Oral health in palliative care: perceptions of public dental practitioners in Sydney, Australia

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Villarosa, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6356426/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Poor oral health among people receiving palliative care is often overlooked among health professionals. Little is known about the experiences of dentists and the potential for an oral health model of care in the palliative setting. Methods: A focus group with 21 dentists was conducted in a public oral health service in Sydney, Australia. The focus group was audio-recorded, transcribed, and thematically analysed. Results: Three themes were identified: Awareness of oral health in palliative care; Challenges to providing oral health care; and A new model of care. While good oral health was perceived to be essential to palliative care management, there were key challenges that prevented adequate delivery of dental treatment. Participants highlighted the need for a new model of care in the future to include interdisciplinary training alongside the dissemination of appropriate protocols for dental training and streamlining referral pathways to prioritise people who may require more urgent dental treatment. Conclusion: Australian dentists working in a public dental service lack insight into planning dental care for palliative patients. Dentists show positive attitudes, but systemic barriers and training limit care provision. A palliative oral health care model is essential with interdisciplinary training, streamlined referrals, and teledentistry for urgent cases. Clinical Relevance The need for palliative care services is increasing in Australia due to an ageing population. Oral health problems are prevalent among palliative patients and impact their quality of life. However, the experiences and perspectives of dentists offering care to palliative patients in Australia remains poorly understood. Our study reveals challenges experienced by dentists in this context, identifies key systemic barriers, and discusses the need for integration of dental and palliative care services. Streamlined referral procedures, with the help of guidelines and protocols, will help provide optimal care and ensure better quality of life in this population. Nursing Dentistry Palliative hospice end-of-life dental oral health Introduction A primary goal of therapeutic interventions for people with life limiting illness is to improve the quality of life through addressing symptoms and improving comfort at end-of-life.( 1 ) Poor oral health can have a significant impact on the quality of life of people with a life limiting illness, but it is often overlooked.( 2 – 4 ) In one study, a majority of informal caregivers reported infrequently evaluating the oral status of their care recipients and over 10% stated that they never assessed oral health even though caregivers were aware of the importance of oral health.( 5 ) Due to their declining health, people receiving palliative care may experience xerostomia (dryness of mouth) which can also cause dry lips, changes in taste and speech, increased sensitivity ( 6 ), denture-related problems such as denture sores and increased frequency of painful oral infections such as mucositis and candidiasis.( 7 ) Oral health problems may be further exacerbated by the patient’s cognitive or physical decline, leading to inadequate oral self-care.( 8 , 9 ) People undergoing palliative care with advanced disease progression may also experience tongue inflammation and dysphagia ( 10 ), reducing their ability to speak, consume food and drinks. In the long term, this can contribute to malnutrition and weight loss, deteriorating their overall health and quality of life.( 11 ) Dental treatment has the potential to improve the oral health of people receiving palliative care.( 7 ) Some studies have demonstrated that prophylactic professional oral health care, including scaling, professional cleaning of teeth and brushing instructions can prevent deterioration in the oral health of people receiving palliative care.( 12 ) However, one of the major barriers people experience to receiving professional care is access to dental services.( 13 ) The reasons for poor rates to accessing dental care are complex, and may be attributed to lower prioritisation by families, financial costs, difficulties with mobility or transport and increased psychological issues.( 3 , 14 , 15 ) Despite the demand for dental treatment among people receiving palliative care, there are some barriers to dentists delivering care. American dentists have reported that their professional training did not adequately equip them to address the complex needs of people with a life-limiting illness.( 16 , 17 ) Inadequate training and experience managing the oral health needs of people receiving palliative care could contribute to poor access to dental care if few dentists are confident to provide dental treatment. Although the need for dental professionals to provide dental care to people receiving palliative care s is not a new concept, it is becoming increasingly relevant in the context of an aging population where people have greater life expectancies but also more complex chronic medical conditions.( 18 , 19 ). To meet the evolving healthcare landscape in Australia, it is important to ensure that dental services are adapted to address the dental needs of palliative care patients. However, little is known of the barriers and challenges that face dental professionals in the palliative care setting in Australia. Although some surveys have identified the practices, needs and barriers of dentists within a palliative setting in other developed countries ( 16 , 17 ), there is currently no published literature exploring the perceptions of dentists in Australia. Understanding the experiences and challenges that contribute to the practices and attitudes of Australian dentists to treat people receiving palliative care is an important step to integrating dental care as part of the holistic care for this population. The aim of this study was to examine the perceptions of public dental practitioners providing oral health care in the palliative care setting. Materials and Methods Study Design A focus group was conducted as part of a descriptive qualitative design to explore the perceptions of dentists providing care in the palliative setting. This study forms part of a larger project that explored the perceptions and practices of palliative care providers regarding oral health (15, 20) to inform the development of a Palliative-oral health model of care. Setting and population The focus group was conducted in a private room at a metropolitan hospital in Greater Western Sydney, consisting of dentists who were practising within a local public health service. In Australia, dental services are provided through various models which include free public dental services for socioeconomically disadvantaged populations, health fund clinics for people with private health insurance and private dentists.(21) This health service was chosen as it has large palliative care services in both hospital and community health settings providing care for approximately 12,000 patients per year (22) per year. It also has a large dental service employing 23 dentists across hospital and community dental clinics. Sampling strategy A purposive sampling technique was employed to recruit study participants. Invitations to participate in the focus group were distributed to dentists working within the public health service. Flyers and participant information sheets were also disseminated through e-mail to eligible staff. Those who were interested to participate in the focus group were asked to contact the study investigator for further information. Ethical considerations Ethical approval was obtained from the South Western Sydney Local Health District Human Research Ethics Committee (HE17/007). Both written and verbal information about the study were provided to all participants before they were invited to participate in an in-person focus group. All participants had the opportunity to clarify aspects of the study or ask questions prior to the focus group. Participants were informed that non-participation would not impact on their working relationship with the health service. Data Collection All dentists who expressed interest to participate in the study participated in one focus group conducted face-to-face in a private room at the hospital. The study was guided by a focus group schedule around their perceptions on oral health among palliative care patients in addition to their recommendations to delivering a targeted oral health program for this population (Appendix 1). The focus group lasted approximately 1 hour and, was conducted at a time appropriate for all participants and was audio-recorded. It was facilitated by the lead author (AG) who is a public oral health expert and professor, a trained dentist, and public oral health promotion researcher. The facilitators were not supervisors or managers of any of the participants; however, the facilitators had a good understanding of the operations of the oral health service. Prior to the focus group, informed consent was obtained from all participants as well as relevant demographic information. Besides the participants and researchers, no other persons were present for the focus group. Data analysis The audio recording from the focus group was professionally transcribed and de-identified prior to analysis. The transcript was imported into NVivo, a program designed to assist in analysing qualitative research by manual coding and sorting of text. An inductive approach was utilised to undertake a thematic analysis of the focus group to develop sub-themes and themes. One author (ARV) independently coded the transcripts. However, this was followed by a consensus meeting with all associate investigators to identify the final list of themes and sub-themes. Rigour Peer-coding, debriefing and triangulation were used to improve the rigour and trustworthiness of the analysis. To develop the coding structure, two researchers (ARV and AK) independently developed the coding structure and discussed the constructed themes with a third researcher (AG). Data source triangulation, which including examining data from two different groups of palliative care nurses and medical practitioners, was used to check for the credibility of the constructed themes. The themes were discussed with the larger team to increase the reliability of the interpreted data. Results Demographics A total of 21 dentists participated in the focus group. Among these participants, 17 identified as female. Although the majority were dentists ( n = 18), a few were also senior dentists ( n = 3). The mean age of the sample was 41.35 years (SD 9.47), with the mean years of experience being 8.24 years (SD 6.23). All dentists had at least a bachelor’s degree, however four participants also had a graduate certificate ( n = 1), masters ( n = 2) or other ( n = 1). Three broad themes and nine subthemes were generated following thematic analysis (Table 1). Awareness of oral health as a key component of quality of life Experiences with treating people receiving palliative care Participants were aware of the prevalence of poor oral health among palliative