ROLE OF ORAL MEDICINE SPECIALIST IN PALLIATIVE CARE

The palliative doctor gives the „touch of God‟ as he/she takes care of the terminally ill patient. Palliative care for the terminally ill is based on a multidimensional approach to provide whole-person comfort care while maintaining optimal function. The oncologist encounters great difficulties in managing oral cavity problems of these patients. It is ideal that palliative care team should include specialists from various fields to provide comprehensive overall care to the patient. The dental or oral medicine specialist can play an important role in alleviating both the physical and psychological pain of dying and in treating the effects caused due to chemotherapy and radiotherapy. In this article, a brief attempt is made to list a few areas in which an oral medicine specialist can help other members of the palliative care team and also the patient in leading a better life. WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES S SJIF Impact Factor 6.647 Volume 6, Issue 4, 947-958 Research Article ISSN 2278 – 4357 *Corresponding Author Dr. Chandhini Begum N. Post Graduate Student, Department of Oral Medicine and Radiology, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India. Article Received on 22 January 2017, Revised on 14 February 2017, Accepted on 05 March 2017 DOI: 10.20959/wjpps20174-8661


INTRODUCTION
Cancer of the oral cavity is the sixth leading cause of cancer worldwide and India is said to have the major number of oral cancer patients, the leading etiological factor being the use of tobacco which is consumed particularly in the smokeless form. Palliative care is defined by the WHO as "the active total care of the patient whose disease is not responsive to curative treatment". [1] Palliative care is a specialized area of healthcare which focuses on relieving and preventing the suffering of patients. Patients with oral cancer often have a complex and prolonged course of illness due to both the patterns of disease recurrence and the adverse effects of treatments that is marked by periods of freedom from disease and symptoms interspersed with bouts of serious illness, debility, and numerous physical and psychological symptoms including pain, dysphagia, disfigurement, weight loss, depression, and xerostomia. Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients, but alleviation of symptoms and improving the quality of life in such patients is of paramount importance.
Dentists most frequently encounter patients who may be anxious or in pain, and are sensitised by the nature of the profession to be compassionate and excellent communicators. Palliative care dentistry was defined by Wiseman as "the study and management of patients with active progressive and far advanced disease in whom the oral cavity has been compromised either by the disease directly or by its treatment; the focus of care is quality of life". [2] Mouth is the most important of expression of any disease and is most affected during the later stages of disease. The consequences of an unhealthy or painful oral cavity have a great impact in the quality of life. Not only are there physical implications of reduced oral intake and weight loss but also there may be psychological effects due to impaired communication  Communication with family and other professionals

ORAL CONSIDERATIONS IN PALLIATIVE CARE
The basic principle of oral care in palliative care is that good oral hygiene is the fundamental for oral integrity. Care of the oral cavity is considered one of the most basic of nursing activities and palliative care patients are especially susceptible to various oral problems. The management of such problems should be carried out in a systematic way in order to relieve the patient"s symptoms.

Palliative care may be required in the following conditions such as ORAL PAIN
Pain is the most common and dreaded symptoms of cancer. 90% of cancer pain is directly related to the tumor or its therapy whereas 10% of it is related to any unknown illness. Many Pain management may be local, systemic, or both. Patients with severe pain may require parenteral opioid therapy during the maximum period of mouth pain. Pain may be managed by the use of topical analgesics to reduce somatic pain, or topical anaesthetics to numb the painful tissues. The WHO has adapted the three step ladder which is presented as the most efficient way to manage cancer pain5.

A) TOPICAL TREATMENT OF ORAL PAIN I). Localized pain
a. Choline salicylate gel is used if the pain is localized.
b. Topical local anaesthetics have a definite but limited role in the management of oral ulceration and should be reserved for severe pain (e.g. Chemotherapy-or radiotherapyinduced mucositis). Lidocaine (lignocaine) 5% ointment or 10% spray is suitable for use.
c. Carmellose paste provides a protective barrier over the ulcer site.

II) Diffuse oral pain
a. Benzydamine mouthwash or spray (a nonsteroidal anti-inflammatory drug) may be useful if the area is more extensive.
b. Diclofenac dispersible tablets can be used as a mouthwash, and the oral cavity should be rinsed before swallowing.
c. Topical morphine can be considered for severe pain. Morphine sulphate10 mg/5 ml solution can be used as a mouthwash.
d. Carbenoxolone provides a protective barrier over the ulcer site, but there is little evidence for its use.
e. Gelclair is a novel viscous gel that forms a protective film round the entire oral cavity (mechanical protection).

