DOI: 10.7860/JCDR/2014/8898.

4427
Review Article

Palliative Dental Care - A Boon for

Dentistry Section

Debilitating

BHAVANA SUJANA MULK1, RAJA LAKSHMI CHINTAMANENI2,

PRABHAT MPV3, SARAT GUMMADAPU4, SHYAM SUNDAR SALVADHI5

ABSTRACT
World Health Organization defines “palliative care” as the active total care of patients whose disease is not responding to curative treatment.
Palliative care actually deals with patients at the terminal end stage of the disease. We always face a question why a dentist should be in
a palliative team? What is the exact role of dentist? Dental treatment may not always be strenuous and curative, but also can focus on
improving quality of life of the patient. Hence forth the present paper enlightens the importance of dentist role in palliative team.

Keywords: Dental expression, Residential aged care facilities (RACF’S), Geriatric oral health assessment index
(GOHAI), Granulocyte colony stimulating factor (G-CSF), Keratinocyte growth factor (KGF)

Introduction proper oral hygiene will be a difficult task for sick and terminally ill
Palliative care dentistry has been defined as the study and patients, hence the main goal of dentist in palliative team should
management of patients with active, progressive, far-advanced focus on oral comfort which comprise maintenance of oral hygiene,
disease in whom the oral cavity has been compromised either by wipe out painful conditions like mucositis, infectious diseases, and
the disease directly or by its treatment [1,2]. Palliative team is a ulcerative conditions of oral cavity. The strategy of dentist should owe
multidisciplinary approach where dental expression serves as on providing comfortable life style to patient rather than traumatic
‘healing hands’ in pain control, social, psychological and spiritual curative treatments. Giles and colleagues predicted that till 2031,
problems. A dentist role in palliative team is oblivious, who actually there is likely to be a 70% increase in the number of older people
can serve a crucial role in improving quality of life of the patient. with profound disability associated with muscoskeletal, nervous
The main role of palliative care is to assure affluent life, rather system, circulatory, respiratory conditions and stroke [6].
than a strenuous curative treatment. In palliative medicine an
Oral considerations in palliative patients – Cause and
interdisciplinary approach is inexorable and essential. In addition,
care
routine dental assessments may identify dental disease and facilitate
The imperative and important problems faced by the palliative
dental interventions for caries, periodontal disease, oral mucosal
patients are discussed briefly. The symptoms that indicate terminal
problems and prosthetic needs. Changing demographics and
phase of life are categorized as [7]:
improved medical management of disease are placing increasing
demands on dental providers for increased knowledge of oral 1) Bed-bound 2) Loss of appetite 3) Profound weakness 4) Trouble
manifestations of systemic diseases and their dental management swallowing 5) Dry mouth 6) Weight loss 7) Becoming semi-
[3]. The overall intervention precludes oral comfort to the patient conscious, with lapses into unconsciousness 8) Experiencing day
at the terminal end stage. The prevention of oral problems like to day deterioration that is not reversible.
xerostomia, mucositis, and candidiasis are some of the important Pain is one of the at most criteria which should be considered in
aspects of palliative oral treatment, which impart positive attitude on palliative care. It remains a central feature of good palliative care. The
patient’s personality and boost them with self confidence. In Toto it common oral problems encountered in palliative patients include
has been projected that by 2031, the number of people requiring xerostomia, mucositis, candidiasis, dental caries, periodontal
this type of accommodation (Palliative care) will increase from diseases, taste disorders, etc. [8]. Early clinical diagnosis of these
520,000 to 1.4 million [4]. oral lesions or conditions in palliative patients should be done to
minimize pain and suffering. A thorough oral assessment based on
Methods a systematic approach is required for sound management of oral
The present article employs review of literature describing the role care and facilitate prevention or minimization of oral complications
of a dentist in palliative team. As a part of complete review and [9]. The most appropriate screening tool use with elderly is Geriatric
discussion of matter, by retrieving relevant sources, the search Oral Health Assessment Index. (GOHAI) [10].
for articles were made through Google search engine using
heading terms palliative dental care, hospice, terminally ill patients, Mucositis and Stomatitis
Residential aged care facilities (RACF’S), Dental Expression and oral Mucositis is a painful condition of oral cavity with ulceration of
manifestations of palliative patients. Accordingly abundant research mucosal linings in the mouth, pharynx and digestive tract. It usually
results were obtained but the articles included in the reference list occurs as a result of toxic chemotherapy like 5-fluorouracil and
were sufficient to fulfill the objectives in the review. methotrexate, which are potent mucositis agents, radiotherapy and
stem cell transplantation [11]. 80% of patients with head and neck
Dental expression in palliative care malignancies receiving radiotherapy and chemotherapy are prone to
Dental expression in palliative care may be defined as the extended mucositis [12]. Clinically it may present as red or white lesion in the
dental services with a central goal of providing pre-eminent feasible mucosa, pseudo membrane formation and ulceration in the initial
oral care to terminally ill or far advanced disease patients, where oral stages although late changes include fibrosis of connective tissue
lesions greatly impact on quality of remaining life of patients, also the and hypovascularity [13]. Fractionated dose of 180-220 cGy/day
initiation and progression of oral lesions may be related to direct or results in mucositis within 1-2 weeks and increases throughout the
indirect succession of disease, its treatment or both [5]. Maintaining course of therapy to maximum in 4 to 5 weeks [14]. The symptoms