care patients. They shared some of their experiences treating palliative care patients in both the clinic and in the patients’ homes. Treatment was focused on providing care that the patient felt improved their quality of life: “I had a patient in the clinic who had cancer... Doesn't want to have any extractions…So, I did a lot of fillings for her…She didn't want denture. She doesn't want to go through all that.” (D2) “I was asked to see a patient in their home who was dying of cancer…They had about two months to live, but they felt their quality of life was going to be improved by having a denture for that last two months of their life.” (D15) Importance of oral health in palliative care These experiences stress the importance of providing patients control over their oral health, emphasising the value of “dignity… So, they feel that even though they're going through this process of the end stages of their life, they feel that they have a big of dignity - a bit of control over that situation.” (D1) In addition to providing patients a sense of dignity, other dentists also believed that oral health among people receiving palliative care was important because it was associated with quality of life and being able to enjoy eating which also had the potential to affect their nutritional intake: “It improves your quality of life in those terminally ill last months… It gives you satisfaction all the way to the end, at least you can eat something good if you’re going to die.” (D3) “If they don't get good nutrition or somethings stopping them from having this proper medication, nutrition's going to go downhill further and sooner.” (D3) Some dentists also identified that many of the medications that patients were prescribed affected their cognitive function and contributed to a dry mouth. These factors aggravated the patient’s oral health if they also had radiation, explaining: “A lot of medications keep them a little bit depressed as well. So, yeah, they forget to take care of oral health, brushing basically. The medicines involved can cause dry mouth.” (D5) Challenges to providing oral health care Competing priorities Dentists experienced a number of challenges when providing care to people receiving palliative care. For many patients, their main concern was their medical condition and their general health. Ensuring that patients maintained their oral health was seen as a challenge for some dentists who recognised that poor oral hygiene had the potential to exacerbate their existing health problems: “ The challenge of keep - like make them keep good oral hygiene when they are worry about their life, about the cancer they have and then they don't think about their oral hygiene…that also will affect on their health or they're going to have gum disease or whatever. That would increase their problems.” (D7) “They keep low priority for the dental issue, because their main thing is their medical condition they focus.” (D8) Condition-specific considerations Due to complex nature of their medical condition, dentists identified that there were additional challenges. Since patients were “medically compromised” one dentist shared that they would “have to deviate from the norm, as in medication and things” to ensure appropriate treatment. Furthermore, the nature of palliative care made it difficult for dentists to plan treatment timelines because “the problem is the long-term planning as well. Because you don't know how long they're going to last. It might be a week, it might be two months maybe.” (D9) One dentist also observed that people receiving palliative care s lacked independence because “they don’t have the strength to take care of themselves.” (D4) Difficulty related to physical accessibility was another theme that emerged. This included challenges related to transporting patients; however, even when community transport services were available, patients also had physical restrictions. “Because sometimes just going through, like a very simple situation, community transport cannot bring them to the clinic on time. Or they themselves can't access it or, do you know what I mean.” (D1) “You might not be able to recline them to position that you want to if you've got them in the dental chair, because of certain illnesses that they have.” (D4) Patients’ physical restrictions also impacted on time restrictions with dental appointments since “even in one hour they will get tired. They can’t handle more than 60 minutes.” (D7) However, these patients were also more challenging for dentists to treat because they also needed to deal with “physical disability or psychological issues or their need to talk sometimes and we need to give them more sympathy and time for the whole treatment.” As a result, these patients “definitely need more than 40 minutes. Otherwise, the patient will be coming and going back and forth.” (D13) Disconnect from other health services Dentists also experienced challenges relating to the coordination of care between the dental service and other health services. They had difficulties in contacting patients’ specialists and not being well informed from other health professionals on the implications of the patient’s condition. They also highlighted the difficulties for some patients to access oral health services who have “had to ring around 20 to 30 different places before they were directed to our [oral health] service. So, there is that barrier as well.” (D1) “Trying to chase down a specialist at a hospital regarding a patient is very, very hard.” (D1) “Sometimes we treat patients with [polio] for example who have no idea that they should have checked their teeth beforehand. I think it's the GPs responsibility to educate them about what complications or side effects their medications have on their oral health which is deficiency. We have a big deficiency” (D13) Knowledge and experience Dentists recognised their lack of experience working with palliative care patients. During undergraduate training, one dentist reported that working with people receiving palliative care “would only be incidental” . They discussed how their lack experience and comprehensive training affected their confidence in treating this patient population. “I've never, I don't have the experience in oral health and palliative care.” (D11) “What palliative care is just book-based knowledge for me personally. I don't have any like real life experience in [comforting] those patients. Which makes it hard. Whatever I say it's just knowledge from the book. Rather than in personal experience” (D12) A new model of care based on interdisciplinary collaboration and priority setting Dental needs Participants discussed in detail the need for further training in palliative care, indicating that “there’s always room for improvement.” Dentists highlighted that they needed further training around the aims of palliative treatment, and more specifically, being able to determine when treating the symptoms compared to the root problem would be more worthwhile: “…we need to have some overall training around what it actually means, what the aims are. What is symptomatic treatment versus we might have a sense of something that you feel needs to be done…” (D11) Dentists also reported on the need for a protocol to address conflicting priorities between families and patients. One dentist explained: “Sometimes their family members are more concerned than the patient. The patients are concerned about living their life. But the family…want them to have perfect teeth and dentures and all that” (D10). This participant also suggested some strategies to resolve conflict: “First we have to assess the oral health, see what the needs are…if they have only a month or two, you're going to extract all their teeth and give them dentures and the patient doesn't want it, then you have to calm down the family members and let them go in peace rather than subjecting them to so much of trauma” (D10) They also emphasised the need for further training on patient communication. This included how to “pick up from them to see whether they are actually vested in their oral health or not” (D1) and “how you can motivate them” (D1). One participant also mentioned the importance of having more training to understand the patient’s psychological needs: “We need … more training in psychological things. Because I believe for dental part, we all have reasonable experience. But how we deal with that person emotionally and psychologically, that's what I think we need to know more.” (D7) Dentists identified the lack of interdisciplinary collaboration with other health professionals, creating a referral process that lacked continuity of care. One dentist explained that patients on medications such as blood coagulants and antibiotics, who require urgent dental extractions, need to follow additional protocols: “It would be helpful to putting a pathway in place where it's understood that if a patient has identified as having pain, it may require extraction… They know that we need antibiotic to be taken at the clinic. They know that we need an INR (international normalised ratio) [blood test for clotting] within 24 hours.” (D11) Participants were concerned that the referring clinician may not provide patients with this information, therefore delaying treatment: “We still have general practitioners who write a script and say to their patients, yeah, just take this on the morning of your [dental] appointment. They arrive and we say sorry, can't do it. We have to see you take that medication.” (D11) Participants recommended that if referrals were accompanied by a full medical history to facilitate the dental appointment, it would help make the appointment more efficient. These comprehensive referrals would also minimise problems around identifying people receiving palliative care s, knowing specific precautions, and reducing the time taken to obtain the patient’s medical history. “That this patient is being referred to you by me. He is terminally ill. He has got all these medications going through and these are the precautions you might have to take when you are treating this patient. So, we are prepared for that. We don't need to go through with the patient all that, when you had the cancer? How many radiations? How many chemo? It takes a lot longer to take that medical history. By the end you have nothing you have done for that patient. Just an assessment.” (D2) “Code two [patients referred from a specialist medical practitioner requiring specific life-saving medical care] are those people who would have organ transplant or cardiac surgery…we have to include palliative care as part of that code two and by educating general practitioners just to send that letter which says what their stage or what their disease, what mediation, all these, so we have to look after them. I think because currently code two doesn't include palliative people.” (D7) When asked about how teledentistry could potentially play a role in the current systems in place, one dentist mentioned that teledentistry could potentially increase efficiency in triaging patients, increasing efficiency in scheduled appointments and developing treatment plans prior to seeing the patient. It was also mentioned that teledentistry could potentially provide an alternative pathway for patients who were not mobile or had accessibility issues. “I think it