• Users Online: 10
  • Print this page
  • Email this page

Table of Contents
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 65-68

Gaps in the teeth: Coming together to address oral needs in the terminally ill

Member, American Dental Association's Council on Ethics, Bylaws and Judicial Affairs; Gratis Faculty Louisiana State University Health School of Dentistry, Private Periodontal Practice in New Orleans, LA, USA

Date of Submission07-Jul-2020
Date of Acceptance06-Sep-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Dr. Kristi M Soileau
3634 Coliseum Street, New Orleans, LA 70115
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INPC.INPC_28_20

Rights and Permissions

For the hospice patient needing palliative care, quality of life must encompass all aspects of comfort management. Often, medical and dental professionals and caregivers under their management in both homes and institutions hesitate or simply do not elect to offer oral care for patients nearing the end of life. This may be due to many factors, including difficulties encountered in patient compliance or lack of education as to how and why such care should be delivered to the hospice patient. This article aims to clarify the reasons why the hospice patient, cognizant or not, needs properly and regularly implemented oral care and why both medical and dental professionals have an ethical responsibility to concomitantly address the current void that exists in delivering it.

Keywords: Dental collaboration, ethics, hospice, medical, oral care

How to cite this article:
Soileau KM. Gaps in the teeth: Coming together to address oral needs in the terminally ill. Int J Prev Clin Dent Res 2020;7:65-8

How to cite this URL:
Soileau KM. Gaps in the teeth: Coming together to address oral needs in the terminally ill. Int J Prev Clin Dent Res [serial online] 2020 [cited 2020 Oct 24];7:65-8. Available from: https://www.ijpcdr.org/text.asp?2020/7/3/65/296539

  Introduction Top

Why care for teeth in the dying?

Dental care is important to all individuals in that it is commonly recognized as being necessary for a healthy long-lasting dentition, and oral health maintenance is vital toward a more pleasant day-to-day experience. Quality of life issues can affect all patient groups, yet one particular subset that seems to be most neglected from the standpoint of oral care is that of the elderly hospice and terminally ill patient.

Hospice care serves those who are certified by a physician as having fewer than 6 months to live and who elect to terminate curative treatment, rather seeking only palliative care, in order to die with us a little suffering as possible.[1] The World Health Organization (WHO) defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with a 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]

According to this definition, there are two main foci: that of improving the quality of life of patients and their loved ones, and developing a system through which care offered best addresses the multilayered suffering indigenous to these patients. Yet, in spite of the WHO statement, oral care in the terminally ill and elderly typically falls well behind that of the norm for many reasons.

Quality of life depends largely on oral care

A clean and properly cared-for mouth matters in every person's overall health, functional and emotional well-being, and sense of self.[3] Further, the lack of oral management can negatively affect nutrition, comfort, and social issues for even the hospice patient.[4],[5],[6],[7],[8],[9] It has been suggested that ideal treatment for the terminal elderly would be gentle oral cleansing three times a day,[10] with a daily general assessment of denture fit, cleanliness, and any lesions that may be affiliated with removable prostheses.[11]

Symptoms commonly found in the mentally and physically stressed, particularly those individuals who are on certain medications commonly administered to the elderly, terminal, and institutionalized are oral candidiasis, which complications are burning and dry mouth,[12] xerostomia,[13],[14],[15] as well as swallowing difficulty, problematic breathing, and inhibited verbal communication.[16] This affects the quality of life not only from the discomfort these may bring but also because these same problems may often become an impediment in understanding the patient's verbiage and efforts at communication. This in turn increases the level of frustration many patients may feel that their needs are not being addressed adequately.

Identification and treatment of multilayered pain

Patient pain is not only physical but also psychological and even spiritual. This can be caused by many oral diseases, such as abscesses teeth, growths and tumors, ill-fitting prostheses, sharp and broken teeth lacerating the tongue and cheeks, and periodontal disease.

