined by Wisemanas the study and management of patients with active progressive and far advanced disease in whom the oral cavity has been compromised either by the disease directly or by its treatment. Palliative care for the terminally ill is based on a multidimensional approach to provide whole-person comfort care while maintaining optimal function; dental care plays an important role in this multidisciplinary approach. A dentist can help to improve the quality of life of the patients as the mouth is the most important organ of expression and it is most often affected in later stages of diseases.Dental surgeons can help the patient right from the initial diagnosis of the oral diseases to the relief of pain and treatment in the terminal stages of the oral diseases. But many a times the general dentist is unaware of his responsibilities toward a terminally ill patient. The community is also unaware of the role that a dentist can play. In this paper, a brief attempt is made to list a few areas in which a palliative care dentist can help other members of the palliative care team and also the patient in leading a better life. This article presents some common problems encountered in palliative care dentistry in relation to adults with terminal cancer and the appropriate treatment of these problems.

PALLIATIVE DENTAL CARE

Oral problems in palliative patients may be related to, (a) direct effect of the primary disease, (b) indirect effect of the primary disease, (c) treatment of the primary disease, (d) direct/indirect effect of a coexisting disease, (e) treatment of coexisting disease, (f) combination of the above factors.1 The palliative care dentist can assess these difficulties, focus on the elimination of these problemsand take appropriate action to at least alleviate symptoms, minimize pain and suffering and provide symptom control. Dental professional are the important members of extended palliative team and they have number of key roles, including (a) training of palliative care professionals, (b) management of complex oral problems and (c) management of specific oral problems.2 Dentists routinely come across the solid tumours of head and neck region, oral manifestations of haematological malignancies, temperomandibular disorders, dry mouth and many other oral diseases.Common oral problems associated with such patients are dry mouth, painful mouth, halitosis, alteration of taste, excessive salivation, angular cheilitis, candida infection taste and swallowing (thrush/yeast) disorders, denture stomatitis etc. They may result from poor oral intake, drug treatments, local irradiation, oral tumours, or chemotherapy. Oral symptoms may significantly affect the person’s quality of life, causing eating, drinking, and communication problems, and oral discomfort and pain.1

The most common oral afflictions of patients requiring palliative care are:

1) STOMATITISAND MUCOSITIS
 

Stomatitis (Figure-1) and Mucositis (Figure-2)are common in patients who receive chemotherapy and radiotherapy. An estimated 40% of chemotherapy patients suffer from mucositis.3 Chemotherapy causes atrophy of tissues leading to ulceration, which may be further complicated by microbial invasion. The decrease in lubrication and the protective agents in saliva render the tissues more susceptible to trauma and invasion by pathogens. The tissues become ulcerated and erythemic.The pain in mucositis can be reduced by topical lidocaine preparations. 2% morphine solution has been used topically to reduce pain.4 Oral cavity must be thoroughly cleaned by a dentist by flushing with povidone iodine preparations and lidocaine. This will help reduce the bacterial colonisation around debri. Soft and liquid diet has to be advised. They are asked to avoid hot and spicy foods, and habits like smoking and alcohol. Patients have to be advised to sip ice cubes. Other preparations used in the treatment of mucositis are water-based lubricants, milk of magnesia, benzydamine, sucralfate suspension etc. The ‘magic mouthwash’ which is a combination of antihistamines, antifungals, topical anesthetics and even antibiotics has been prescribed.5 Before any of the above measures is initiated, it is important to identify local traumatic factors such as fractured restorations or teeth, or an impinging removable prosthesis.

2) ORAL CANDIDIASIS
 

The incidence of candidiasis in palliative care patients has been estimated to be 70% to 85%. Predisposing factors for fungal infections include poor oral hygiene, xerostomia, immunosuppression, use of corticosteroids or broad-spectrum antibiotics, poor nutritional status, diabetes and the wearing of dentures.6 Candida infections are manifested as pseudomembranous (Figure-3), erythematous, hyperplastic candidiasis or angular cheilitis.Higher salivary Candida levels are more frequently encountered in denture wearers than in dentate patients. Candidiasis may be treated by a combination of topical and systemic applications.The most commonly used topical antifungal is clotrimazole troche, 10 mg, 5 times daily for 14 days. Another topical agent is nystatin (200000-400000IU). Systemic antifungals such as ketoconazole (200-400 mg orally 7-14 days) and fluconazole (50-100 mg 7-14 days) can be given for severe cases. Palliative care givers should take care of the oral conditions of the patient.6