sounds like a more thorough system of triage ... it's about setting up pathways where there are identified people and it can become part of the roster. Say for example there was someone coming in, then when that person is triaged through the intake centre, through our now defined pathway, it would be identified that maybe this person is suitable, can't travel and therefore you have a time rostered where we can sit in front of a computer, be on the end of a phone and actually give some as you say in real time feedback.” (D11) Patient needs Dentists identified a number of needs to improve dental service provision. Since patients were limited to appointments that were under 60 minutes, dentists explained that they needed to ensure that the appointment provided maximum treatment to reduce the number of dental visits patients need to make: “But we may be able to achieve quite a lot in a 60 minute initial appointment…we don't know how easy it is for that person or their family members to bring them…even if we are just talking about or teaching the family members about how to provide oral care…you might be able to get something done in terms of the relief of immediate pain and some ongoing advice if you have long enough.” (D11) Dentists were also concerned that patients who were near end of life may not be able to receive appropriate treatment, and needed expedited or prioritised access to the service. However, currently scheduling did not provide additional appointments for these patients. One dentist described: “If you know that we're going to see some [terminally ill] patients like that on regular basis, we should have some extra spots … available for them so that we can book them quicker. Not like four weeks away. We had one patient like that and we got a phone call from her daughter saying I just want to cancel his appointment because he's passed away. You feel like your day is gone. You saw that patient four weeks away and you told them that you were going to build up this tooth. He was very happy that he is going to have this tooth and now he's gone. Because it was four weeks. Maybe if I did it on the next day, he would have stayed at least three weeks with it.” (D2) Furthermore, another dentist recalled that access to public dental treatment was limited to patients with a Health Care Card, irrespective of whether they were receiving palliative care. One participant explained, “For those who don't have Centrelink card, like those who have cancer but unfortunately, they are not on Centrelink so they won't be able to have a treatment. I don't know if we can get any exemption for those people to be treated in public service, despite they don't have patient card or health care card.” (D7) Discussion Dentists in this study shared positive attitudes towards the need for dental treatment in the palliative setting; however, there was still the need to implement a tailored palliative model of oral health care that would address key challenges that impeded the delivery of appropriate and timely dental care. Good oral health in palliative care was perceived as important; it was a matter of dignity as well as quality of life. Among those who had experience providing palliative dental treatment, their focus was on patient-centred care, and their treatment goals were based on client’s needs and individualised to their preference. Such views align with the cornerstone of palliative care management, which is to manage the relief of symptoms, such as pain or discomfort, for patients.( 23 ) According to Mulk, Chintamaneni ( 7 ), both pain management and early clinical diagnosis are key considerations to the prevention and minimisation of oral health problems among people receiving palliative care. Nevertheless, participants identified several complex challenges, at both a systems and individual level, that limited the delivery of appropriate palliative dental planning and treatment. From a systems perspective, there was a lack of integration between palliative care services and the oral health services, and no protocols were implemented to guide dental treatment planning. Timely and prompt access to appropriate dental care was a key concern among dentists since the limited physical mobility of many patients was a barrier to delivering dental treatment, which was similarly found in Switzerland.( 13 ) Since palliative care services did not link with oral health services, access to medical records and advice to inform dental treatment planning was restricted, further delaying the provision of treatment to alleviate symptoms and patient concerns. In a related study by the authors ( 20 ) palliative medical practitioners identified the need to refer clients for dental treatment but reflected on the limited pathways to dental services. Kong, George ( 15 ) also explored the perspectives of palliative care nurses and suggested that a trained registered nurse could be designated as an oral health coordinator to facilitate the referrals of palliative care clients to dental services. Another challenge was that no evidence-based protocol was implemented within the system to direct dental treatment planning and management despite complex needs of clients receiving palliative care. Disseminating a protocol could aid dentists to manage client priorities ( 24 ) especially since experience in palliative dental care, and available staff time ( 25 , 26 ) among dentists may be limited. Most palliative oral health guidelines have focused on general oral care for primary care providers ( 27 – 29 ) or carers ( 30 – 32 ) whereas specific guidelines for dental professionals is limited.( 33 ) Although Silva, Bodanezi ( 34 ) developed an evidence-based protocol for dental treatment planning among terminal cancer patients, a protocol for people receiving palliative care more broadly would need to be developed alongside tailored recommendations for the Australian context. Further training for dentists to assist with palliative dental care management was also discussed. Currently, no undergraduate dental training programs in Australia ( 35 ) or elsewhere ( 16 , 35 ) adequately prepare graduates to manage clients receiving palliative care, and no continuing professional development programs in palliative dental care exist to upskill practicing Australian dentists. Training programs would need to focus on both the clinical and psychosocial aspects of wellbeing, which was similarly reported in the United States.( 16 ) Among dental hygienists in Japan, many lacked the confidence and knowledge to manage dental treatment and planning among people receiving palliative care for advanced cancer.( 36 ) Future training will need to assist dentists in the communication skills needed for shared decision-making to clearly articulate treatment goals and treatment choices for people receiving palliative care; provide guidance on managing family expectations; and increase understanding on the psychological needs of clients. These areas indicate that the training development would need to be interdisciplinary, with palliative primary care providers and social workers playing a role.( 37 , 38 ) An interdisciplinary model of palliative oral health care would therefore need to address several factors. The model would need to deliver training and appropriate protocols to dentists to better manage the needs of people receiving palliative care; enhance the flow of information between palliative primary care providers and oral health services to address the client’s oral health needs; and consider strategies to reduce the number of dental appointments. IT support systems that enable the secure sharing of patient information are one avenue that could facilitate integrated dental care.( 39 ) In the absence of these implemented systems; however, a non-dental oral health champion or coordinator, trained by a dental professional, could promote oral health care through education and by facilitating dental referrals.( 2 , 15 ) Integrated oral health models using non-dental professionals have been implemented in other populations with demonstrated effectiveness.( 40 , 41 ) Employing an oral health coordinator could also facilitate teledentistry consultations to mitigate the need to physically access services. In the literature, palliative care nurses identified some limitations with teledentistry, including unreliable internet coverage and the cost of implementation.( 15 ) Following the social mobility restrictions during the COVID-19 pandemic; however, the uptake of the telehealth platform has increased across different population groups.( 42 ) Teledentistry could be implemented as a triage model by dental clinicians to identify and prioritise patients who require the most urgent care. Trained dental clinicians could then provide appropriate oral health recommendations and advice for people who require less urgent care. A potential model that could inform future planning of programs is the Seattle Care Pathway for older patients, which uses a matrix that outlines recommendations for oral health assessment, prevention, treatment, and communication, based on a person’s level of dependency and need.( 43 ) Limitations There were a few limitations to this study, particularly around the sample population. Dentists from private practices were not included and only one group of dentists from the same public oral health service participated. This restricted the breadth of perspectives that were shared to further inform the development of a model of care. It was also difficult to determine whether data saturation was reached due to the limitations in staff availability and funding constraints. Nevertheless, the facilitators ensured that all participants had an opportunity to voice their opinions, and there was a reasonable number of people who participated. Another limitation was that there was a lack of follow up to verify coding structures and themes due to funding and scheduling constraints. Conclusion Little is known about the perspectives and challenges of dentists, particularly in Australia, on dental treatment planning and management for people receiving palliative care. The findings from this qualitative study identify that while dentists in the public health service have generally positive attitudes towards palliative oral health care, there are key barriers within the system and in their training that limited the extent to which they believed that they could provide adequate care. 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Herrler A, Valerius L, Barbe AG, Vennedey V, Stock S. Providing ambulatory healthcare for people aged 80 and over: Views and perspectives of physicians and dentists from a qualitative survey. PLOS ONE. 2022;17(8):e0272866. Venkatasalu MR, Murang ZR, Husaini HAbH, Idris DR, Dhaliwal JS. Why oral palliative care takes a backseat? A national focus group study on experiences of palliative doctors, nurses and dentists. Nursing Open. 2020;7(5):1330-7. Jones JA, Chavarri-Guerra Y, Corrêa LBC, Dean DR, Epstein JB, Fregnani ER, et al. MASCC/ISOO expert opinion on the management of oral problems in patients with advanced cancer. Support Care Cancer. 2022;30(11):8761-73. Deutsch A, Jay E. Optimising oral health in frail older people. Aust Prescr. 