Periodontal disease is very common in the general populous, with profession increasing with age. Periodontitis, or loss of the supportive structures surrounding the teeth, affects approximately 46% of Americans[17] and can cause gingival bleeding, loose teeth that cause pain on eating or even self-exfoliate, suppuration, as well as many other symptoms that create physiological and psychological distress. In addition, caring properly for the periodontium can reduce aspiration pneumonia,[18] as well as heart disease, diabetes and cancer,[19] release of gingival inflammatory cytokines, and prostaglandins.[20] Such chronic inflammation has also been shown to cause depression.[21]

Addressing the disconnect: Impediments to meeting the World Health Organization goals in oral care

In preserving the quality of life and alleviating suffering, it is imperative to examine where stumbling blocks may be found on the road to better hospice oral care. One such explanation may stem from the fact that a dentist is not listed as required staff recommendations of the National Hospice and Palliative Care Organization Guidelines.[22] There are 1.5 million hospice patients currently at risk of oral care neglect.[23]

Without a dentist on staff, there will be no philosophical stance of terminal oral care with either the institution or its employees. Failing to put forth a “standard” of oral care indigenous to these patients is neglectful in identifying issues that may be causing patient distress, yet which might easily remain unnoticed by family and/or staff.

Another explanation which may be promulgating and perpetuating the absence of adequate oral care may stem from traditions deeply entrenched in medicine and dentistry wherein there often appears to be a border at which there is too little crossover. This is present not only in communications but also in shared responsibilities which, if ameliorated, would ultimately result in better patient management and comprehensive care.

Third, another enormous stumbling block to treatment is the lack of funding for community and hospital-based oral health services, which largely affects the elderly and dying. If there is not adequate compensation, there will be few participants in oral health care to the level that is actually required and desired, translating into a sadly limited number of dental and medical professionals who are able and willing to treat this population adequately.[24]

Further, Medicare and Medicaid funding for oral conditions has for decades only been available for treatment in cases of injury responsible for or caused by disease.[25]

In addition, many dental and medical professionals alike often see performing treatment on the seriously ill, older patient as unnecessary and perhaps even a waste of time.[5] Related issues include lack of staff time, too few numbers of adequately trained staff, staff apathy, and inadequate knowledge about where to fit oral care into their list of caregiving priorities.

Finally, patients oftentimes are the largest impediment to their own properly implemented oral care, regardless of whether there were to be adequate funding and staffing. Hesitancy by staff in working with the terminally and elderly ill may stem understandably from several sources, such as limitations in lighting and awkward positioning required of both caregiver and patient in less-than-ideally equipped dental clinics.[26] Certainly, aggression, biting, or other defensive mechanisms exhibited by patients will hinder one's good intentions at proper caregiving. However, dental and medical professionals alike are called to respond empathetically to treat the whole person, preserving their humanity, while working through challenges as best they can.[27]

Rozas et al.[28] suggest that an oral evaluation into a nursing home should take place upon admission, followed by regular dental screenings. This is because many problems in these patients otherwise go unnoticed by health-care professionals, and these patients' unexpressed needs may be addressed more expeditiously with the decreased time between evaluations.[29] Affiliated staff must be mindful of the fact that patients with diminished consciousness may still experience oral discomfort,[30] and that compassionate care given in this way is just, respects autonomy, and is beneficent.

Moving forward

Dentists must help educate hospice and long-term care institutions, their entire medical teams, and other dentists who work with hospice patients to create positive changes in the oral care of the terminally ill by developing, implementing, and monitoring programs that are realistic and effective to the level that is permitted by their patients. Further, dental school deans and course development administrators are urged to develop a curriculum that emphasizes basic dental care in the areas of mental and physical disabilities, geriatrics, and hospice oral health.[31]

Physicians and dentists should take note of Kultgen's[32] description of professionalism, which claims that proficiency must be moral and psychological, as well as technical. Ellershaw and Ward[33] feel that training of all health-care professionals must include educational objectives related to oral care in the dying. Educated caregivers who educate other caregivers to comply with oral health routines in these patients are vital.[27] The WHO also calls for improvement in palliative care education through heightened research in this field.[2] To these effects, it is expected that the number of previously unenlightened health-care professionals might multiply exponentially, which is sorely needed.

