Oral Health Problems

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

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Overview of Palliative Care Services in Canada
Why is it that people, in general, do not want to think about the end of their life journey?
We all know that our journey will end in death. Yet, most of us do not have any plans in place which can make it very difficult for those we leave behind. We need to look at the barriers and find solutions to Palliative Care so that all Canadians, regardless of where they live, could have access to quality care that would make their end-of-life experience as comfortable as possible.
In Canada, most individuals have access to universal healthcare. This universal healthcare, includes Palliative Care, which most people do not want to think about until they are forced into a situation. Usually, this happens when they or a member of their family are referred to Palliative Care when dealing with an end-of- life crisis. According to Wister and McPherson (2014), “Since the 1970s, many provinces and many communities have created
integrated  Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Oral care is important for patients’ health and well-being for a variety of reasons. Not only is the mouth vital for eating, drinking, taste, breathing, verbal and non-verbal communication, saliva also has antibacterial properties and is part of the body’s defence against infection.Poor oral hygiene is well known to be associated with painful, unpleasant diseases such as gingivitis (Fig 1), dental caries, halitosis and xerostomia and, more recently, has been linked to chest infections and pneumonia (Ministry of Health, 2004). Box 1 gives a glossary of oral health terms.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Box 1. Glossary of oral health terms

Cheilitis– reddened, crusting or bleeding area.
Debris– dead, diseased or damaged tissue and any foreign material that is to be removed from a wound or other area being treated.
Dental caries – a plaque-induced disease caused by the complex interaction of food, especially starches and sugars, with bacteria that form dental plaque.
Dental plaque – a biofilm composed of microorganisms that attaches to the teeth and causes dental caries and infections of the gingival tissue.
Gingivitis– a condition in which the gingival margin around the teeth may be red, swollen and bleeding.
Halitosis– offensive breath commonly caused by poor oral hygiene, dental or oral infections.
Oral candidiasis – also known as oral thrush, this common fungus can become prevalent when the natural fauna and flora of the body are unbalanced (Fig 2, image attached).
Oral hygiene – the condition or practice of maintaining the tissues and structures of the mouth in a healthy state.
Stomatitis– inflammation of the oral cavity with or without ulceration.
Tartar– hardened plaque adhered to teeth.
Xerostomia – dryness of the mouth caused by reduced saliva secretion.
The Essence of Care (Department of Health, 2001) highlighted oral hygiene as a priority, acknowledging it as an indicator of the standard of patient care. The importance of oral care for good communication and nutrition should not be underestimated.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Nutrition is one of the key skills highlighted in the essential skills clusters (NMC, 2007). Assessing factors that influence patients’ nutritional state are key objectives for improving care, although oral care is not specifically identified. However, oral problems can lead to reduced dietary intake and increase the possibility of malnutrition (World Health Organization, 2007).

Inadequate oral care can be detrimental to social and emotional well-being and adversely affect interaction with others (Rawlins and Trueman, 2001). Poor oral hygiene also increases the risk of infection (British Society for Disability and Oral Health, 2000). This risk is often significantly underestimated, resulting in lower priority for oral care compared with other nursing activities (Furr et al, 2004).

In 2007, 50% of UK adults attended an NHS dentist. Older people in residential care are at considerable risk of oral infection, with infection identified in 80% of one study population (Nicol et al, 2005). There are indications that 69% of adults may have periodontal disease (Xavier, 2000). With current regional dental attendance ranging from 40% in southern areas to 60% in the North East (DH, 2007), it is reasonable to assume that many patients might have pre-existing poor oral health before contact with health services.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

A healthy mouth
Oral health is defined by the WHO (2007) as: ‘Being free of chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, periodontal (gum) disease, tooth decay and tooth loss, and other diseases and disorders that affect the mouth and oral cavity.’

The mouth’s primary functions are the mastication of food and communication, both of which involve the lips, tongue and teeth or dentures and need adequate salivation (Rawlins and Trueman, 2001). In a healthy mouth, oral mucosa and the tongue should be pink and moist, with smooth and moist lips and clean teeth or well-fitted dentures. Difficulties with swallowing or eating may make it hard to maintain the mouth’s healthy condition, as build-up of debris can alter its pH and inadequate dietary intake can reduce salivary flow.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Infection
Saliva is essential for keeping oral infections at bay. Its protective, antibacterial properties maintain a healthy balance of resident bacteria, which include Staphylococcus and Candida, and it is also responsible for washing away debris and food particles (Cooley, 2002).

Inflammation and infection can occur as a result of reduced saliva production, with the accumulation of debris forming plaque on teeth at the gum line, which leads to gingivitis, dental caries or periodontal disease. The process decalcifies teeth leaving microscopic crevices that can harbour pathogenic organisms, which can lead to abscess formation (Xavier, 2000).

