Dr. Xi Chen

Dr. Chen is an assistant professor in the Department of Dental Ecology at the University of North Carolina Chapel Hill School of Dentistry. Dr. Chen currently holds a NIH K23 Career Development Award. His expertise includes oral health management for older adults with dementia, end-of-life oral health care, and clinical decision-making for medically compromised elderly patients.

ElderBranch interviewed Dr. Chen to discuss his paper, “Self-reported Oral Health and Oral Health Behaviors in Older Adults in the Last Year of Life.” Dr. Chen wrote the paper along with colleagues from the University of North Carolina: Dr. Supawadee Naorungroj, Miss Christian Douglas and Dr. James Beck.

What led you to research this topic? Why is it important?
Older adults may experience complex physiological, psychological and functional changes at the end of life. These changes may dramatically affect oral health and increase the risk of oral infection, dental pain and oral soft tissue pathology, which in turn may exacerbate systemic health decline and further compromise quality of life in these vulnerable individuals.

Although the end of life course may be short in some patients, such as some cancer patients, it could also linger up to a year or longer. During this slow, prolonged process, severe dry mouth, oral pain and oral infection may substantially affect a patient’s quality of life. Poor oral hygiene and oral infection may cause severe, even fatal, systemic complications such as aspiration pneumonia. Severe dry mouth, impaired chewing function and swallowing disorders can further aggravate malnutrition which may in turn worsen patient’s health and functional status and accelerate the terminal decline. Therefore, oral health should be addressed as part of end-of-life care.

Unfortunately, however, oral health is often overlooked in end-of-life patients. In the course of my work, I often notice that although oral health is poor, many older adults with terminal illnesses do not receive any oral health care prior to death, which may substantially compromise quality of life of these patients. While under-treatment is a concern, unnecessary treatments are also commonly provided to persons with short survival.

As a fellowship training geriatric dentist, I, therefore, think we need more research and evidence-based guidelines to guide our clinical practice to better manage our patients who have advanced health conditions and are at the end of life.

Why is oral health so often overlooked, or secondary in comparison, to general health?
There are multiple issues that contribute to this.

Physicians and other health care providers lack training in oral health and managing oral health conditions. As a result many have a lack of appreciation of the two-way-relationship between oral health and systemic health. Research shows that only approximately 20% of physicians consider oral health as part of general health. Therefore, oral health is often overlooked in geriatric patients. This is a particular concern for nursing home patients who are more likely relying on caregivers to identify issues, including dental issues.

Another reason has to do with lack of training among dentists on oral health management for end of life and the lack of evidence-based clinical guidelines. Therefore, dental management may be insufficient to address the oral health needs for some patients, resulting in prolonged suffering of treatable pain, infection and compromised quality of life. On the other hand, aggressive, futile treatment may also be unintentionally provided to this vulnerable population, raising concerns for quality of care.

In addition, terminally-ill patients and their family members may be less likely to prioritize oral health needs due to increased disease burden, transportation difficulty and psychological distress at the end-of-life.

Please describe your study. What was your in-going hypothesis regarding self-rated oral health and oral health behaviors in the elderly, and how did you test this?
This study was a retrospective longitudinal study. It examined self-reported oral health and oral health behaviors in community-dwelling older adults in the last year of life. We hypothesized that along with general health and functional decline, oral health may also decline.

To test this hypothesis, we retrospectively followed 810 dentate community-dwelling older adults aged 65 and older up to 8 years. Participants were interviewed using a structured questionnaire at baseline, 18, 36, 60, and 84 months regarding their sociodemographics, self-reported oral health, oral conditions, use of oral health services, and preventive behaviors.

Participants who died within 1 year (end of life group) after an interview were identified using the National Death Index. Their self-perceived oral health and oral health behaviors (e.g. brushing of teeth, use of mouth rinse) were compared with those of the comparison group, meaning those who did not die within one year after an interview.

What were the keys findings from your work?
We found that community-dwelling older adults in the last year of life were about 2-3 times more likely to report poor oral health and general health and dislike their mouth appearance and ability to chew food than those not in the last year of life. Neurosensory function such as taste and smell also remarkably declined at the end of life.

However, there was no difference in self-reported oral conditions, use of oral health services, and preventive behaviors between two groups.

What are the main implications? How can your research on this topic be used to help improve elderly people’s self-rated oral health at the end of life?
The findings of our study suggest the following:

  1. When systemic health deteriorates at the end of life, as an integrated component of health, oral health also declines and people are able to recognize and report those changes.
  2. Rather than pain, tooth sensitivity, dry mouth and looseness of teeth, dentally-related aesthetic concerns, and impaired oral function might underlie the self-perceived poor oral health in community-dwelling older adults in the last year of life.

These finding outline the oral health needs of community-dwelling older adults in the last year of life and provide valuable information for dental professionals to better address oral health needs and improve the quality of the remaining life of these individuals.

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