Dr. Xi Chen, assistant professor in Department of Dental Ecology, led a study that has been published as the cover story in the Journal of the American Dental Association (JADA) examining dental care issues for frail older adults in the last year of life.
The study was the first to examine the dental treatment provided to chronically ill long-term care residents in the last year of life. Researchers found that although oral health was poor in the 197 patients retrospectively evaluated, more than half of those examined received no dental care leading up to death. However, of those who received treatment, 62.9 percent received usual care instead of limited care focusing on pain and infection. Researchers also found that having dental insurance coverage significantly increased the likelihood of a patient’s receiving dental care before death. There was no correlation between patient’s oral health conditions and how much care they received.
“Essentially what we learned was that this most vulnerable group seems to either receive no care – and subsequently suffer dental-related pain and infection before death – or receive more care than is needed to maintain their quality of life for their life stage,” explained Chen. “Both are a concern from a public health perspective.”
The dying process can linger up to a year or longer in patients with chronic diseases or advanced frailty. During this process, severe dry mouth, repetitive oral pain and oral infection may substantially affect a patient’s quality of life. Poor oral hygiene and oral infection may also cause severe, and sometimes fatal, systemic complications such as aspiration pneumonia. Impaired chewing function and swallowing disorders can also further aggravate malnutrition and accelerate the terminal decline.
“To that end, it’s essential to prevent oral pain and infection, and to maintain good oral health in those with serious illnesses. Although oral diseases and conditions are highly prevalent, oral health is often neglected among these individuals, especially in cognitively-impaired patients who lose language function to report pain,” said Chen.
Conversely, Chen’s study shows that among those who received dental treatment prior to death, nearly two-thirds received comprehensive treatment that would be expected in a healthy elderly patient, including multiple tooth fillings, extractions and/or new denture treatment. More than 60 percent of those patients had their treatment completed within the last three months of life.
“Given the short survival time of such a great percentage of those patients, some may have never benefited from these treatments, which raises a concern for better use of our society’s limited health care resources given many have government-subsided dental insurance. These futile treatments can also invoke unnecessary pain, discomfort and physical distress, increase the risk of systemic complications associated with dental treatment, and sometimes even cause death in seriously-ill patients,” explained Chen.
Chen continued, “Our basic recommendation is that we, as a profession, more closely examine palliative oral health care in patients with serious illnesses. Oral health care needs to be considered within a larger context and be included as a part of overall care plan. A new care model which enables physicians, dental professionals, nurses and other palliative care staff to work more closely is a possible solution to the wide disparity in provided dental care at the end of life.”
The study was published in the November 2013 issue of JADA. Full text of the study is availablehere. Other authors include Dr. Hong Chen, UNC School of Dentistry Department of Endodontics; Dr. John Preisser, UNC Gillings School of Public Health Department of Biostatistics; Mr. Christian Douglas, a Ph.D. student studying biostatistics at the UNC Gillings School of Public Health; and Dr. Stephen Shuman, University of Minnesota School of Dentistry Department of Primary Dental Care. This study was supported through funding from NIH/NIDCR and internal funding from UNC.