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 Bhavana Sujana Mulk et al., Palliative Dental Care - A Boon for Debilitating www.jcdr.net

include severe pain, compromised oropharyngeal function and oral Management include preventive, symptomatic and curative
bleeding that effect quality of life. modalities. “Magic mouth wash” composed of antacids, dipheny­
The patient judged mucositis scale, a modified version of WHO hdramine and the topical antifungal nystatin and viscous lidocaine in
mucositis scale used by Mahmood et al., Papadeas et al., and various formulations has gained importance due to its pronounced
karagogzoglu et al., is best assessed for general, physical and therapeutic effect now days [21].
nutritional status as well as inspection of oral cavity [15]. The new Preventive therapy includes maintenance of meticulous oral hygiene,
modalities include cell morphology and assessment of viability of cells frequent visits to dentist, supplemental fluoride, remineralizing
by tryptan blue dye exclusion test. Palliative treatment for mucositis solutions and noncariogenic diet [19,22]. Nevertheless symptomatic
[Table/Fig-1] Maintenance of proper oral hygiene, good nutrition and therapy like water intake, oral rinses and gels, alcohol free
hydration is also needed [16,17]. Prevention of mucositis following mouthwashes, humidifiers, use of topical salivary stimulants like sugar
chemo and radiotherapy can be done by administration of amifostine free gums, artificial salivary substitutes, systemic secretogogues
that scavenges free radicals generated in the tissues which are like bromohexine, anetholitrithione, pilocarpine Hcl and cevimeline
known to potentiate mucositis and promote repair of damaged DNA Hcl [23-25]. New modalities include electrical stimulation of salivary
glands for salivary hypofunction which delivers low voltage electric
Diluting Saline, Bicarbonate rinses, Frequent water rinses, Ice chips charge to tongue and palate [16,26]. when meta-analysis of
agents randomized control trial of pilocarpine was done by schuller et al.,
Coating Kaolin-pectin, Aluminum chloride, Aluminum and the overall improvement in condition of xerostomia was superior with
agents Magnesium Hydroxide, Hydroxypropyl cellulose, Sucralfate pilocarpine. Hence, pilocarpine is superior to other novel agents [27].
Lip lubricant Wax, Water based lubricants, Lanolin Curative treatment needs proper diagnosis of underlying pathology
for hyposalivation which includes sialometry, sialochemistry, salivary
Topical Dyclonine Hcl, Xylocaine Hcl, Benzocaine Hcl,
gland imaging, etc. [28]. Based on investigative procedures and
anesthetics Diphenhydramine Hcl, Doxepin Hcl
accurate diagnosis, treatment plan should be done accordingly.
[Table/Fig-1]: Management of mucositis [16]
Candidiasis
[18]. Studies have been conducted on new modalities like biological The incidence of candidiasis in palliative care has been estimated
response modifiers granulocyte colony stimulating factor (G-CSF) to be 70-85% [1]. Candida albicans is the most common infectious
and keratinocyte growth factor (KGF) [2]. organism encountered in candidiasis. Predisposing factors are
The Severity of mucositis can be assessed by World health embraced with poor oral hygiene, poor nutrition, smoking, denture
organization mucositis grading [9] wearers, immuno suppression, use of broad spectrum antibiotics
and corticosteroids [1,2].
Grade 0 - None
Types of primary candidiasis include pseudomembranous,
Grade 1 - Erythema, painful ulcers, mild sore throat
erythematous, atrophic candidasis and candida associated
Grade 2 - Painful erythema and ulcers, oedema of oral mucosa, but infections (angular chelitis, median rhomboid glossitis, and denture
able to eat solid food. stomatitis) [28]. The most common type in terminal end stage
Grade 3 - Painful erythema and ulcers, painful oedema of oral immuno comprimised patients is pseudomembranous type which
mucosa that interferes with eating solid food presents as loosely attached membranes comprised of fungal
Grade 4 - Need for parenteral or enteric support due to severe elements and debris, upon on scraping it leaves erythematous area.
stomatitis. Hyperplastic candidiasis is usually non scrapable. Erythematous
candidiasis appears as red lesions, frequently on hard palate
Xerostomia and tongue. Angular chelitis appears as red and white fissures
The subjective report of oral dryness is termed xerostomia, which
is a symptom and not a diagnosis or disease. Xerostomia may not
always be associated with hyposalivation. It is common in palliative
patients mostly as a result of radiotherapy and medication [1]. It is
practically difficult to assess the severity of xerostomia as it may
sometimes be totally subjective, and impart serious negative effect
on patient’s quality of life effecting dietary habits and nutritional
status. Causes of xerostomia are included in [Table/Fig-2] [19].
The symptoms include oral dryness, burning sensation, difficulty
in chewing, swallowing, altered taste etc. Clinical signs that aid
in diagnosis include thick ropey saliva, [Table/Fig-3] lip stick sign,
tongue blade sign, bald and fissured tongue, candidiasis, increased
rate of dental caries and erosion of teeth etc. Simon et al., assumed
that plaque retention, fissured tongue, and oral ulceration are
[Table/Fig-3]: Thick ropy saliva
considered the main problems regarding oral health [20].