2021;44(5):153-60. Fricker A, Lewis A. Better Oral Health in Residential Care: Final Report. In: Ageing AGDoHa, editor. Adelaide, South Australia: Australian Government; 2009. Milligan S, McGill M, Sweeney MP, Malarkey C. Oral care for people with advanced cancer: an evidence-based protocol. International journal of palliative nursing. 2001;7(9):418-26. NHS Scotland. Mouth Care [Internet]. UK: NHS Scotland; 2020 [cited 2023 July 19]. Available from: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/mouth-care.aspx. Lewis A, Fricker A. Better Oral Health in Residential Care: Professional portfolio [Internet]. Adelaide, South Australia: SA Dental Service; 2008 [cited 2023 July 19]. Available from: https://ltctoolkit.rnao.ca/sites/default/files/resources/BOHRC_Professional_Portfolio_Full_Version%5b1%5d.pdf. Rohr Y, Adams J, Young L. Oral discomfort in palliative care: results of an exploratory study of the experiences of terminally ill patients. International journal of palliative nursing. 2010;16(9):439-44. Silva ARP, Bodanezi AV, Chrun ES, Lisboa ML, de Camargo AR, Munhoz EA. Palliative oral care in terminal cancer patients: Integrated review. World J Clin Cases. 2023;11(13):2966-80. Mills J, Kim S-H, Chan HYL, Ho M-H, Montayre J, Liu MF, et al. Palliative care education in the Asia Pacific: Challenges and progress towards palliative care development. Progress in Palliative Care. 2021;29(5):251-4. Nakajima N. Challenges of Dental Hygienists in a Multidisciplinary Team Approach During Palliative Care for Patients With Advanced Cancer: A Nationwide Study. American Journal of Hospice and Palliative Medicine®. 2020;38(7):794-9. Flick K, Marchini L. The interprofessional role in dental caries management: from the social worker perspective. Dental Clinics. 2019;63(4):663-8. Helgeson M, Glassman P. Oral health delivery systems for older adults and people with disabilities. Special Care in Dentistry. 2013;33(4):177-89. Carter K, Chalouhi E, McKenna S, Richardson B. What it takes to make integrated care work [Internet]. London: McKinsey’s Health Systems and Services Practice; 2011 [cited 2023 July 19]. Available from: https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/ healthcare%20systems%20and%20services/health%20international/issue%2011%20new%20pdfs/hi11_ 48%20integratedcare_noprint.pdf. George A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S, Ellis S, et al. Evaluation of a midwifery initiated oral health-dental service program to improve oral health and birth outcomes for pregnant women: A multi-centre randomised controlled trial. International Journal of Nursing Studies. 2018;82:49-57. Harnagea H, Lamothe L, Couturier Y, Esfandiari S, Voyer R, Charbonneau A, et al. From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care. BMC Oral Health. 2018;18(1):23. Erikson C, Park YH, Felida N, Dill M. Telehealth Use and Access to Care for Underserved Populations Before and During the COVID-19 Pandemic. J Health Care Poor Underserved. 2023;34(1):132-45. Pretty IA, Ellwood RP, Lo ECM, MacEntee MI, Müller F, Rooney E, et al. The Seattle Care Pathway for securing oral health in older patients. Gerodontology. 2014;31(s1):77-87. Table Table 1: Themes and sub-themes from analysis Themes Sub-themes Awareness of palliative care as a key component of quality of life Experiences with treating people receiving palliative care Importance of oral health in palliative care Challenges to providing oral health care Competing priorities Condition-specific considerations Disconnect from other health services Knowledge A new model of care based on interdisciplinary collaboration and priority setting Dentist needs Interdisciplinary collaboration Patient needs Additional Declarations The authors declare no competing interests. Supplementary Files Appendix1.docx guide- Focus Group Discussions Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6356426","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":437117032,"identity":"1acf5bf6-b2d6-44a1-afa9-464c18cb3a51","order_by":0,"name":"Ajesh George","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-6795-2546","institution":"Australian Centre for Integration of Oral Health (ACIOH), School of Nursing and Midwifery, Western Sydney University","correspondingAuthor":true,"prefix":"","firstName":"Ajesh","middleName":"","lastName":"George","suffix":""},{"id":437117033,"identity":"9a7818d5-83bd-4506-bbcb-b3ca0d8ecf02","order_by":1,"name":"Ariana Kong","email":"","orcid":"","institution":"Australian Centre for Integration of Oral Health (ACIOH), School of Nursing and Midwifery, Western Sydney University","correspondingAuthor":false,"prefix":"","firstName":"Ariana","middleName":"","lastName":"Kong","suffix":""},{"id":437117034,"identity":"73b6e70c-9e33-404c-a5fc-8f955da58d26","order_by":2,"name":"Agnivo Sengupta","email":"","orcid":"","institution":"Australian Centre for Integration of Oral Health (ACIOH), School of Nursing and Midwifery, Western Sydney University","correspondingAuthor":false,"prefix":"","firstName":"Agnivo","middleName":"","lastName":"Sengupta","suffix":""},{"id":437117035,"identity":"f57ce348-3d12-4d4c-a2c8-02f06388aca0","order_by":3,"name":"Meera Agar","email":"","orcid":"","institution":"IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney","correspondingAuthor":false,"prefix":"","firstName":"Meera","middleName":"","lastName":"Agar","suffix":""},{"id":437117036,"identity":"8e27d268-8f95-4813-824d-bde90770ad10","order_by":4,"name":"Amy R. Villarosa","email":"","orcid":"","institution":"Australian Centre for Integration of Oral Health (ACIOH), School of Nursing and Midwifery, Western Sydney University","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"R.","lastName":"Villarosa","suffix":""},{"id":437117037,"identity":"d2032352-47c7-44ad-86cf-ea12c4b73049","order_by":5,"name":"Janeane Harlum","email":"","orcid":"","institution":"Department of Palliative Care, South Western Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Janeane","middleName":"","lastName":"Harlum","suffix":""},{"id":437117038,"identity":"37d80ac3-553b-4d1a-8238-2ace34e4524b","order_by":6,"name":"Deborah Parker","email":"","orcid":"","institution":"IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Parker","suffix":""},{"id":437117039,"identity":"fff65709-015f-481b-ba94-97a02b38f41a","order_by":7,"name":"Jennifer Wiltshire","email":"","orcid":"","institution":"Department of Palliative Care, South Western Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Wiltshire","suffix":""},{"id":437117040,"identity":"0f768579-f992-43e9-9b0f-0b75af27ce3e","order_by":8,"name":"Ravi Srinivas","email":"","orcid":"","institution":"Oral Health Services, South Western Sydney Local Health District","correspondingAuthor":false,"prefix":"","firstName":"Ravi","middleName":"","lastName":"Srinivas","suffix":""}],"badges":[],"createdAt":"2025-04-02 00:38:27","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6356426/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6356426/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79810485,"identity":"111725ee-2c93-4d50-89d7-a400cbe3b315","added_by":"auto","created_at":"2025-04-03 06:29:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":583991,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6356426/v1/062e2437-f0cc-48cf-9de8-fd05d013c637.pdf"},{"id":79809674,"identity":"beada429-60f5-4d59-acd3-43ad6fe9a0ce","added_by":"auto","created_at":"2025-04-03 06:21:37","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28978,"visible":true,"origin":"","legend":"\u003cp\u003eguide- Focus Group Discussions\u003c/p\u003e","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6356426/v1/d1bfa640acc030e3119c6d0a.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eOral health in palliative care: perceptions of public dental practitioners in Sydney, Australia\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA primary goal of therapeutic interventions for people with life limiting illness is to improve the quality of life through addressing symptoms and improving comfort at end-of-life.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Poor oral health can have a significant impact on the quality of life of people with a life limiting illness, but it is often overlooked.(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) In one study, a majority of informal caregivers reported infrequently evaluating the oral status of their care recipients and over 10% stated that they never assessed oral health even though caregivers were aware of the importance of oral health.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Due to their declining health, people receiving palliative care may experience xerostomia (dryness of mouth) which can also cause dry lips, changes in taste and speech, increased sensitivity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), denture-related problems such as denture sores and increased frequency of painful oral infections such as mucositis and candidiasis.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Oral health problems may be further exacerbated by the patient\u0026rsquo;s cognitive or physical decline, leading to inadequate oral self-care.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) People undergoing palliative care with advanced disease progression may also experience tongue inflammation and dysphagia (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), reducing their ability to speak, consume food and drinks. In the long term, this can contribute to malnutrition and weight loss, deteriorating their overall health and quality of life.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDental treatment has the potential to improve the oral health of people receiving palliative care.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Some studies have demonstrated that prophylactic professional oral health care, including scaling, professional cleaning of teeth and brushing instructions can prevent deterioration in the oral health of people receiving palliative care.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) However, one of the major barriers people experience to receiving professional care is access to dental services.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) The reasons for poor rates to accessing dental care are complex, and may be attributed to lower prioritisation by families, financial costs, difficulties with mobility or transport and increased psychological issues.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite the demand for dental treatment among people receiving palliative care, there are some barriers to dentists delivering care. American dentists have reported that their professional training did not adequately equip them to address the complex needs of people with a life-limiting illness.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Inadequate training and experience managing the oral health needs of people receiving palliative care could contribute to poor access to dental care if few dentists are confident to provide dental treatment. Although the need for dental professionals to provide dental care to people receiving palliative care s is not a new concept, it is becoming increasingly relevant in the context of an aging population where people have greater life expectancies but also more complex chronic medical conditions.