  Conclusion Top

Hospice care does not demand perfection nor does it demand that one practice a standard of care as compared to the norm. What it does beg is that the terminally ill be treated with compassion and dignity, recognizing the fact that oral care delivers more than just prevention. It is not so linked to rules and regulations, but to a general, well-intended alleviation of distress and response to the desire for touch, feeding, and cleansing. Dentists and physicians need to come together on the hospice front to bring a much needed practicality and overall health-care balance into focus on the subject of what tissues lie beyond the lips. If physicians and dentists fail to advance intercommunicative efforts in these areas, oral neglect for the elderly and dying will increase as the average age of Americans continues to rise.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Abel EK. The Inevitable Hour: A History of Caring for Dying Patients in America. Baltimore, MD: Johns Hopkins University Press; 2013. p. 166-9.  Back to cited text no. 1
World Health Organization. Palliative Care for Older People: Better Practices. WHO Regional Office for Europe: World Health Organization; 2011.p. 1-25. Available from: http://www.euro.who.int/__data/assets/pdf_file/0017/143153/e95052.pdf. [Last accessed on 2018 Feb 28].  Back to cited text no. 2
Sischo L, Broder HL. Oral health-related quality of life: what, why, how, and future implications. J Dent Res 2011;90:1264-70.  Back to cited text no. 3
Slaughter A. Providing dental care for older adults in long term care. Univ Pennsylvania Sch Med 2006.  Back to cited text no. 4
Chen X, Kistler CE. Oral health care for older adults with serious illness: When and how? J Am Geriatr Soc 2015;63:375-8.  Back to cited text no. 5
Wiseman M. The treatment of oral problems in the palliative patient. J Can Dent Assoc 2006;72:453-8.  Back to cited text no. 6
Meier DE, McCormick E, Arnold RM, Savarese DM. Benefits, Services, and Models of Subspecialty Palliative Care; 2017. Available from: https://www.uptodate.com/contents/benefits-services- and-models-of-subspecialty-palliative-care. [Last accessed on 2017 May 15].  Back to cited text no. 7
Miller S, Ryndes T. Quality of life at the end of life: The public health perspective. Generations 2005;29:41-7.  Back to cited text no. 8
CDHB Hospital Palliative Care Service. Oral Care in Patients at the end of Life. New Zealand, Canterbury: CDHB Hospital Palliative Care Service; 2013.  Back to cited text no. 9
O'Conner L, Capezuti L, Fulmer TT, Zwicker DA, Boltz M. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York: Springer Publishing Company; 2016.  Back to cited text no. 10
Rassett B. Denture Information for Caregivers, Dentures & Denture Problems: What Seniors Need to Know. Tooth Wisdom. Available from: http://www.toothwisdom.org/resources/entry/denture-information-for-caregivers. Published February 4, 2013. [Last accessed on 2017 May 18].  Back to cited text no. 11
Jobbins J, Bagg J, Finlay IG, Addy M, Newcombe RG. Oral and dental disease in terminally ill cancer patients. BMJ 1992;304:1612.  Back to cited text no. 12
Spolarich E. Medicines and your Mouth [Health Resource]. Available from: http://www.toothwisdom.org/resources/entry/medicines-and-your-mouth. [Last accessed on 2013 Feb 04; Last acessed on 2017 May 14].  Back to cited text no. 13
Roderick R. Reasons why you have Dry Mouth; 2016. Available from: http://www.toothwisdom.org/resources/entry/reasons-why-you-may-have-dry-mouth. [Last accessed on 2017 May 14].  Back to cited text no. 14
Salinas T. Dry Mouth Treatment: Tips for Controlling Dry Mouth. Mayo Clinic; 2017. Available from: http://www.mayoclinic.org/diseases-conditions/dry-mouth/expert-answers/dry mouth/FAQ-20058424. [Last accessed on 2017 May 13].  Back to cited text no. 15