Developmental Salivary gland aplasia

Water/ Impaired fluid intake, hemorrhage, vomiting/diarrhoea
metabolite loss
Iatrogenic origin Medications, radiation therapy to head and neck,
chemotherapy
Systemic Sjogren’s syndrome, diabetes mellitus, sarcoidosis,
diseases HIV, hepatitis C infection, graft versus host disease,
psychogenic disorders
Local factors Decreased mastication, smoking, mouth breathing

[Table/Fig-2]: Etiology of xerostomia

[Table/Fig-4]: Angular cheilitis

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Drug Form Dosage

Amphotericin B 1. Lozenge 10mg Dissolve in mouth slowly 3-4 per day or 2 weeks
2. Oral suspension 100mg/ml
Nystatin 1. Cream 1. Apply to affected areas 3-4 times per day
2. Oral suspension 100,000 U 2. Apply after meals 4 times per day for 7days
Clotrimazole 1. Cream 1. Apply to affected areas 2-3 times daily for 3-4 weeks
2. Solution 2. 2.5ml 3-4times daily for 2 weeks.
Ketoconazole Tablets 200-400mg tablets twice daily with food for 2weeks.
Fluconazole Capsules 50-100mg once daily for 2-3 weeks.
Itraconazole Capsules 100mg capsules daily taken immediately after meals for 2 weeks
Miconazole 1. Oral gel 1. Apply to the affected area 3-4times daily
2. Cream 2. Apply twice per day and continue for 10 to 14 days after the lesion heals.
[Table/Fig-5]: Treatment of candidiasis [16]
emanating from the corners of mouth which consists bacterial and
fungal components [Table/Fig-4]. In palliative patients candidiasis is
mostly because of xerostomia [29].
Treatment of candidiasis includes topical and systemic antifungal
drugs grouped into polyenes and azoles [Table/Fig-5] [19,30].
Many trial interventions have been done regarding the administration
of antifungals and its absorption in GIT. According to Finlay, Flynn,
Oude and Bensadoun fluconazole is the best absorbed drug,
this presumes that absorption of drugs plays an important role in
hospice receiving radio and chemotherapy [31,32]. Despite the
number of commercial products available, research has shown that
rinsing with water, cleansing with a soft tooth brush and regular
soaking of dentures in a weak non-toxic solution are the most [Table/Fig-6]: Radiation caries
effective oral cleansing agents. Dentures should be stored in vessels
in solution of water, mouth wash 0.12% chlorohexidine or 100,000 action and debris accumulation leading to increased rate of caries
IU of nystatin suspension. The suspension of agent like nystatin has and periodontitis [Table/Fig-6] The best method of reducing caries
high sugar content and must therefore be administered cautiously is by combination of restorative dental procedures, proper oral
in xerostomic dentate patients [33]. hygiene and topical application of sodium fluoride. Avoidance of
dietary sucrose further reduces concentration of streptococcal
Nutrition and Taste disorders mutants and lactobacillus [36]. Teeth which are grossly decayed
Nutrition is the most important aspect of health and well being. and severely periodontally compromised should be extracted based
Nutrition is required for physical and alert active mental status. on patients health status, as it improves patients comfort for intake
However it is most commonly compromised in people suffering of food. Rehabilitation of missing teeth should be done to improve
from end stage disease and patients undergoing treatment for the masticatory efficiency.
same. Development of malnutrition and its consequence is usually
a slow process, and is most often neglected aspect in management Osteoradionecrosis of the jaw
of palliative patients. Compromised nutritional status can lead to Osteoradionecrosis is best defined as a slow healing radiation
severe neural, muscular, bony, hematological and mental disorders induced ischemic necrosis of bone with associated soft tissue
affecting the general health and rarely proved to be fatal [28]. necrosis of variable extent occurring in the absence of local primary
The most common causes of malnutrition in palliative patients tumour necrosis, recurrence or metastatic disease [37]. Its incidence
are xerostomia, Taste and olfactory dysfunction stomatitis and is three times higher in dentate patients than in edentulous principally
compromised dental status. due to injury from extractions and infection from periodontal disease
[38].
The risk factors for diminished taste and smell are typically due
to nervous system disorders, chronic renal and liver diseases, Radiation dose < 3000 cGy Mucositis, Candidiasis, Xerostomia &
endocrine disorders, medication and multitude of disorders affecting Dysgeusia begins
