Assessment of dental care level in pediatric palliative care unit

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Introduction

The need for palliative care for adults and children around the world has never been greater or grown as rapidly as it is today.

In most countries around the world, palliative care for the population is not sufficiently developed. Outside North America, Europe, and Australia, access to quality palliative care remains minimal, even though up to 76.0 % of the population in these areas needs it¹.

Modern, high-quality palliative care improves the quality of life of patients with life-threatening illnesses and their families by preventing and alleviating suffering through early detection, proper assessment, and treatment of pain, as well as physical, psychosocial, spiritual, or other problems [3].

Palliative care for children, as a special area of palliative medicine, involves active, comprehensive care for the sick child's body, mind, and soul, as well as support for family members [3].

In Russia, more than 180,000 children under the age of 18 require palliative care every year. The structure of diseases among patients requiring palliative care in this age group includes 7.0 % malignant neoplasms, 93.0 % non-oncological diseases, of which congenital malformations and genetic diseases account for 42 %, cardiovascular diseases – 23 %, neonatal diseases – 12 %, and other non-oncological diseases – 16 % [1; 2].

According to data from the annual monitoring of the palliative care (PC) system in the constituent entities of the Russian Federation, 29,584 children received palliative care in 2024.

Among the child population of the Perm Krai, PC (both outpatient and inpatient) is associated with severe diseases of the central nervous system (severe cerebral palsy, neurodegenerative diseases, drug-resistant epilepsy) in 65.0–70.0 % of cases, in 16 % of cases due to congenital malformations, in 5.0 % due to neoplasms, in 4.5 % due to perinatal conditions, and in 7.5 % due to the consequences of infectious diseases [5].

An analysis of contemporary specialized literature [4; 6–8] shows that children with severe somatic diseases who are under observation in palliative care units have significantly worse dental hard tissue condition compared to the general population, which is objectified by high prevalence of dental caries and poor oral hygiene, as well as difficulties in obtaining dental care [4; 6–8].

Materials and Methods

The study was conducted in the inpatient palliative care unit of the children's hospice at Children's Clinical Hospital No. 13 in Perm.

The hospital provides palliative care to children aged one month to 18 years living in Perm and the Perm Territory. The hospice employs qualified specialists in various medical fields, including massage therapists, exercise therapy instructors, a medical psychologist, as well as special education teachers, educators, and social workers².

However, dental care, including prevention and treatment of major dental diseases, is not provided to children receiving palliative care, as there is no pediatric dentist on the permanent staff [9; 10]³. Thus, there is a need to improve existing standards of palliative care by including rational dental treatment and preventive measures that are methodologically adapted to the specific characteristics of this pediatric population.

A comprehensive dental examination was conducted on 48 children aged between one and 18 years who were receiving palliative care in a hospice. Boys dominated the group examined (60.0 %).

The structure of diseases for which sick children were hospitalized in the hospice included (Figure):

• nervous system disorders (G00–G99) – 75.0 %;
• congenital developmental abnormalities,
• deformities, and chromosomal abnormalities (Q00–Q99) – 23.0 %;
• endocrine system diseases, eating disorders, and metabolic disorders (E00–E90) – 2.0 %.

Fig. Structure of diseases in children receiving palliative care in hospices: a – diseases of the nervous system; b – congenital anomalies (malformations), deformities, and chromosomal abnormalities; c – diseases of the endocrine system, eating disorders, and metabolic disorders

The dental status of hospitalized children was characterized by indicators of dental caries intensity and oral hygiene level. The condition of the examinee's dental occlusion was taken into account. The assessment of dental plaque in children receiving palliative care was carried out in accordance with recommendations developed and adapted to the specifics of the examined pediatric population (rationalization proposal No. 2883 of 12/17/2024 “Method for assessing oral hygiene in children receiving palliative care,” M.A. Danilova, M.V. Manaeva, O.A. Tsarkova) and included the following stages:

1. Drying the enamel with a cotton roller.
2. Application of methylene blue solution to the outer surface of the teeth in the accessible area.
3. Assessment of the intensity of tooth crown staining:

1 – no staining;

2 – staining of 1/4 of the tooth crown surface;

3 – staining of 1/2 of the tooth crown surface;

4 – staining of 3/4 of the tooth crown surface;

5 – staining of the entire tooth crown surface.

