The need and availability of dental services for terminally ill cancer patients: a nationwide survey in Japan

Comparison of nurse-led oral health care and dental professional-led oral health management in terminally ill cancer patients receiving palliative care: a longitudinal study

PURPOSE

To examine the impact of oral health care provided by nurses who received instruction from dental professionals on the oral health of terminally ill cancer patients and determine the optimal cutoff value of the Oral Health Assessment Tool (OHAT) total score for triaging patients in need of oral health management by dental professionals.

METHODS

In total, 115 terminally ill cancer patients (66 males and 49 females; average age 73.5 ± 10.9 years) who received oral health management during palliative care at Tokyo Medical and Dental University Hospital between April 2017 and August 2019 were included. Oral health management was conducted by dental professionals (D group) or nurses educated by dental professionals (Ns group). Oral health status was evaluated using the OHAT at the initial dental consultation in palliative care and approximately 2 weeks later.

RESULTS

Both groups showed significant improvement in the OHAT total score and OHAT sub-items of the lips, tongue, gums and tissues, saliva, oral cleanliness, and dental pain. However, sub-items of natural teeth and dentures improved significantly only in the D group. Additionally, the optimal cutoff value for the OHAT total score in determining the need for oral health management by dental professionals was 6.

CONCLUSION

Oral health care conducted by nurses who received instruction from dental professionals can improve oral health status. Patients with OHAT total scores of ≥ 6 should be considered for oral health management by dental professionals.

Oral clinical findings and intensive care unit prognostic scores

OBJECTIVE

Hospitalisation in intensive care unit (ICU) may cause changes in oral environment, which may influence patients' health status. The aim of this study was to evaluate the frequency of intraoral and extraoral findings observed during ICU admission, and to verify if there is an association with clinical prognosis scores.

METHODS

Data regarding clinical characteristics of patients hospitalised in an ICU were collected from medical records. The prognostic scores Sepsis Related Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score (SAPS 3) were estimated with data collected from admission and SOFA on the day of the oral examination as well. Data on oral mucosa lesions, saliva, dental condition and oral hygiene were evaluated during oral examinations.

RESULTS

The association of oral findings with prognostic scores was statistically verified. The majority (92.2%) of the 170 evaluated patients showed extraoral or intraoral findings during ICU admission. The most frequent findings were chapped and crusted lips, coated tongue, pale mucosa, haemorrhagic lesions, candidiasis, depapillated tongue and traumatic lesions. There were significant higher prognostic scores in the presence of the following extraoral and intraoral findings: crusted and ulcerated lips, haemorrhagic lesions, jaundice, spontaneous oral bleeding, coated and depapillated tongue. Median SAPS 3 was higher in patients with poor oral hygiene.

CONCLUSIONS

Oral findings were frequent in the population of patients hospitalised in the ICU and some of them were associated with worse prognostic scores. Routine oral examinations must be performed in hospitalised patients from ICUs for detection of oral markers of worse clinical prognosis.

MASCC/ISOO expert opinion on the management of oral problems in patients with advanced cancer

PURPOSE

The Palliative Care Study Group in conjunction with the Oral Care Study Group of the Multinational Association for Supportive Care in Cancer (MASCC) formed a sub-group to develop evidence-based guidance on the management of common oral problems in patients with advanced cancer.

METHODS

This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews and trials, respectively. Guidance was categorised by the level of evidence, and "category of guideline" (i.e., "recommendation", "suggestion" or "no guideline possible").

RESULTS

Twelve generic suggestions (level of evidence - 5), three problem-specific recommendations and 14 problem-specific suggestions were generated. The generic suggestions relate to oral hygiene measures, assessment of problems, principles of management, re-assessment of problems and the role of dental/oral medicine professionals.

CONCLUSIONS

This guidance provides a framework for the management of common oral problems in patients with advanced cancer, although every patient requires individualised management.

Dental needs in palliative care and problems in dental hygienist education: survey study of palliative care ward homepage, university syllabus, and academic conference abstracts

BACKGROUND

Although end-of-life patients have a variety of oral-related symptoms, the involvement of dentists and dental hygienists in the palliative care teams is limited. This study investigates the current state of palliative care education in universities that train dentists and dental hygienists and the need for dentistry in the clinical setting of palliative medicine in Japan.

METHODS

First, we investigated the involvement of dentistry in hospitals with palliative care units from a website. The number of reports on palliative care presented by dental hygienists at academic conferences around 2016, when the public medical insurance system in Japan covered oral care for patients with terminal illnesses, were examined. We also surveyed the syllabuses of the university that trained nurses, dentists, and dental hygienists to determine their education regarding palliative care.