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo meet the evolving healthcare landscape in Australia, it is important to ensure that dental services are adapted to address the dental needs of palliative care patients. However, little is known of the barriers and challenges that face dental professionals in the palliative care setting in Australia. Although some surveys have identified the practices, needs and barriers of dentists within a palliative setting in other developed countries (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), there is currently no published literature exploring the perceptions of dentists in Australia. Understanding the experiences and challenges that contribute to the practices and attitudes of Australian dentists to treat people receiving palliative care is an important step to integrating dental care as part of the holistic care for this population. The aim of this study was to examine the perceptions of public dental practitioners providing oral health care in the palliative care setting.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\n\u003cp\u003eA focus group was conducted as part of a descriptive qualitative design to explore the perceptions of dentists providing care in the palliative setting. This study forms part of a larger project that explored the perceptions and practices of palliative care providers regarding oral health (15, 20) to inform the development of a Palliative-oral health model of care.\u003c/p\u003e\n\u003ch2\u003eSetting and population\u003c/h2\u003e\n\u003cp\u003eThe focus group was conducted in a private room at a metropolitan hospital in Greater Western Sydney, consisting of dentists who were practising within a local public health service. In Australia, dental services are provided through various models which include free public dental services for socioeconomically disadvantaged populations, health fund clinics for people with private health insurance and private dentists.(21) This health service was chosen as it has large palliative care services in both hospital and community health settings providing care for approximately 12,000 patients per year (22) per year. It also has a large dental service employing 23 dentists across hospital and community dental clinics. \u003c/p\u003e\n\u003ch2\u003eSampling strategy \u003c/h2\u003e\n\u003cp\u003eA purposive sampling technique was employed to recruit study participants. Invitations to participate in the focus group were distributed to dentists working within the public health service. Flyers and participant information sheets were also disseminated through e-mail to eligible staff. Those who were interested to participate in the focus group were asked to contact the study investigator for further information.\u003c/p\u003e\n\u003ch2\u003eEthical considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the South Western Sydney Local Health District Human Research Ethics Committee (HE17/007). Both written and verbal information about the study were provided to all participants before they were invited to participate in an in-person focus group. All participants had the opportunity to clarify aspects of the study or ask questions prior to the focus group. Participants were informed that non-participation would not impact on their working relationship with the health service.\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eAll dentists who expressed interest to participate in the study participated in one focus group conducted face-to-face in a private room at the hospital. The study was guided by a focus group schedule around their perceptions on oral health among palliative care patients in addition to their recommendations to delivering a targeted oral health program for this population (Appendix 1). The focus group lasted approximately 1 hour and, was conducted at a time appropriate for all participants and was audio-recorded. It was facilitated by the lead author (AG) who is a public oral health expert and professor, a trained dentist, and public oral health promotion researcher. The facilitators were not supervisors or managers of any of the participants; however, the facilitators had a good understanding of the operations of the oral health service. Prior to the focus group, informed consent was obtained from all participants as well as relevant demographic information. Besides the participants and researchers, no other persons were present for the focus group. \u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eThe audio recording from the focus group was professionally transcribed and de-identified prior to analysis. The transcript was imported into NVivo, a program designed to assist in analysing qualitative research by manual coding and sorting of text. An inductive approach was utilised to undertake a thematic analysis of the focus group to develop sub-themes and themes. One author (ARV) independently coded the transcripts. However, this was followed by a consensus meeting with all associate investigators to identify the final list of themes and sub-themes.\u003c/p\u003e\n\u003ch2\u003eRigour\u003c/h2\u003e\n\u003cp\u003ePeer-coding, debriefing and triangulation were used to improve the rigour and trustworthiness of the analysis. To develop the coding structure, two researchers (ARV and AK) independently developed the coding structure and discussed the constructed themes with a third researcher (AG). Data source triangulation, which including examining data from two different groups of palliative care nurses and medical practitioners, was used to check for the credibility of the constructed themes. The themes were discussed with the larger team to increase the reliability of the interpreted data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographics\u003c/p\u003e \u003cp\u003eA total of 21 dentists participated in the focus group. Among these participants, 17 identified as female. Although the majority were dentists (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18), a few were also senior dentists (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3). The mean age of the sample was 41.35 years (SD 9.47), with the mean years of experience being 8.24 years (SD 6.23). All dentists had at least a bachelor\u0026rsquo;s degree, however four participants also had a graduate certificate (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1), masters (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2) or other (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1). Three broad themes and nine subthemes were generated following thematic analysis (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eAwareness of oral health as a key component of quality of life\u003c/p\u003e \u003cp\u003eExperiences with treating people receiving palliative care\u003c/p\u003e \u003cp\u003e Participants were aware of the prevalence of poor oral health among palliative care patients. They shared some of their experiences treating palliative care patients in both the clinic and in the patients\u0026rsquo; homes. Treatment was focused on providing care that the patient felt improved their quality of life:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I had a patient in the clinic who had cancer... Doesn't want to have any extractions\u0026hellip;So, I did a lot of fillings for her\u0026hellip;She didn't want denture. She doesn't want to go through all that.\u0026rdquo; (D2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I was asked to see a patient in their home who was dying of cancer\u0026hellip;They had about two months to live, but they felt their quality of life was going to be improved by having a denture for that last two months of their life.\u0026rdquo; (D15)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eImportance of oral health in palliative care\u003c/p\u003e \u003cp\u003eThese experiences stress the importance of providing patients control over their oral health, emphasising the value of \u003cem\u003e\u0026ldquo;dignity\u0026hellip; So, they feel that even though they're going through this process of the end stages of their life, they feel that they have a big of dignity - a bit of control over that situation.\u0026rdquo; (D1)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e In addition to providing patients a sense of dignity, other dentists also believed that oral health among people receiving palliative care was important because it was associated with quality of life and being able to enjoy eating which also had the potential to affect their nutritional intake:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It improves your quality of life in those terminally ill last months\u0026hellip; It gives you satisfaction all the way to the end, at least you can eat something good if you\u0026rsquo;re going to die.\u0026rdquo; (D3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If they don't get good nutrition or somethings stopping them from having this proper medication, nutrition's going to go downhill further and sooner.\u0026rdquo; (D3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome dentists also identified that many of the medications that patients were prescribed affected their cognitive function and contributed to a dry mouth. These factors aggravated the patient\u0026rsquo;s oral health if they also had radiation, explaining: \u003cem\u003e\u0026ldquo;A lot of medications keep them a little bit depressed as well. So, yeah, they forget to take care of oral health, brushing basically. The medicines involved can cause dry mouth.\u0026rdquo; (D5)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eChallenges to providing oral health care\u003c/p\u003e \u003cp\u003eCompeting priorities\u003c/p\u003e \u003cp\u003eDentists experienced a number of challenges when providing care to people receiving palliative care. For many patients, their main concern was their medical condition and their general health. Ensuring that patients maintained their oral health was seen as a challenge for some dentists who recognised that poor oral hygiene had the potential to exacerbate their existing health problems: \u0026ldquo;\u003cem\u003eThe challenge of keep - like make them keep good oral hygiene when they are worry about their life, about the cancer they have and then they don't think about their oral hygiene\u0026hellip;that also will affect on their health or they're going to have gum disease or whatever. That would increase their problems.\u0026rdquo; (D7)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They keep low priority for the dental issue, because their main thing is their medical condition they focus.\u0026rdquo; (D8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eCondition-specific considerations\u003c/p\u003e \u003cp\u003eDue to complex nature of their medical condition, dentists identified that there were additional challenges. Since patients were \u003cem\u003e\u0026ldquo;medically compromised\u0026rdquo;\u003c/em\u003e one dentist shared that they would \u003cem\u003e\u0026ldquo;have to deviate from the norm, as in medication and things\u0026rdquo;\u003c/em\u003e to ensure appropriate treatment. Furthermore, the nature of palliative care made it difficult for dentists to plan treatment timelines because \u003cem\u003e\u0026ldquo;the problem is the long-term planning as well. Because you don't know how long they're going to last. It might be a week, it might be two months maybe.