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Release: April 12, 2000

NOTE TO EDITORS: Ronald Ettinger's D.D.Sc. below reflects the doctorate in dental science that he received at the University of Sydney in Australia.

End-of-life care project features oral health component

IOWA CITY, Iowa -- University of Iowa dentistry and public health faculty are working together to address oral health care for people near or at the end of life, an issue often overlooked in discussions about end-of-life care for elderly or terminally-ill patients.

The oral health component is part of "Improving End-of-Life Care in Iowa," a statewide, interdisciplinary coalition of health care professionals, policy makers, educators and the public based at the UI College of Public Health. Supported by a three-year, $350,000 grant from the Robert Wood Johnson Foundation, its goal is to identify end-of-life issues, get feedback from caregivers and communities, and shape policy for improving care for the dying in Iowa. Douglas Wakefield, Ph.D., UI professor and head of health management and policy, leads the coalition.

"Oral health concerns don't get much attention when considering end-of-life care," Wakefield said. "Yet oral health profoundly affects diet and nutrition, medication use, pain management and the overall quality of life of dying patients."

UI dental faculty, led by Cathy Watkins, D.D.S., Ph.D., and Howard Cowen, D.D.S., both UI assistant professors of preventive and community dentistry, and Ronald Ettinger, D.D.Sc., UI professor of prosthodontics, are leading the coalition's work group on oral health. The group is conducting a survey of Iowa dentists to gauge their current understanding and participation in end-of-life care. The researchers want to determine how many of Iowa dentists' patients are near the end of life, live in a nursing home or hospice, or receive home health care. They also are interested in how many of the state's dentists actually travel to an end-of-life patient's home to deliver care.

"We know that most dentists are not doing house calls as a rule," Watkins said, "but we're getting responses from 11 to 15 percent who say they go out to treat a patient when they're called, all without reimbursement."

Medicare does not cover dental costs, and Medicaid has minimal coverage, Watkins said, but she noted that while the lack of reimbursement is an issue, the lack of awareness of oral health problems at the end of life among all health disciplines and the public is just as important.

A range of oral symptoms can accompany terminal illnesses -- some caused by the disease itself, others by medications. These can include dry mouth, mouth sores, difficulty speaking from loose dentures, and yeast infections. Yet dying patients and their families often overlook the fact that dental care is an option late in life, assuming that diminished oral health is untreatable or simply part of "getting old."

"It's not uncommon to see terminally-ill or elderly patients who've lost so much weight that their dentures don’t fit well. Or they are taking medications that can cause dry mouth and they cannot speak well," Watkins said. "Realigning dentures, repairing a crown or providing an artificial saliva for the dryness can go a long way toward making things more comfortable for the patient in terms of eating or speaking. We're not talking major mouth reconstruction, but relatively simple steps that are cost-effective and help the patient."

Many nursing homes and hospices have agreements with oral health professionals in their communities to provide care on an on-call, as-needed basis. With end-of-life patients, however, oral health professionals typically are called if there is an emergency or when the patient finally reaches a critical point, Watkins said.

"We don’t have a good mechanism to include oral health professionals as part of the end-of-life care team," she said. Watkins added that the Iowa Dental Association and other state health officials are looking into policies that would address reimbursement issues and improve access to oral care for end-of-life patients in nursing homes and hospices and for those who receive home health care. Another improvement would be for dentists and hygienists to provide assessments or dental record reviews to help determine if an end-of-life patient needs treatment.

Asking end-of-life patients directly about their oral health status also would benefit patients, Wakefield noted. "'How are the dentures fitting?' or 'Are you having any hot-cold sensitivity?' These questions are not routinely asked by professionals in the other health disciplines," he said.

The UI is home to the nation's first and oldest geriatric dental education program, which began in the 1970s. Nearly all UI dental students learn about geriatric oral health issues, and a course on end-of-life care is offered as part of the college's third-year curriculum. Wakefield noted that of all the grant applications to the Robert Wood Johnson Foundation for end-of-life care projects, the UI proposal was the only one to have an oral health component.

In terms of oral health, "end of life" could mean anywhere from the last two years to the last six months of life, Watkins said, which is why improving the quality of life for an elderly or terminally-ill patient is so important.

"Obviously, people are not dying from dental pain," she said, "but when you transition from a curing model to a caring model -- which is what we do as caregivers when a patient nears the end of life -- the focus is on providing comfort. Maintaining these patients' oral health so they can comfortably eat, speak and smile can make a major contribution to the quality of a patient's end of life."

University of Iowa Health Care describes the partnership between the UI College of Medicine and the UI Hospitals and Clinics and the patient care, medical education and research programs and services they provide.