RESULTS

Of the 376 hospitals with palliative care units, 176 (46.8%) had dentistry in the hospital. Additionally, 321 hospitals (85.4%), which included those without dentistry, responded that they provided oral care by dentists and dental hygienists in the palliative care unit. There were only two presentations on palliative care in the annual meetings of the two major academic societies by dental hygienists between 2012 and 2016. However, this number increased rapidly to 47 between 2017 and 2020. The syllabus surveys showed that, compared to nursing universities, universities that trained dentists or dental hygienists had lesser education in palliative care. Furthermore, education in the universities that trained dental hygienists was mostly related to the oral care of patients with terminal illnesses, while the physical and mental conditions of end-of-life patients were not well educated.

CONCLUSION

Considering that society requires the involvement of dental hygienists in the field of palliative care, it is necessary to enhance basic and clinical education of palliative care in universities that train dentists and dental hygienists to provide good oral care to patients with terminal illnesses and contribute to improving their quality of life.

Association between oral health and advisability of oral feeding in advanced cancer patients receiving palliative care: a cross-sectional study

PURPOSE

Maintenance of oral feeding is important in terms of maintaining and improving the quality of life in terminal cancer patients receiving palliative care. Although adequate oral health status is essential for oral feeding in hospitalized patients, the relationship between oral health and oral feeding in patients receiving palliative care remains unclear. This cross-sectional study aimed to examine how the general condition and oral health status of these patients relate to decisions regarding their nutritional intake methods.

METHODS

This retrospective cross-sectional study included 103 terminal cancer patients (59 men and 44 women; mean age, 73.8 ± 10.9 years) who received palliative care between April 2017 and August 2019. The nutritional method was assessed using the Functional Oral Intake Scale (FOIS). We assessed two types of nutritional methods: (1) the method advised by the attending physician until the initial dental examination (FOIS-I) and (2) the recommended method based on consultation with a palliative care doctor and dentist after the initial oral examination (FOIS-R). Furthermore, the participants' basic information and Dysphagia Severity Scale (DSS) and Oral Health Assessment Tool (OHAT) scores were assessed.

RESULTS

There was a divergence between FOIS-I and FOIS-R. FOIS-R was significantly higher than FOIS-I (p < 0.001). Multiple regression analysis revealed that the time until death, DSS score, and OHAT score had a significant impact on determining the food form for oral feeding.

CONCLUSIONS

Appropriate oral health assessment is important in determining the food form and indication for oral feeding among patients receiving palliative care.

Utilização de serviços odontológicos por pacientes em tratamento oncológico

Resumo Introdução a busca por atendimento odontológico é um parâmetro importante para averiguar como os indivíduos compreendem a saúde bucal. Objetivo avaliar a utilização de serviços odontológicos e fatores associados em pacientes oncológicos em Minas Gerais, Brasil. Material e método estudo transversal, realizado com uma amostra de 441 pacientes adultos frequentadores de uma associação voluntária de apoio a pacientes oncológicos no Estado de Minas Gerais, Brasil. O desfecho foi avaliado por meio do autorrelato de consulta odontológica no último ano. As variáveis independentes incluíram condições socioeconômicas, saúde geral e relacionada ao câncer, saúde bucal e cuidados odontológicos. As associações entre o desfecho e as variáveis independentes foram testadas por meio de regressão logística bivariada e múltipla, sendo os resultados expressos por meio de odds ratio (OR) e intervalos de confiança de 95% (IC95%). Resultado a prevalência de consulta odontológica no último ano foi de 33,3%. Os indivíduos que possuem entre quatro e sete (OR: 1,80; IC95%: 1,02-3,18) e aqueles com oito ou mais anos de estudo (OR: 3,20; IC95%: 1,07-9,60) apresentaram maiores, enquanto os edêntulos (OR: 0,44; IC95%: 0,21-0,92) apresentaram menores chances de consulta odontológica no último ano, independentemente de condições socioeconômicas, saúde geral e saúde bucal. Conclusão foi baixa a procura por consulta odontológica no último ano entre os pacientes oncológicos. Além disso, houve desigualdades relacionadas à escolaridade e ao número de dentes remanescentes na utilização dos serviços. A identificação e priorização dos grupos com acesso desfavorável aos serviços são fundamentais no planejamento da prestação de cuidados odontológicos a essa população.

Factors affecting the oral health of inpatients with advanced cancer in palliative care

Purpose

Patients with terminal cancer undergoing multidisciplinary palliative care often have oral health problems, but these details are still unclear. This cross-sectional study aimed to elucidate the oral health of patients with terminal-stage cancer who are inpatient recipients of acute-phase palliative care, and to unveil the factors affecting their oral health.