\u0026rdquo; (D9)\u003c/em\u003e One dentist also observed that people receiving palliative care s lacked independence because \u003cem\u003e\u0026ldquo;they don\u0026rsquo;t have the strength to take care of themselves.\u0026rdquo; (D4)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDifficulty related to physical accessibility was another theme that emerged. This included challenges related to transporting patients; however, even when community transport services were available, patients also had physical restrictions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Because sometimes just going through, like a very simple situation, community transport cannot bring them to the clinic on time. Or they themselves can't access it or, do you know what I mean.\u0026rdquo; (D1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You might not be able to recline them to position that you want to if you've got them in the dental chair, because of certain illnesses that they have.\u0026rdquo; (D4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePatients\u0026rsquo; physical restrictions also impacted on time restrictions with dental appointments since \u003cem\u003e\u0026ldquo;even in one hour they will get tired. They can\u0026rsquo;t handle more than 60 minutes.\u0026rdquo; (D7)\u003c/em\u003e However, these patients were also more challenging for dentists to treat because they also needed to deal with \u003cem\u003e\u0026ldquo;physical disability or psychological issues or their need to talk sometimes and we need to give them more sympathy and time for the whole treatment.\u0026rdquo;\u003c/em\u003e As a result, these patients \u003cem\u003e\u0026ldquo;definitely need more than 40 minutes. Otherwise, the patient will be coming and going back and forth.\u0026rdquo; (D13)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDisconnect from other health services\u003c/p\u003e \u003cp\u003eDentists also experienced challenges relating to the coordination of care between the dental service and other health services. They had difficulties in contacting patients\u0026rsquo; specialists and not being well informed from other health professionals on the implications of the patient\u0026rsquo;s condition. They also highlighted the difficulties for some patients to access oral health services who have \u003cem\u003e\u0026ldquo;had to ring around 20 to 30 different places before they were directed to our\u003c/em\u003e [oral health] \u003cem\u003eservice. So, there is that barrier as well.\u0026rdquo; (D1)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Trying to chase down a specialist at a hospital regarding a patient is very, very hard.\u0026rdquo; (D1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes we treat patients with [polio] for example who have no idea that they should have checked their teeth beforehand. I think it's the GPs responsibility to educate them about what complications or side effects their medications have on their oral health which is deficiency. We have a big deficiency\u0026rdquo; (D13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eKnowledge and experience\u003c/p\u003e \u003cp\u003eDentists recognised their lack of experience working with palliative care patients. During undergraduate training, one dentist reported that working with people receiving palliative care \u003cem\u003e\u0026ldquo;would only be incidental\u0026rdquo;\u003c/em\u003e. They discussed how their lack experience and comprehensive training affected their confidence in treating this patient population.\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;I've never, I don't have the experience in oral health and palliative care.\u0026rdquo; (D11)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What palliative care is just book-based knowledge for me personally. I don't have any like real life experience in [comforting] those patients. Which makes it hard. Whatever I say it's just knowledge from the book. Rather than in personal experience\u0026rdquo; (D12)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA new model of care based on interdisciplinary collaboration and priority setting\u003c/p\u003e \u003cp\u003eDental needs\u003c/p\u003e \u003cp\u003eParticipants discussed in detail the need for further training in palliative care, indicating that \u003cem\u003e\u0026ldquo;there\u0026rsquo;s always room for improvement.\u0026rdquo;\u003c/em\u003e Dentists highlighted that they needed further training around the aims of palliative treatment, and more specifically, being able to determine when treating the symptoms compared to the root problem would be more worthwhile: \u003cem\u003e\u0026ldquo;\u0026hellip;we need to have some overall training around what it actually means, what the aims are. What is symptomatic treatment versus we might have a sense of something that you feel needs to be done\u0026hellip;\u0026rdquo; (D11)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDentists also reported on the need for a protocol to address conflicting priorities between families and patients. One dentist explained: \u003cem\u003e\u0026ldquo;Sometimes their family members are more concerned than the patient. The patients are concerned about living their life. But the family\u0026hellip;want them to have perfect teeth and dentures and all that\u0026rdquo; (D10).\u003c/em\u003e This participant also suggested some strategies to resolve conflict: \u003cem\u003e\u0026ldquo;First we have to assess the oral health, see what the needs are\u0026hellip;if they have only a month or two, you're going to extract all their teeth and give them dentures and the patient doesn't want it, then you have to calm down the family members and let them go in peace rather than subjecting them to so much of trauma\u0026rdquo; (D10)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThey also emphasised the need for further training on patient communication. This included how to \u003cem\u003e\u0026ldquo;pick up from them to see whether they are actually vested in their oral health or not\u0026rdquo; (D1)\u003c/em\u003e and \u003cem\u003e\u0026ldquo;how you can motivate them\u0026rdquo; (D1).\u003c/em\u003e One participant also mentioned the importance of having more training to understand the patient\u0026rsquo;s psychological needs: \u003cem\u003e\u0026ldquo;We need \u0026hellip; more training in psychological things. Because I believe for dental part, we all have reasonable experience. But how we deal with that person emotionally and psychologically, that's what I think we need to know more.\u0026rdquo; (D7)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDentists identified the lack of interdisciplinary collaboration with other health professionals, creating a referral process that lacked continuity of care. One dentist explained that patients on medications such as blood coagulants and antibiotics, who require urgent dental extractions, need to follow additional protocols: \u003cem\u003e\u0026ldquo;It would be helpful to putting a pathway in place where it's understood that if a patient has identified as having pain, it may require extraction\u0026hellip; They know that we need antibiotic to be taken at the clinic. They know that we need an INR (international normalised ratio) [blood test for clotting] within 24 hours.\u0026rdquo; (D11)\u003c/em\u003e Participants were concerned that the referring clinician may not provide patients with this information, therefore delaying treatment: \u003cem\u003e\u0026ldquo;We still have general practitioners who write a script and say to their patients, yeah, just take this on the morning of your [dental] appointment. They arrive and we say sorry, can't do it. We have to see you take that medication.\u0026rdquo; (D11)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Participants recommended that if referrals were accompanied by a full medical history to facilitate the dental appointment, it would help make the appointment more efficient. These comprehensive referrals would also minimise problems around identifying people receiving palliative care s, knowing specific precautions, and reducing the time taken to obtain the patient\u0026rsquo;s medical history.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That this patient is being referred to you by me. He is terminally ill. He has got all these medications going through and these are the precautions you might have to take when you are treating this patient. So, we are prepared for that. We don't need to go through with the patient all that, when you had the cancer? How many radiations? How many chemo? It takes a lot longer to take that medical history. By the end you have nothing you have done for that patient. Just an assessment.\u0026rdquo; (D2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Code two [patients referred from a specialist medical practitioner requiring specific life-saving medical care] are those people who would have organ transplant or cardiac surgery\u0026hellip;we have to include palliative care as part of that code two and by educating general practitioners just to send that letter which says what their stage or what their disease, what mediation, all these, so we have to look after them. I think because currently code two doesn't include palliative people.\u0026rdquo; (D7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWhen asked about how teledentistry could potentially play a role in the current systems in place, one dentist mentioned that teledentistry could potentially increase efficiency in triaging patients, increasing efficiency in scheduled appointments and developing treatment plans prior to seeing the patient. It was also mentioned that teledentistry could potentially provide an alternative pathway for patients who were not mobile or had accessibility issues.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it sounds like a more thorough system of triage ... it's about setting up pathways where there are identified people and it can become part of the roster. Say for example there was someone coming in, then when that person is triaged through the intake centre, through our now defined pathway, it would be identified that maybe this person is suitable, can't travel and therefore you have a time rostered where we can sit in front of a computer, be on the end of a phone and actually give some as you say in real time feedback.\u0026rdquo; (D11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePatient needs\u003c/p\u003e \u003cp\u003eDentists identified a number of needs to improve dental service provision. Since patients were limited to appointments that were under 60 minutes, dentists explained that they needed to ensure that the appointment provided maximum treatment to reduce the number of dental visits patients need to make:\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;But we may be able to achieve quite a lot in a 60 minute initial appointment\u0026hellip;we don't know how easy it is for that person or their family members to bring them\u0026hellip;even if we are just talking about or teaching the family members about how to provide oral care\u0026hellip;you might be able to get something done in terms of the relief of immediate pain and some ongoing advice if you have long enough.