Oral infections can present as sore, reddened areas or swelling. Fungal infections often present as creamy white coatings or yellow curd-like mounds that are easily removed, sometimes leaving bleeding areas that quickly become recoated (Arkell and Shinnick, 2003). Patients can complain of soreness or difficulty swallowing and are at risk of systemic fever if the infection remains untreated.

Risk factors
Certain medications and predisposing conditions can put patients at increased risk of poor oral hygiene. Dependent, dysphagic, critically or terminally ill people are particularly vulnerable (BSDOH, 2000).

Age
Older people and very young children may have difficulty managing their own oral care due to problems with dexterity, as well as being unable to tell their carer when they are in pain. Additionally, denture wearers are at increased risk of chronic atrophic candidosis (denture stomatitis) as the acrylics within the dentures provide favourable conditions for Candida albicans (Arkell and Shinnick, 2003).Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Mental health
Those with mental health problems may not have an awareness of the need or importance of oral care and may also be unable to express to health professionals when they have problems.

Poor diet
Inadequate dietary intake reduces the secretion of saliva, while a lack of sufficient vitamins and minerals can predispose patients to infection (BSDOH, 2000) and malnutrition.

Medical conditions
Immunosuppression related to conditions such as HIV, leukaemia, diabetes and cancer and their associated treatments, including radiotherapy, can impact on hydration and natural flora of the oral cavity, putting patients at risk of infection or malnutrition. Dehydration or the absence of oral intake will reduce the protective production and function of saliva (xerostomia).

Medications
Medicines that can alter the fauna and flora of the oral cavity by reducing protective salivary secretion include:

Anticholinergics;
Antiemetics;
Antibiotics;
Diuretics;
Antihypertensives;
Anticonvulsants;
Antidepressants;
Antispasmodics;
Analgesics – particularly opiate based.
Medicines that suppress the immune system include:

Steroid therapy;
Chemotherapy.
Oxygen has been noted to have a drying effect on the mucosa.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Learning and physical disabilities
Some patients may be unable to carry out oral care or express their problems with it (Bollard, 2002). Medications given in syrup form, in addition to a tendency to mouth breathe, can result in dental caries and xerostomia. Those with severe and profound learning disabilities may have behavioural problems with biting that make their oral hygiene difficult to maintain (Bernal, 2005).

Unconscious, intubated patients
The oropharynx of critically ill patients becomes colonised with potential respiratory pathogens (Furr et al, 2004). This study said oral care had been shown to reduce oropharyngeal bacteria and ventilator-associated pneumonia.

Mouth breathing is common in unconscious patients, putting them at risk of xerostomia.

Assessment
The purpose of oral care should be to keep the lips and mucosa soft, clean, intact and moist. Cleaning the mouth and teeth (including dentures) of food debris and dental plaque should alleviate any discomfort, enhance oral intake and prevent halitosis (Fitzpatrick, 2000). These activities should also prevent oral infection, although treatment for this may be required (Arkell and Shinnick, 2003).Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Assessment is needed to identify and initiate interventions and evaluate progress. This requires an understanding of related anatomy and physiology yet there appears to be a lack of nursing knowledge about oral care (Evans, 2001). Assessment can also be hindered by reluctance and nurses’ perceptions about oral care (Clay, 2000).

Several assessment tools have been proposed but evidence is limited on their effect (Cooley, 2002). The Jenkins oral calculator (1989) includes identification of at-risk patients; however, the interpretations are subjective, which can influence the tool’s validity and reliability.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

White (2000) identified that the state of the oral mucosa, teeth, inner and outer surface moistness as well as lip softness should be recorded. These are consistent with other oral assessment tools (Eilers et al, 1988) and these observation details are included in Xavier’s (2000) tool adaptation. Lockwood’s (2000) oral assessment tool combined less specific oral structure assessment than other tools and omitted speech ability but included quite specific details with grading on many of the risk factors.

Vocal assessment and swallowing reflex were incorporated into Eilers’ (1988) tool, although nurses are not usually involved in these assessments as patients are commonly referred to speech and language therapists. Nutritional assessment occurs during most admission procedures and many trusts use the Malnutrition Universal Screening Tool (MUST). This tool, designed by the British Association for Parenteral and Enteral Nutrition, includes a swallowing assessment for ability to maintain oral intake (Elia, 2003). The ability to assess swallowing is a required outcome in the essential skills cluster for nutrition (NMC, 2007) and linking the oral assessment to this would provide a holistic model of care.

The consistent application and use of tools in nursing practice has frequently been reported as problematic (Perry, 2009). Applying assessment tools in oral care must be consistent to improve reliability and validity but this will only occur with staff education in their use.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

Inadequate assessment and poor knowledge leads to uninformed choice of equipment and techniques in oral care (Evans, 2001). On the other hand, early assessment and intervention reduces the incidence of infection and oral complications (Ministry of Health, 2004) and oral assessment should occur on admission or initial referral (DH, 2001).

The evidence for clinically effective oral care is available (Bowsher et al, 1999) but implementation depends on proper assessment.Oral Health Problems Among Palliative and Terminally Ill Patients Essay

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