ORAL MUCOSITIS AND STOMATITIS
Oral mucositis is described as the inflammation of oral mucosa resulting from chemotherapeutic agents for oral cancer or due to ionizing radiation. Mucositis typically manifests as erythema or ulcerations resulting from the exposure of the underlying connective tissue to the oral environment. It is a major cause of morbidity in cancer patients. The oral mucosa in the path of radiation first appears hyperaemic and oedematous and as the treatment continues, the mucosa becomes denuded, ulcerated and covered with a fibrinous exudate leading to mucositis. Oral mucositis can lead to great deal of discomfort, pain, difficulty in mastication, dysphagia and sometimes secondary infection can occur. [8]  Most people with drug-induced dry mouth respond after the first dose.

CANDIDIASIS
The incidence of candidiasis in palliative care patients has been estimated to be 70% to 85%.
Poor oral hygiene, xerostomia, immunosuppression, use of corticosteroids or broad-spectrum antibiotics, poor nutritional status, diabetes and the wearing of dentures are considered as predisposing factors for fungal infections. Candida albicans is the most common organism in candidiasis.
Higher salivary levels of candida are more frequently encountered in denture wearers than in dentate patients. Soaking the denture in bleach (15 mL) and water (250 mL) for 30 minutes will help rid of the denture odours. Dentures can also be soaked in benzalkonium chloride and systemic applications [11] ( Table 4). Due to the association of adverse effects like tardive dyskinesia and xerostomia, conventional can hence be advised for palliative care patients. Rehabilitation of missing teeth can be done to improve masticatory efficiency depending upon the patient"s compliance. [14]

PSYCHOLOGICAL CHANGES IN PALLIATIVE PATIENTS
The most common psychological problems for patients requiring a palliative approach are depression, confusion and anxiety. It is important to distinguish between normal levels of sadness and abnormal levels of depression. Therefore, the interactive effects of psychological and physical well-being need to be duly considered. By the time the patients reach palliative care stage, they would have already gone through the process of investigation, diagnosis and treatment with varying degrees of pain and trauma, dependency and disfigurement, following the diagnosis of their illness.
Cancer patients who undergo high dose chemotherapy or radiation can experience fatigue, either related to their disease or its treatment. These can produce insomnia or metabolic disorders, which collectively contribute to compromised oral status. It is prudent to support the patient during the periods of fatigue and frustration. Reassurance that the feelings are normal and that it will improve in time should be balanced with gentle but firm encouragement and the patients must be encouraged to continue the mouth care practices even when they seem to have no energy. Demonstration of empathy by eye contact or gentle touching of the patient"s hand or shoulder can help to a great extent in gaining patient"s confidence and it helps to support patient emotionally. [15] Palliative care psychiatry focuses on social and emotional issues that arise in someone who is receiving hospice or palliative care. Depressed patients are prescribed antidepressants which are also used as adjuvants for pain palliation and many of these medications cause xerostomia. Dentist should guide the physician in choosing a saliva sparing antidepressant like amitriptyline which is more xerogenic16. Because of lack of proper oral hygiene depressed patients often present with increased rate of dental caries, periodontitis and halitosis. Due to these conditions, even the near and dear ones will often refrain them which in turn imposes severe negative impact. Therefore, it is imperative for a dentist to promote good oral hygiene and referral to a specialist for psychological counselling.

CONCLUSION
Palliative care dentistry is an evolving branch and gaining immense importance in this advancing world. In terminal care, examination and re-examination of the mouth is a very important task. Oral problems are common complications of cancer treatments, and are highly prevalent in palliative care patients. They are often overlooked, or perceived as trivial, but if ignored causes great distress, pain and discomfort, interfere with appetite, taste, chewing, swallowing, nutrition, speech, social interactions, and sleeping. The palliative care dentist should focus on the elimination of these problems and appropriate actions must be instituted to alleviate symptoms, minimize pain and suffering and provide symptom control.
Dental professional are the important members of extended palliative team17 and they have number of key roles, including (a) training of palliative care professionals, (b) management of complex oral problems, and (c) management of specific oral problems. Increased awareness by all health care professionals of palliative oral care would go a long way in providing relief, comfort, and consolation to terminally ill patients as well as their families. It should be kept in mind that palliative care of such patients should also involve a multidisciplinary approach that addresses the physical, emotional, social and spiritual concerns of the patient.