4. Calculate the index using the formula:

Total number of points for stained teeth / n, where n is the number of teeth in the accessible area.

The final results allowed us to determine the level of oral hygiene as:

good at FH = 1.1–1.5;

satisfactory at FH = 1.6–2.0;

unsatisfactory at FH = 2.1–2.5;

poor at FH = 2.6–3.4;

very poor at FH = 3.5 points and above.

The severity of dental caries in the examined patients was assessed using traditional indices.

Based on the dental problems identified in the children and taking into account their general condition, recommendations were formulated regarding the scope and specifics of therapeutic and preventive dental measures to be carried out in a hospital setting.

Results and Discussion

According to the results of the study, out of 48 children, 27.0 % had a milk bite, 40.0 % had a mixed bite, and 33.0 % had a permanent bite.

Analysis of the data obtained on the assessment of dental plaque in children receiving PC indicates a high (65.95 %) percentage of individuals with unsatisfactory oral hygiene. At the same time, 8 patients were found to have extensive mineralized dental deposits covering the vestibular and oral surfaces of the teeth.

Twenty-one children (43.75 %), predominantly female, hospitalized for nervous system diseases, were on enteral nutrition. Among them, eight patients had a mixed bite.

Intact dentition was diagnosed in 14 children (29.1 %), whose average age was 4 years and 10 months.

68.0 % of children were found to have dental caries and its complications. It was found that children with nervous system diseases are more prone to dental caries, with the most critical situation observed in girls during the mixed dentition period (24.0 %). Boys with permanent dentition also had a high dental caries intensity index. Among children with congenital anomalies, deformities, and chromosomal abnormalities, the highest number of carious teeth was found in girls during the deciduous dentition period (20 teeth).

Surgery was required for 9 of the 33 children in need of sanitation, and 4 children had already had at least one permanent tooth removed.

11 (22.9 %) of the 48 children examined had previously sought dental care (Table).

The condition of hard tooth tissue in patients receiving palliative care depending on the nosological form of the disease

Conclusions

Thus, dental health in children receiving palliative care is poor. Children with nervous system diseases show a tendency toward an increase in the number of carious teeth with the transition from the deciduous to the permanent dentition. At the same time, the number of filled teeth remains very low, which indicates poor oral hygiene and a low level of dental care.

In addition, there is a correlation between the activity of the carious process and developmental defects that formed during the antenatal period, not excluding morphological changes in hard tooth tissues.

It is necessary to develop and implement specialized dental care programs that take into account the systemic and dental health characteristics of this category of patients in order to improve the dental status of children in palliative care units. It is also necessary to review and include a dentist in the core staff of palliative care units. This need is particularly important when working with children.

1 Global Atlas of Palliative Care, 2020.

2 Children's hospice, available at: https://dkb13.ru/otdeleniya/otdelenie-palliativnoy-pomoshchi/otdelenie-palliativnoy-pomoshchi; Order of the Ministry of Health of the Russian Federation and the Ministry of Labor and Social Protection of the Russian Federation dated May 31, 2019, No. 345n/372n. M. 2019.

3 Cerebral palsy in children: clinical guidelines. Ministry of Health of the Russian Federation, Union of Pediatricians of Russia. 2016, available at: https://nasdr.ru/wp-content/uploads/2019/06/kr_dcp.pdf

About the authors

M. V. Manaeva

Author for correspondence.
Email: manaeva.m.v@yandex.ru
ORCID iD: 0009-0007-3132-8665

Postgraduate Student of the Department of Pediatric Dentistry and Orthodontics

References

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2. Fig. Structure of diseases in children receiving palliative care in hospices: a – diseases of the nervous system; b – congenital anomalies (malformations), deformities, and chromosomal abnormalities; c – diseases of the endocrine system, eating disorders, and metabolic disorders

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