Methods

Participants were 121 patients with terminal-stage cancer (68 males, 53 females, mean age: 73.6 ± 11.1 years) and oral health complaints. They received palliative care at Tokyo Medical and Dental University Medical Hospital between April 2017 and August 2019. Their demographic and medical details were extracted, retrospectively, from their medical records, and their oral health status, such as the number of natural teeth, removable denture usage, Oral Health Assessment Tool (OHAT), and Dysphagia Severity Scale, were evaluated. All outcomes were assessed by a dentist from the palliative care team.

Results

The problems with soft tissue, saliva, and oral cleanliness were observed. The absence of posterior occlusal support was common, and the use of removable dentures was often inadequate. In contrast, swallowing function was relatively well-conserved and 46.3% of the participants were capable of nutrition intake solely by mouth. Multiple regression analysis revealed a significant association between total OHAT score and age, consciousness level, prognostic level, and method of nutritional intake.

Conclusion

The results revealed that the oral health of terminal cancer patients under palliative care declined despite receiving routine oral care from nurses, and suggest the importance of including dental professionals in multidisciplinary palliative care.

Oral Care Experiences of Palliative Care Patients, Their Relatives, and Health Care Professionals: A Qualitative Study

Oral symptoms in a growing number of palliative care patients are often neglected. Dental professionals are not always involved in palliative care. Oral care is often inadequately delivered to palliative care patients, while oral problems can affect the quality of life. A qualitative study was conducted to explore oral care experiences of palliative care patients, their relatives, and health care professionals (HCPs). Four patients, 4 relatives, and 4 HCPs were interviewed in a hospice. Transcripts were analyzed using thematic analysis and revealed 3 themes. Patients who were capable of performing oral care mainly brushed their teeth and looked after their dentures. Other care tended to be carried out by relatives and HCPs, adapted based on a person's level of consciousness. When describing the effects on oral health, relatives and HCPs tended to focus on xerostomia, whereas patients provided detailed accounts denoting the psychological and social impact of oral symptoms. Perceptions of enablers and barriers to oral care differed between groups. Patients reported lack of access to professional dental care and patients' fatigue were the main barriers to oral care. Nevertheless, there is great scope for further research into good oral care practices identified in this study and possible implementation in other settings.

The need for oral assessment and referral practices tool for palliative patients in Brunei Darussalam: A cross-sectional study

Aim

This study aimed to investigate knowledge, experiences, perceptions and barriers of healthcare professionals regarding palliative oral care.

Methods

The study involved 169 palliative care professionals in Brunei. Data collection tool was pretested, validated and self-administered with sections on demographics; knowledge, attitude and practices; referral of patients; perspectives; and barriers to oral palliative care.

Results

97.3% of participants believed that palliative patients need oral care, and 11.6% of participants were trained in this area. 43.8% were unsure about referral process, and 66.1% of participants had never used a tool to assess oral conditions of palliative patients. Most common oral condition encountered was mucositis (54.5%). 74.1% of participants expected family members to be responsible, and the absence of proper guidelines for assessment (66.1%) was the top challenge in providing oral care for palliative patients.

Conclusion

This study highlights perceptions and experiences of healthcare professionals and need for improved care through development of oral assessment and referral practices tool for palliative patients.

Diagnostic accuracy of patient-reported dry mouth as a predictor for oral dryness in terminally ill cancer patients

PURPOSE

The aim of the study was to determine the diagnostic accuracy of patient-reported dry mouth using an oral moisture-checking device in terminally ill cancer patients.

METHODS

The study was conducted following the STARD guidelines, and the participants were recruited prospectively from the Palliative Care Unit, Kyoto Medical Center, Japan, between 1 January 2017 and 30 November 2018. Patients reporting dry mouth were asked to rate oral dryness on a 5-point rating scale. The outcome was oral dryness at the lingual mucosa, measured using an oral moisture-checking device. Receiver operating characteristic (ROC) curves were plotted, and the sensitivity, specificity, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LR), and overall diagnostic accuracy were calculated.

RESULTS

Of 103 participants, the prevalence of oral dryness was 65.0%. ROC analysis indicated that patient-reported dry mouth was a poor predictor of oral dryness, with an area under the curve of 0.616 (95% confidence interval: 0.508-0.723), a sensitivity of 46.3%, a specificity of 75.8%, a PPV of 55.9%, an NPV of 68.1, a positive LR of 1.9, a negative LR of 0.7, and an overall diagnostic accuracy of 64.1%, with a cut-off value of 3 points.

CONCLUSION

In conclusion, patient-reported dry mouth is not a useful parameter for the assessment of oral dryness in terminally ill cancer patients.

Why oral palliative care takes a backseat? A national focus group study on experiences of palliative doctors, nurses and dentists

Aim

Poor oral care among frail older people at the end of life endangers quality of life. However, only few dying people have access to oral palliative care services. Therefore, this study aimed to investigate oral palliative care practices and referral patterns for palliative patients in the Brunei healthcare settings.

Design

An exploratory qualitative study.