\u0026rdquo; (D11)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eDentists were also concerned that patients who were near end of life may not be able to receive appropriate treatment, and needed expedited or prioritised access to the service. However, currently scheduling did not provide additional appointments for these patients. One dentist described: \u003cem\u003e\u0026ldquo;If you know that we're going to see some [terminally ill] patients like that on regular basis, we should have some extra spots \u0026hellip; available for them so that we can book them quicker. Not like four weeks away. We had one patient like that and we got a phone call from her daughter saying I just want to cancel his appointment because he's passed away. You feel like your day is gone. You saw that patient four weeks away and you told them that you were going to build up this tooth. He was very happy that he is going to have this tooth and now he's gone. Because it was four weeks. Maybe if I did it on the next day, he would have stayed at least three weeks with it.\u0026rdquo; (D2)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFurthermore, another dentist recalled that access to public dental treatment was limited to patients with a Health Care Card, irrespective of whether they were receiving palliative care. One participant explained, \u003cem\u003e\u0026ldquo;For those who don't have Centrelink card, like those who have cancer but unfortunately, they are not on Centrelink so they won't be able to have a treatment. I don't know if we can get any exemption for those people to be treated in public service, despite they don't have patient card or health care card.\u0026rdquo; (D7)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDentists in this study shared positive attitudes towards the need for dental treatment in the palliative setting; however, there was still the need to implement a tailored palliative model of oral health care that would address key challenges that impeded the delivery of appropriate and timely dental care. Good oral health in palliative care was perceived as important; it was a matter of dignity as well as quality of life. Among those who had experience providing palliative dental treatment, their focus was on patient-centred care, and their treatment goals were based on client\u0026rsquo;s needs and individualised to their preference. Such views align with the cornerstone of palliative care management, which is to manage the relief of symptoms, such as pain or discomfort, for patients.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) According to Mulk, Chintamaneni (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), both pain management and early clinical diagnosis are key considerations to the prevention and minimisation of oral health problems among people receiving palliative care. Nevertheless, participants identified several complex challenges, at both a systems and individual level, that limited the delivery of appropriate palliative dental planning and treatment.\u003c/p\u003e \u003cp\u003eFrom a systems perspective, there was a lack of integration between palliative care services and the oral health services, and no protocols were implemented to guide dental treatment planning. Timely and prompt access to appropriate dental care was a key concern among dentists since the limited physical mobility of many patients was a barrier to delivering dental treatment, which was similarly found in Switzerland.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Since palliative care services did not link with oral health services, access to medical records and advice to inform dental treatment planning was restricted, further delaying the provision of treatment to alleviate symptoms and patient concerns. In a related study by the authors (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) palliative medical practitioners identified the need to refer clients for dental treatment but reflected on the limited pathways to dental services. Kong, George (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) also explored the perspectives of palliative care nurses and suggested that a trained registered nurse could be designated as an oral health coordinator to facilitate the referrals of palliative care clients to dental services.\u003c/p\u003e \u003cp\u003eAnother challenge was that no evidence-based protocol was implemented within the system to direct dental treatment planning and management despite complex needs of clients receiving palliative care. Disseminating a protocol could aid dentists to manage client priorities (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) especially since experience in palliative dental care, and available staff time (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) among dentists may be limited. Most palliative oral health guidelines have focused on general oral care for primary care providers (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) or carers (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) whereas specific guidelines for dental professionals is limited.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Although Silva, Bodanezi (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) developed an evidence-based protocol for dental treatment planning among terminal cancer patients, a protocol for people receiving palliative care more broadly would need to be developed alongside tailored recommendations for the Australian context.\u003c/p\u003e \u003cp\u003eFurther training for dentists to assist with palliative dental care management was also discussed. Currently, no undergraduate dental training programs in Australia (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) or elsewhere (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) adequately prepare graduates to manage clients receiving palliative care, and no continuing professional development programs in palliative dental care exist to upskill practicing Australian dentists. Training programs would need to focus on both the clinical and psychosocial aspects of wellbeing, which was similarly reported in the United States.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Among dental hygienists in Japan, many lacked the confidence and knowledge to manage dental treatment and planning among people receiving palliative care for advanced cancer.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) Future training will need to assist dentists in the communication skills needed for shared decision-making to clearly articulate treatment goals and treatment choices for people receiving palliative care; provide guidance on managing family expectations; and increase understanding on the psychological needs of clients. These areas indicate that the training development would need to be interdisciplinary, with palliative primary care providers and social workers playing a role.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAn interdisciplinary model of palliative oral health care would therefore need to address several factors. The model would need to deliver training and appropriate protocols to dentists to better manage the needs of people receiving palliative care; enhance the flow of information between palliative primary care providers and oral health services to address the client\u0026rsquo;s oral health needs; and consider strategies to reduce the number of dental appointments. IT support systems that enable the secure sharing of patient information are one avenue that could facilitate integrated dental care.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) In the absence of these implemented systems; however, a non-dental oral health champion or coordinator, trained by a dental professional, could promote oral health care through education and by facilitating dental referrals.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Integrated oral health models using non-dental professionals have been implemented in other populations with demonstrated effectiveness.(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEmploying an oral health coordinator could also facilitate teledentistry consultations to mitigate the need to physically access services. In the literature, palliative care nurses identified some limitations with teledentistry, including unreliable internet coverage and the cost of implementation.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) Following the social mobility restrictions during the COVID-19 pandemic; however, the uptake of the telehealth platform has increased across different population groups.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) Teledentistry could be implemented as a triage model by dental clinicians to identify and prioritise patients who require the most urgent care. Trained dental clinicians could then provide appropriate oral health recommendations and advice for people who require less urgent care. A potential model that could inform future planning of programs is the Seattle Care Pathway for older patients, which uses a matrix that outlines recommendations for oral health assessment, prevention, treatment, and communication, based on a person\u0026rsquo;s level of dependency and need.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eThere were a few limitations to this study, particularly around the sample population. Dentists from private practices were not included and only one group of dentists from the same public oral health service participated. This restricted the breadth of perspectives that were shared to further inform the development of a model of care. It was also difficult to determine whether data saturation was reached due to the limitations in staff availability and funding constraints. Nevertheless, the facilitators ensured that all participants had an opportunity to voice their opinions, and there was a reasonable number of people who participated. Another limitation was that there was a lack of follow up to verify coding structures and themes due to funding and scheduling constraints.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLittle is known about the perspectives and challenges of dentists, particularly in Australia, on dental treatment planning and management for people receiving palliative care. The findings from this qualitative study identify that while dentists in the public health service have generally positive attitudes towards palliative oral health care, there are key barriers within the system and in their training that limited the extent to which they believed that they could provide adequate care. To address some of these challenges, implementing a palliative model of oral health care is critical to include further interdisciplinary training alongside appropriate protocols to guide dental treatment; a coordinator to streamline the referral of clients to dental services; and employ the use of teledentistry to triage and prioritise people who may require more urgent dental care.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFerrell B, Connor SR, Cordes A, Dahlin CM, Fine PG, Hutton N, et al. The National Agenda for Quality Palliative Care: The National Consensus Project and the National Quality Forum. Journal of Pain and Symptom Management. 2007;33(6):737-44.\u003c/li\u003e\n \u003cli\u003eGillam J, Gillam DG. The assessment and implementation of mouth care in palliative care: a review. 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Perceptions of nurses towards oral health in palliative care: A qualitative study. Collegian. 