nasal and oropharyngeal region [4]. Radiation dose > 3000 cGy Xerostomia (permanent) and
The role of dental professional is to assess nutritional status, oral Dysgeusia, saliva is thick, more
acidic, altered flora
implications causes of complaints provide guidelines and refer to
appropriate provider [34]. Radiation dose > 5000 cGy Trismus,Concerns for Osteo
radionecrosis
Our capacity to taste and smell allows us to distinguish the flavour
and aroma of food or drink, whether pleasant or unpleasant. Radiation dose > 6000-6500 cGy Significant concerns for
Osteoradionecrosis
Indeed alterations in these senses significantly impact our quality
of life [35]. Nutrition risk may be minimized or avoided with early [Table/Fig-7]: Effects of radiation pertaining to dosage
intervention, proper diet instructions and referral to appropriate
Most common cause for osteoradionecrosis preclude radiation
health professional.
dose higher than 65-75 Gy [Table/Fig-7] [39]. Trauma can be a
Dental caries and Periodontitis pathophysiology in theory of infection and radiation. Unrepairable
Patients with terminal end stage are usually prone to caries and teeth due to caries, periodontal disease or root lesions can cause
periodontitis, with most common reasons being radiation therapy infection to bone and progress to osteoradionecrosis. Abuse of
which in turn causes changes in salivary flow, decreased pH, alcohol and tobacco are identified as risk factor for the same.
reduced buffering capacity, increased viscosity, reduced cleansing The classification for Osteo radionecrosis was given by Clayman
based on the overlying mucosa being intact or not.
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Type 1- for the cases in which lysis of bone occurs under intact proper oral hygiene depressed patients often present with increased
gingiva. rate of dental caries, periodontitis and halitosis. Faced with these
Type 2- more aggressive type called as “Radiation osteomyelitis” conditions, even the near and dear ones will refrain them which in
when there is soft tissue break down, exposing the bone to saliva turn imposes severe negative impact. Therefore, it is imperative for a
with secondary contamination [40]. dentist to promote good oral hygiene.
The concept of “three H” (hypoxic, hypovascular, hypocellular) Role of dentist in palliative team from inception till
of Marx is well accepted [41]. Marx and Johnson found physical date
diagnostic signs to correlate with increased degrees of radiation Palliative dental care is a novel emerging branch, which provides
tissue injury which are described as follows: 1) induration of tissue symptomatic relief to the terminal end stage patients. The key role
2) mucosal radiation telengiectasias 3) loss of facial hair growth of dentist in palliative team was enlightened only since 2006 and
4) cutaneous atrophy 5) cutaneous flaking and keratinization 6) accordingly in the present article, literature search was made from
profoundness of xerostomia 7) profoundness of taste loss [42]. inception till date.
Radiological investigations may include Orthopantamography The role of dentist in the management of oral complications either
(OPG), Computed tomography, magnetic resonance imaging, due to progressive far advanced disease or by its treatment can
positron emission tomography and radionucleide bone scanning be managed through various modalities. Comprehensive clinical
with 99mTc-MDP and Near infrared spectroscopy. examination of the extra and intra oral soft tissues, periodontium
Precautions to be followed in averting complications of radiotherapy and dentition is essential. High patient awareness and motivation
at hospice of head & neck cancer patients [43,44]: are essential to minimize potentially devasting dental complications.
Oral care protocols should strive to maintain the integrity of oral
Precautions to be followed prior to Radiotherapy mucosa and lips, prevent caries and periodontal disease, alleviate
• Oral prophylaxis. oral pain and discomfort and prevent or treat infectious complications
• Extract teeth with more than 4-6 mm pockets, grade-II mobility [50,51].
and furcation involvement. Oral mucositis is a prime complication which surpasses through
• Remove partially erupted third molars and carious teeth with various degrees of severity and accordingly the treatment focuses
periapical lesions. on palliation with administration of systemic opiate analgesics
• Weekly dental checkups during radiation therapy and three for moderate to severe mucositis pain, topical anesthetics and
month dental checkups, possibly lifelong. mucosal coating agents such as lidocaine, benzocaine, dyclonine,