Methods

Five focus groups were conducted among palliative care nurses (N = 7), palliative medicine doctors (N = 4), dentists (N = 6), oncologists (N = 4) and oncology nurses (N = 4). Verbatim was analysed using qualitative thematic analysis.

Results

Analyses revealed four distinct themes emerging as current oral palliative care assessment and referral practice in the Brunei healthcare settings: "taking a back seat," "opportunistic oral care," "they refused and refused" and "challenging healthcare resources and oral palliative care."

Oral health problems among palliative and terminally ill patients: an integrated systematic review

BACKGROUND

High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to communicate their sufferings. Therefore, it may lead to under-reporting of oral conditions among these patients. This review systematically synthesized the published evidence on the presence of oral conditions among palliative patients, the impact, management, and challenges in treating these conditions.

METHODS

An integrative review was undertaken with defined search strategy from five databases and manual search through key journals and reference list. Studies which focused on oral conditions of palliative patients and published between years 2000 to 2017 were included.

RESULTS

Xerostomia, oral candidiasis and dysphagia were the three most common oral conditions among palliative patients, followed by mucositis, orofacial pain, taste change and ulceration. We also found social and functional impact of having certain oral conditions among these patients. In terms of management, complementary therapies such as acupuncture has been used but not well explored. The lack of knowledge among healthcare providers also posed as a challenge in treating oral conditions among palliative patients.

CONCLUSIONS

This review is first in its kind to systematically synthesize the published evidence regarding the impact, management and challenges in managing oral conditions among palliative patients. Although there is still lack of study investigating palliative oral care among specific group of patients such as patients with dementia, geriatric or pediatric advanced cancer patients, this review has however provided baseline knowledge that may guide health care professionals in palliative settings.

Oncology Curricula in Postgraduate General Dentistry Programs: a Survey of Residency Program Directors

Management of patients undergoing treatment for cancer requires a multidisciplinary team including general dentistry providers; however, the relative knowledge and training of general dentists in the management of this patient population are relatively unknown. The purpose of this study was to assess the oncology curricula of postgraduate general dentistry training programs, from the perspective of the program directors, to better understand the opportunities for and/or barriers to dental care for cancer patients. A cross-sectional survey was sent to the 275 Commission on Dental Accreditation-accredited programs; 82 program directors responded (response rate, 30%). More than 50% of respondents indicated "none" or "little" curricular emphasis on cancer biology, bone marrow transplantation, immunotherapy, or prosthetics for use during head and/or neck surgery. Conversely, more than 50% of respondents indicated "moderate" or "substantial" emphasis on acute oral effects of cancer-related therapy, long-term oral effects of cancer-related therapy, antiresorptive medication pharmacology, radiotherapy techniques and biological effects, and osteonecrosis of the jaw. Residents had the most experience with radiotherapy patients and the least with bone marrow or transplantation patients. Overall, general dentistry program directors were enthusiastic to participate in the multidisciplinary team but reported challenges to including oncology curricula in residency training programs. Training for general dentistry providers in formalized postgraduate residency programs may be variable or limited-as a result, communication regarding patient management is critical. Opportunities exist to enhance the general dentistry curricula and, thereby, improve access to dental care for patients receiving treatment for cancer.

Change in Food Intake Status of Terminally Ill Cancer Patients during Last Two Weeks of Life: A Continuous Observation

BACKGROUND

The oral food intake of terminally ill cancer patients is known to gradually decrease, but there are few reports about how oral intake changes around the terminal stage. It is important to clarify changes in oral food intake, as such changes affect the support and care of terminally ill cancer patients.

OBJECTIVE

We aimed to clarify changes in oral food intake in terminally ill cancer patients during the last 2 weeks before death.

METHODS

This retrospective cohort study was conducted at a designated cancer center hospital in Japan from January 2013 to June 2013. The subjects were recognized as clinically terminally ill cancer patients who were hospitalized for ≥14 days, and who had death as their reason for hospital discharge. One researcher investigated basic patient information and the food intake status of the subjects using their medical records. The basic information investigated was gender, age, type of cancer, and the presence of gastrointestinal obstruction 14 days prior to death. The Food Intake LEVEL Scale (FILS) was prospectively recorded.

RESULTS

After applying the exclusion criteria, 108 subjects were finally included in the analysis (59 males aged 70.3 ± 13.3 years; 49 females aged 70.3 ± 14.5 years). The FILS gradually declined, and half of the subjects were unable to take food orally 6 days before death. In 81 subjects, after excluding subjects with gastrointestinal obstruction, the FILS gradually declined, and half of the subjects were unable to take food orally 4 days prior to death.

CONCLUSIONS

Many terminally ill cancer patients can take food orally up to a few days prior to their death. Therefore, various specialists should support the oral intake of terminally ill cancer patients until immediately before their death.