2020;27(5):499-505.\u003c/li\u003e\n \u003cli\u003eWilwert MM, Watkins CA, Ettinger RL, Cowen HJ, Qian F. The involvement of Iowa dentists in hospice care. Special Care in Dentistry. 2011;31(6):204-9.\u003c/li\u003e\n \u003cli\u003eSirmons KL, Dickinson GE, Burkett TL. Teaching end-of-life issues: survey of U.S. dental schools and dentists. Journal of Dental Education. 2010;74(1):43-9.\u003c/li\u003e\n \u003cli\u003eWorldwide Palliative Care Alliance, World Health Organization. Global atlas of palliative care at the end of life. London: Worldwide Palliative Care Alliance. 2014:111.\u003c/li\u003e\n \u003cli\u003eRoberts AW, Ogunwole SU, Blakeslee L, Rabe MA. The population 65 years and older in the United States: 2016: US Department of Commerce, Economics and Statistics Administration, US \u0026hellip;; 2018.\u003c/li\u003e\n \u003cli\u003eVillarosa AR, Agar, M., Kong, A., Sousa M., Harlum, J., Parker, D., Srinivas, R., Wiltshire, J., George A. The perceptions of palliative care medical practitioners towards oral health: a descriptive qualitative study [Manuscript under review]. Journal of Palliative Medicine. 2023.\u003c/li\u003e\n \u003cli\u003eAustralian Institute of Health and Welfare. Oral health and dental care in Australia. Australia; 2023.\u003c/li\u003e\n \u003cli\u003eSouth Western Sydney Local Health District. SWSLHD CANCER SERVICES ANNUAL REPORT 2021/2022. 2022. Available from: https://www.swslhd.health.nsw.gov.au/cancer/pdf/Reports/Annual2022.pdf.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Strengthening of palliative care as a component of comprehensive care throughout the life course [Internet]. Geneva: WHO; 2014 [cited 2023 July 18]. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf?ua=1\u0026amp;ua=1.\u003c/li\u003e\n \u003cli\u003eSoileau K, Elster N. The Hospice Patient\u0026rsquo;s Right to Oral Care: Making Time for the Mouth. Journal of Palliative Care. 2018;33(2):65-9.\u003c/li\u003e\n \u003cli\u003eHerrler A, Valerius L, Barbe AG, Vennedey V, Stock S. Providing ambulatory healthcare for people aged 80 and over: Views and perspectives of physicians and dentists from a qualitative survey. PLOS ONE. 2022;17(8):e0272866.\u003c/li\u003e\n \u003cli\u003eVenkatasalu MR, Murang ZR, Husaini HAbH, Idris DR, Dhaliwal JS. Why oral palliative care takes a backseat? A national focus group study on experiences of palliative doctors, nurses and dentists. Nursing Open. 2020;7(5):1330-7.\u003c/li\u003e\n \u003cli\u003eJones JA, Chavarri-Guerra Y, Corr\u0026ecirc;a LBC, Dean DR, Epstein JB, Fregnani ER, et al. MASCC/ISOO expert opinion on the management of oral problems in patients with advanced cancer. Support Care Cancer. 2022;30(11):8761-73.\u003c/li\u003e\n \u003cli\u003eDeutsch A, Jay E. Optimising oral health in frail older people. Aust Prescr. 2021;44(5):153-60.\u003c/li\u003e\n \u003cli\u003eFricker A, Lewis A. Better Oral Health in Residential Care: Final Report. In: Ageing AGDoHa, editor. Adelaide, South Australia: Australian Government; 2009.\u003c/li\u003e\n \u003cli\u003eMilligan S, McGill M, Sweeney MP, Malarkey C. Oral care for people with advanced cancer: an evidence-based protocol. International journal of palliative nursing. 2001;7(9):418-26.\u003c/li\u003e\n \u003cli\u003eNHS Scotland. Mouth Care [Internet]. UK: NHS Scotland; 2020 [cited 2023 July 19]. Available from: https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/mouth-care.aspx.\u003c/li\u003e\n \u003cli\u003eLewis A, Fricker A. Better Oral Health in Residential Care: Professional portfolio [Internet]. Adelaide, South Australia: SA Dental Service; 2008 [cited 2023 July 19]. Available from: https://ltctoolkit.rnao.ca/sites/default/files/resources/BOHRC_Professional_Portfolio_Full_Version%5b1%5d.pdf.\u003c/li\u003e\n \u003cli\u003eRohr Y, Adams J, Young L. Oral discomfort in palliative care: results of an exploratory study of the experiences of terminally ill patients. International journal of palliative nursing. 2010;16(9):439-44.\u003c/li\u003e\n \u003cli\u003eSilva ARP, Bodanezi AV, Chrun ES, Lisboa ML, de Camargo AR, Munhoz EA. Palliative oral care in terminal cancer patients: Integrated review. World J Clin Cases. 2023;11(13):2966-80.\u003c/li\u003e\n \u003cli\u003eMills J, Kim S-H, Chan HYL, Ho M-H, Montayre J, Liu MF, et al. Palliative care education in the Asia Pacific: Challenges and progress towards palliative care development. Progress in Palliative Care. 2021;29(5):251-4.\u003c/li\u003e\n \u003cli\u003eNakajima N. Challenges of Dental Hygienists in a Multidisciplinary Team Approach During Palliative Care for Patients With Advanced Cancer: A Nationwide Study. American Journal of Hospice and Palliative Medicine\u0026reg;. 2020;38(7):794-9.\u003c/li\u003e\n \u003cli\u003eFlick K, Marchini L. The interprofessional role in dental caries management: from the social worker perspective. Dental Clinics. 2019;63(4):663-8.\u003c/li\u003e\n \u003cli\u003eHelgeson M, Glassman P. Oral health delivery systems for older adults and people with disabilities. Special Care in Dentistry. 2013;33(4):177-89.\u003c/li\u003e\n \u003cli\u003eCarter K, Chalouhi E, McKenna S, Richardson B. What it takes to make integrated care work [Internet]. London: McKinsey\u0026rsquo;s Health Systems and Services Practice; 2011 [cited 2023 July 19]. Available from: https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/\u003cbr\u003ehealthcare%20systems%20and%20services/health%20international/issue%2011%20new%20pdfs/hi11_\u003cbr\u003e48%20integratedcare_noprint.pdf.\u003c/li\u003e\n \u003cli\u003eGeorge A, Dahlen HG, Blinkhorn A, Ajwani S, Bhole S, Ellis S, et al. Evaluation of a midwifery initiated oral health-dental service program to improve oral health and birth outcomes for pregnant women: A multi-centre randomised controlled trial. International Journal of Nursing Studies. 2018;82:49-57.\u003c/li\u003e\n \u003cli\u003eHarnagea H, Lamothe L, Couturier Y, Esfandiari S, Voyer R, Charbonneau A, et al. From theoretical concepts to policies and applied programmes: the landscape of integration of oral health in primary care. BMC Oral Health. 2018;18(1):23.\u003c/li\u003e\n \u003cli\u003eErikson C, Park YH, Felida N, Dill M. Telehealth Use and Access to Care for Underserved Populations Before and During the COVID-19 Pandemic. J Health Care Poor Underserved. 2023;34(1):132-45.\u003c/li\u003e\n \u003cli\u003ePretty IA, Ellwood RP, Lo ECM, MacEntee MI, M\u0026uuml;ller F, Rooney E, et al. The Seattle Care Pathway for securing oral health in older patients. Gerodontology. 2014;31(s1):77-87.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Themes and sub-themes from analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"608\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of palliative care\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eas a key component of quality of life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eExperiences with treating people receiving palliative care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eImportance of oral health in palliative care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChallenges\u003c/strong\u003e \u003cstrong\u003eto providing oral health care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eCompeting priorities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eCondition-specific considerations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eDisconnect from other health services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eKnowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 211px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eA new model of care\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ebased on interdisciplinary collaboration and priority setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eDentist needs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003eInterdisciplinary collaboration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 397px;\"\u003e\n \u003cp\u003ePatient needs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Western Sydney University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palliative, hospice, end-of-life, dental, oral health","lastPublishedDoi":"10.21203/rs.3.rs-6356426/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6356426/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Poor oral health among people receiving palliative care is often overlooked among health professionals. Little is known about the experiences of dentists and the potential for an oral health model of care in the palliative setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A focus group with 21 dentists was conducted in a public oral health service in Sydney, Australia. The focus group was audio-recorded, transcribed, and thematically analysed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Three themes were identified: Awareness of oral health in palliative care; Challenges to providing oral health care; and A new model of care. While good oral health was perceived to be essential to palliative care management, there were key challenges that prevented adequate delivery of dental treatment. Participants highlighted the need for a new model of care in the future to include interdisciplinary training alongside the dissemination of appropriate protocols for dental training and streamlining referral pathways to prioritise people who may require more urgent dental treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Australian dentists working in a public dental service lack insight into planning dental care for palliative patients. Dentists show positive attitudes, but systemic barriers and training limit care provision. A palliative oral health care model is essential with interdisciplinary training, streamlined referrals, and teledentistry for urgent cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Relevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for palliative care services is increasing in Australia due to an ageing population. Oral health problems are prevalent among palliative patients and impact their quality of life. However, the experiences and perspectives of dentists offering care to palliative patients in Australia remains poorly understood. Our study reveals challenges experienced by dentists in this context, identifies key systemic barriers, and discusses the need for integration of dental and palliative care services. Streamlined referral procedures, with the help of guidelines and protocols, will help provide optimal care and ensure better quality of life in this population.\u003c/p\u003e","manuscriptTitle":"Oral health in palliative care: perceptions of public dental practitioners in Sydney, Australia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 06:21:33","doi":"10.21203/rs.3.rs-6356426/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ef4e5245-0e29-4cd7-961e-7c9d815b746d","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46545020,"name":"Nursing"},{"id":46545021,"name":"Dentistry"}],"tags":[],"updatedAt":"2025-04-03T06:21:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-03 06:21:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6356426","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6356426","identity":"rs-6356426","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}