Bean L. Monitoring the Mouth – Oral Considerations for Hospice Patients; 2017. Available from: http://wilbeadme.com/general/monitoring-the-mouth-oral considerations-for-hospice-patients/. [Last accessed on 2017 May 08].  Back to cited text no. 16
Eke PI, Dye BA, Wei L, Slade GD, Thornton-Evans GO, Borgnakke WS, et al. Update on prevalence of periodontitis in adults in the United States: NHANES 2009 to 2012. J Periodontol 2015;86:611-22.  Back to cited text no. 17
McLearan S. Guidelines for Providing Dental Services in Skilled Nursing Facilities. Center for Oral Health; 2013. Available from: http://www.centerfororalhealth.org/images/lib_PDF/Skilled _Nursing_Facility_Dental_Services_Guidelines.pdf. [Last accessed on 2017 May 05].  Back to cited text no. 18
Atchley M. Mouth Body Connection: A Holistic Approach to Dentistry. Dental Bliss; 2016. Available from: http://dentalbliss.com/mouth-and-body-connection-a-holistic-approach-to-dentistry/. [Last accessed on 2017 Aug 15].  Back to cited text no. 19
Rajesh KS, Thomas D, Hegde S, Kumar MS. Poor periodontal health: A cancer risk? J Indian Soc Periodontol 2013;17:706-10.  Back to cited text no. 20
[PUBMED]  [Full text]  
Goldie M. How Depression Threatens Oral Health, and Other Oral-Systemic Links. Dentistry IQ; 2016. Available from: http://www.dentistryiq.com/articles/2016/03/how-depression-threatens-oral-health-and-other-oral-systemic-links.html. [Last accessed on 2017 May 27].  Back to cited text no. 21
National Hospice and Palliative Care Organization. The hospice team. n.d. Available from: http://www.carinfo.org/i4a/pages/index.cfm?pageid=3357. [Last accessed on 2018 Feb 28].  Back to cited text no. 22
Jucan A, Saunders R. Maintaining healthcare in palliative care patients. ALTC. Clin Care Aging 2015;23:15-20.  Back to cited text no. 23
Vargas CM, Kramarrow EA, Yellowitz JA. The oral health care of older Americans. Aging Trends, No. 3. Hayatsville, Maryland: Nation Center for Health Statistics; 2001. p. 1-7.  Back to cited text no. 24
CMS.gov. Medicare Dental Coverage. Medicare. gov the Official U.S. Government Site for Medicare. Available from: https://www.cms.gov/Medciare/Coverage/MedicareDental coverage/index.html?redirect=/MedicareDentalCoverage/. [Last accessed on 2017 Aug 08].  Back to cited text no. 25
Dolan TA, Atchison KA. Implications of access, utilization and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system. J Dent Educ 1993;57:876-87.  Back to cited text no. 26
Ozolinņš J T, Grainger J. Foundations of Healthcare Ethics: Theory to Practice. Melbourne, Victoria: Cambridge University Press; 2015. p. 26.  Back to cited text no. 27
Rozas NS, Sadowsky JM, Jeter CB. Strategies to improve dental health in elderly patients with cognitive impairment: A systematic review. J Am Dent Assoc 2017;148:236-45000.  Back to cited text no. 28
Strömgren AS, Groenvold M, Pedersen L, Olsen AK, Spile M, Sjøgren P. Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating. J Pain Symptom Manage 2001;21:189-96.  Back to cited text no. 29
Martin S. Oral hygiene in dying patients with diminished consciousness. End Life J 2015;4:1-8.  Back to cited text no. 30
Welie JV. Justice in Oral Health Care: The Preferential Option for the Poor: A Social Justice Perspective on Oral Health Care. Milwaukee, WI: Marquette University Press; 2006. p. 127-38.  Back to cited text no. 31
Kultgen JH. Ethics and Professionalism. Philadelphia: University of Pennsylvania Press; 1998. p. 269-359.  Back to cited text no. 32
Ellershaw J, Ward C. Care of the dying patient: The last hours or days of life Commentary: A “good death” is possible in the NHS. BMJ 2003;326:30-4.  Back to cited text no. 33


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded6    
    Comments [Add]    

Recommend this journal