• Restore all dental caries. diphenhdramine,doxepin and benzydamine for moderate pain,
and bland rinses for mild pain [52]. Other agents also has been
• Antibiotics may be necessary for surgical procedures. investigated with variable responses like oral capsaicin, oral
• Avoid removable or fixed prosthesis for six months before or sulfasalazine and growth factor mouth washes. The novel clinical
after radiotherapy. trials have been carried on Olive leaf extracts and sedative hypnotics
• Precautions to be pursued after Radiation Therapy. like ketamine in the form of mouth washes with its pronounced
• First three month dental checkups, possibly lifelong. analgesic and anesthetic properties [53,54]. Similarly xerostomia
a debilitating condition for terminally ill individuals was treated
• Restore all dental caries.
conventionally by stimulating agents like sugar free chewing gums,
• Endodontic treatments can be done. later secretagogues like cevimeline, pilocarpine and oral moisturize
• Antibiotics may be necessary for surgical procedures. rs,lubricants,artificial saliva and bedside humidifiers were employed
• Avoid removable prosthetics for six months. [55]. Novel approaches like acupuncture and trans cutaneous
electric nerve stimulation (TENS) which increases the amount of
• Crown and bridge can be given after six months of
calcitonin gene related peptide (CGRP) which in turn increases the
radiotherapy.
salivary flow [56], Gene transfer(Recombinant technology) and GTR
Ruggiero et al., concluded combination of antibacterials, antifungals (guided tissue regeneration) two novel areas of exploration which
and antivirals as the combined pharmacological therapy for could repair the damaged salivary parenchyma [57]. Artificial type
osteoradionecrosis [45]. of salivary glands with use of irradiated NIH 3T3 fibroblasts which
serve as feeding layer are also in process. Short span edentulous
Psychological changes in palliative patients areas should be restored by fixed partial dentures with supragingival
Psychological distress is the term applied predominantly to
margins as it reduces mucosal contact and further irritation [55].
anxiety, phobic and depressive symptoms [45]. The most common
Removable partial dentures should be designed with minimal tissue
psychological problems for elderly requiring a palliative approach
coverage with modified de van clasp at the end of flange which
are depression, confusion and anxiety, with depression being one
would be more suitable. Zinc oxide Eugenol and impression plaster
of the most prevalent psychiatric problems among older persons in
should be avoided rather as they adhere to dry mucosa which
general [46].
cause burning sensation and severe irritation, it should be replaced
Therefore, the interactive effects of psychological and physical well by silicone impression materials as they are well tolerated [58].
being need to be carefully considered. By the time the patients reach
The treatment of candidiasis was formerly treated with polyenes
palliative care stage, they have typically gone through the process of
and azoles however new emerging technologies in dentistry have
investigation, diagnosis and treatment with varying degrees of pain
been replaced with echinocandins which are large lipopeptide
and trauma, dependency and disfigurement, following the diagnosis
molecules that inhibit synthesis of 1, 3-d-glucan which is essential
of life threatening illness, many patients experience shock punctuated
component of many fungi [59]. Presently Caspofungin, micafungin
by periods of dysphoria, anxiety, fatalism and grief [47]. Palliative care
and anidulafungin are echinocandins which have been used
psychiatry often focuses on emotional and social issues that arise
extensively. A once daily dosing regimen can be given through IV
in someone who is receiving hospice or palliative care. Depressed
Loading dose of caspofungin 75mg day 1 followed by 50mg/ day
patients are prescribed antidepressants which are used for pain
and anidulafungin 200mg loading dose on day 1 followed by 100
palliation and many of these medications cause xerostomia. Dentist
mg/day [60]. Higher salivary candidal levels are encountered in
should guide the physician in choosing a saliva sparing antidepressant
denture wearers than in dentate patients. Soaking the denture in
like amitriptyline which is more xerogenic [48,49]. Because of lack of
bleach (15ml), water (250ml) and benzalkonium chloride for 30min
4 Journal of Clinical and Diagnostic Research. 2014 Jun, Vol-8(6): ZE01-ZE06
www.jcdr.net Bhavana Sujana Mulk et al., Palliative Dental Care - A Boon for Debilitating

