Implant Surgery to Improve the Oral Health-related Quality of Life During Palliative Care - a Case Report

Introduction: It is the task of palliative care to care for patients who are terminally ill. At this stage, no excessive interventions should be carried out and the quality of life is paramount. As palliative care is based on an interdisciplinary approach, it should also include oral health care. Case Report: A 71-year-old patient presented with a lack of function of his maxillary full denture. All treatment measures by the family dentist with dental modifications and the use of adhesion aids could not improve the operability. Upon clinical examination, physiological salivation was measured and a flattened vestibule throughout the maxilla could be diagnosed. The patient complained of an extremely stressful life, which had deteriorated due to the intraoral situation and asked for implant-mediated rehabilitation to improve the oral quality of life. After asking about his medical history, the patient reported that the following diagnoses had been made: a multifocal hepatocellular carcinoma in cirrhotic-modified liver, arterial hypertension, an absolute arrhythmia in atrial fibrillation, heart failure NYHA II, and hemifacial spasm on the left side. The hemifacial spasm was initially treated with botulinum toxin injections, and ultimately with micro-euro surgical decompression by Jannetta in 2011. For the treatment of histologically confirmed multifocal hepatocellular carcinoma, intra-arterial chemoembolization of several HCC foci was carried out with doxorubicin in 2014. Because of the cardiac symptoms, warfarin was also given. The last abdomen MRI, natively and with contrast agent, showed no progress in size of the liver foci. In several hours of talks with the patient - at his request without the presence of family - all conventional and surgical intraoral treatment options were discussed in detail. In the foreground of all considerations, expected lifetime played an important role. Based on a preoperative dental digital volume tomographic investigation, adequately sized bone site for insertion of implants was identified in the anterior maxilla. In October 2015, 4 implants were placed without complications in regio 24, 22, 12, and 14, and in December 2015 the existing complete maxillary denture was fixed by locators to ensure function. Discussion: The present case shows the extraordinary stress of patients and therapists. Complex therapeutic strategies should be avoided following the standards of palliative care, but the plan is highly individual and totally dependent on the physical and cognitive limitations and the desires of the patient and possibly his family. After the four basic principles of action autonomy (respect and esteem of the patient), justice (equality), beneficence (weighing of potential benefit to potential harm) and non-maleficence (fundamental obligation to avoid the damage), the required oral surgical treatment was performed. Keywords: palliative care, ethical considerations, dental implants, oral health care