3) XEROSTOMIA
 

Xerostomia is common in palliative care patients, mainly as a result of medication or radiotherapy to the head and neck.Vomiting, diarrhoea, fever, swallowing difficulties and anorexia may cause dehydration, which in turn can lead to xerostomia. Water-soluble lubricants should be used to lubricate the oral tissues.7 Saliva substitutes (Figure-4) are beneficial for the patient and should be used before eating to improve swallowing. Topical use of malic acid, vitamin C and citric acids can stimulate saliva; however, their low pH contributes to tooth demineralization. Topical fluoride/Fluoridated toothpastes (Figure-5) should be applied in dentate xerostomic patients to prevent dental caries, and oral hygiene instructions are also very important. Oral candidiasis is prevalent in patients with hyposalivation, and should be treated modifications that may be helpful in xerostomic patients include consuming tart foods which stimulate saliva secretion and soft diet which is easier to swallow (e.g., applesauce, banana, fruit nectar, pureed or mashed vegetables, avocado, and yogurt).8

4) NUTRITION, HYDRATION AND TASTE DISORDERS

Palliative care patients are unable to consume food or fluids if their oral cavity is compromised. Taste alterations (dysgeusia, ageusia, hypogeusia, hypergeusia) affect 56–76% of cancer patients treated by chemo- or radiotherapy. Palliative care patients should be gently encouraged to increase their fluid intake. During winter months, a room humidifier can help reduce oral dryness, especially for mouth breathers. Counselling with a dietician is required to ensure proper caloric and protein intake.The patient should be instructed to choose soft foods that are atraumatic to the oral mucosa, to chew and swallow small amounts carefully (using a small spoon), and to ease chewing and swallowing by wetting the food using small sips.9 Other intake deficiencies may be corrected by vitamin and mineral supplementation. Additional measures to support nutrition are needed when a patient suffers from severe dysphagia, such as delivery of nutrition by a nasogastric or gastrostomy tube.

5) ORAL HYGIENEMAINTENANCE
 

Oral hygiene is very important in palliative care patients as they are prone to oral infections due to their immunocompromised health. Adequate oral hygiene is essential for patient comfort, aesthetics and self-esteem. It is very important after tumor excision from the head-neck region, because the procedure often results in extensive three-dimensional defects that complicate reconstruction and predispose to the leakage of saliva and other secretions and predispose for accumulation of microorganisms and debri.9 Hygiene measures to mechanically remove food debris as well as the dental bacterial bio-film include twice-daily tooth brushing, inter-dental cleaning (with dental floss or toothpick), and tongue brushing which should be continued regardless of blood counts. Extra or super-soft nylon toothbrush (Figure-6) should be used, which should be replaced when worn or at least every 2–3 months. Oral sponges can be used temporarily when the patient cannot tolerate using a toothbrush. Electric toothbrushes/round toothbrushes especially for cancer patients (Figure-7) may improve hygiene, especially in individuals with impaired manual skills.Mouth washes with chlorhexidine gluconate (alcohol-free) solution may improve oral hygiene and reduce halitosis. For optimal mucosal hygiene, dentures should be removed at night (and before daytime sleeping), washed with a gentle brush and soap, and soaked in an antiseptic solution such as water, sodium bicarbonatesolution or chlorhexidine mouthwash.10

6) NAUSEA AND VOMITING

Nausea and vomiting in palliative care patients may have many causes, including chemotherapy, opioid use, bowel obstruction, pancreatitis and electrolyte imbalance, or they may be movement induced or even an emotional reaction.1 Vomiting has a caustic effect on the hard tissues and can also increase the morbidity of mucositis. It may also delay healing if the patient cannot consume nutrients essential for tissue repair. Many of the drugs prescribed to control nausea and vomiting have oral side effects,the most notable being tardive dyskinesia and xerostomia. Although the oral effects of the antiemetic’s are great, the inability to consume foods and medications orally has more serious implications. Emotional outbursts are treated by the palliative care team by listening to the patient’s concerns and suggesting relaxation techniques.

CONCLUSION

Though there is availability of literature regarding palliative care, the oral health problems remain a less discussed field. The importance of dental care is often ignored due to the non-inclusion of the dentist as a member of the palliative care team. Establishing protocols, emphasizing the compendious examination is pre-eminent to the oral and overall health of patients. Palliative care patients require special dental attention.The dentist’s role in palliative care is to improve the quality of life of the patient. In India organisations like NNPC and Pallium India are making enormous contribution in the field of Palliative care.The palliative care movement is one example of how health services can go well beyond the biomedical model of health and be seen as an affirmative act of living with dignity even whilst accepting that death is an inevitable part of life. This extends from operative and preventive care to the concept of total patient care covering both the physical and emotional aspects of well-being.

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