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PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Oral Medicine & Radiology, Drs Sudha and Nageswararo, Siddhartha Institute of Dental Sciences,
Chinaoutpalli, Gannavaram Mandal, Andhra Pradesh, India.
2. Assistant Professor, Department of Oral Medicine & Radiology, Drs Sudha and Nageswararo, Siddhartha Institute of Dental Sciences,
Chinaoutpalli, Gannavaram Mandal, Andhra Pradesh, India.
3. Professor & HOD, Department of Oral Medicine & Radiology, Drs Sudha and Nageswararo, Siddhartha Institute of Dental Sciences,
Chinaoutpalli, Gannavaram Mandal, Andhra Pradesh, India.
4. Professor, Department of Oral Medicine & Radiology, Drs Sudha and Nageswararo, Siddhartha Institute of Dental Sciences,
Chinaoutpalli, Gannavaram Mandal, Andhra Pradesh, India.
5. Associate Professor, Department of Periodontics, Lenora Institute of Dental Sciences Internal Rd, Konthamuru, Rajahmundry,
Andhra Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Sujana Mulk Bhavana,
Assistant Professor, Department of Oral Medicine and Radiology, Drs Sudha and Nageswara Rao
Siddhartha Institute of Dental Sciences, Chinaoutpalli, Gannavaram Mandal, Andhra Pradesh, India. Date of Submission: Feb 12, 2014
Phone: 09666648325, 09493245173, E-mail: sujana_55@yahoo.com Date of Peer Review: Mar 24, 2014
Date of Acceptance: May 02, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Jun 20, 2014

6 Journal of Clinical and Diagnostic Research. 2014 Jun, Vol-8(6): ZE01-ZE06