Death and dying are not topics that we receive formal training in during dental hygiene school, nor are there many continuing education opportunities about death. Before becoming a dental hygienist, my experience with loss was from a personal perspective, but it did not take long before I learned about loss from my patients. I did not anticipate the day when a parent would share the tragic news of losing their child, or that they were diagnosed with a terminal illness. As an RDH in alternative practice in California, I have many patients who are older or in hospice care. Working with them is bittersweet and challenges me in ways different from the patients I encountered in private practice.
Dental professionals are well positioned to assess changes in our patients’ self-care, blood pressure, and overall wellness. We also play an important role in providing care to patients who are battling a terminal illness or nearing the end of life. Conditions commonly associated with hospice patients are xerostomia, dysphagia, dysgeusia, candidiasis, mucositis, ulcerations, and pain.1 Unfortunately, there is little information for dental professionals about how they should engage with people who are nearing death or experiencing grief.2-3 In fact, dentists report not feeling adequately prepared to deal with sudden deaths or listen to their patients who have incurable illnesses.2-4 While dental hygienists cannot offer counseling or therapy to patients on this subject, we must understand grief and have the communication skills to listen compassionately.2
Grief literacy explained
“Grief literacy” uses a public health model of bereavement care that encompasses a community-based approach designed to educate all members of society about grief.5 The study surrounding death and dying is referred to as thanatology and includes coping with grief and bereavement.6 Grief is considered a process and the natural emotional response to loss, whereas bereavement is the amount of time grief is experienced.7 Mourning refers to how grief is publicly demonstrated and varies based on culture and religious beliefs.7 Loss is not limited to death and dying. Besides illness and age-related death, people endure loss from a variety of events. Grief can result from a pregnancy loss, a breakup, a move away, loss of a pet, natural disasters, accidents, suicide, overdose, and a loss of safety due to acts of violence.8 People also grieve the loss of health, including tooth loss.3,9
A person’s response to loss is influenced by age, religion, culture, type of loss, preexisting medical and psychiatric conditions, level of social support, and coping skills.10 There are different types of grief. Anticipatory grief might be felt by a person who is nearing end of life or by those who are close to a dying person.7 According to the National Cancer Institute, 25% of patients with untreatable cancers experience anticipatory grief.10 Normal grief is the general grief that occurs soon after a loss. People experiencing normal grief may feel a range of emotions such as sadness, shock, disbelief, anxiety, confusion, numbness, anger, and guilt.7
The intensity and duration of these feelings differ from person to person. Symptoms of normal grief can take six months to two years and usually lessen over time.3 Some individuals have delayed grief. Up to 10% of the population will encounter complicated grief, which persists for a longer time. Prolonged grief has the potential to interfere with a person’s everyday life and may require psychiatric treatment.3,10
Symptoms of grief are not always obvious or observable. Besides a wide range of cognitive and emotional effects, grief has biological and social impacts on a person. Physical symptoms of grief are fatigue, upset stomach, nausea, decreased appetite, headaches, shortness of breath, and tightness in the chest and throat.12 Children experience grief in different ways than adults. Some show regression, difficulty controlling bladder and bowels, and changes in behavior. Experiencing the loss of a parent is considered a traumatic and adverse childhood event that can have a negative effect on health.13
People who are grieving have been found to have elevated inflammatory biomarkers thought to be related to emotional dysregulation and poor immune response.8,14 In some instances, grief leads to elevated blood pressure and cortisol levels due to stress and can raise the risk of a heart attack. Takotsubo cardiomyopathy, aka “broken heart syndrome,” is a temporary heart condition triggered by severe emotional or physical stress.7-8 Research shows an increase in morbidity and mortality among people who have lost a loved one.14 Men have been found to have poorer health outcomes and higher mortality rates when compared to women who have lost a spouse.7 Adverse effects of loneliness also impact health and well-being, especially in older individuals.15
Sometimes we may not know
Dental professionals will not always be made aware about a person’s recent loss or changes in their health. Sometimes patients are not as cooperative as we’d like them to be. We need to remember to be kind and consider the patient as a whole person. Trauma-informed care of patients includes our ability to understand what’s happened to them, and we must also be able to recognize emotional distress. An article published by the Journal of the American Dental Association in 1970 recommends dentists ask patients about grief.16 The COVID-19 pandemic and the increase in violence has brought about significant trauma and loss, and we ought to be mindful of this when assessing and providing care.17-18
Children are a vulnerable population affected by loss. It is estimated that one in 500 children lost a parent or grandparent who was a caregiver due to a COVID-19 death, with racial and ethnic minorities being disproportionately affected.17 Restrictions in social distancing and isolation resulting in the inability to hold funerals or be with loved ones also created additional difficulties for people.19
The dental profession should take a proactive approach to develop grief literacy and communication skills to improve support for our patients who suffer loss. Although further research is needed, grief can influence patients’ wellness and oral health behaviors. It is imperative for us to have a better understanding of the attitudes and beliefs of dental providers on death and grief. Interprofessional education and training about mental and behavioral health may be beneficial for dental professionals.
We need to get educated
As dentistry continues to integrate into medical and behavioral health, we need to be ready to engage with patients and communities experiencing trauma and loss. Palliative oral care also deserves more attention as nurses have said oral care is often overlooked.20 Providing palliative care to patients who are medically compromised and nearing the end of their life can be intimidating, especially if we don’t possess the appropriate skills.
Learning to listen empathetically requires we pay close attention to the dangers of compassion fatigue as this can contribute to burnout.21 We cannot ignore the impact of grief on the human experience. For me, caring for patients in hospice is a beautiful gift as it has taught me to be a better listener and to be more present and understanding. It also serves as a reminder of just how fragile life is.
Editor's note: This article appeared in the August 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
- Venkatasalu MR, Murang ZR, Ramasamy DTR, Dhaliwal JS. Oral health problems among palliative and terminally ill patients: an integrated systematic review. BMC Oral Health. 2020;20(1):79. doi:10.1186/s12903-020-01075-w
- Macdonald ME, Singh HK, Bulgarelli AF. Death, dying, and bereavement in undergraduate dental education: A narrative review. J Dent Educ. 2020;84:524–533. https://doi-org.ezproxymcp.flo.org/10.1002/jdd.12058
- Macdonald ME. It's time to make dental education ‘grief ’J Dent Educ. 2021;85:1718–1720. https://doi-org.ezproxymcp.flo.org/10.1002/jdd.12753
- Klieb HB, Wiseman Death, dying and bereavement: a survey of dental practitioners. Spec Care Dent. 2008);28:58-60. https://doi-org.ezproxymcp.flo.org/10.1111/j.1754-4505.2008.00017.x
- Breen LJ, Kawashima D, Joy K, et al. Grief literacy: A call to action for compassionate communities. Death Stud. 2022;46(2):425-433. doi:10.1080/07481187.2020.1739780
- Merriam Webster. Thanatology. Accessed June 01, 2022. https://www.merriam-webster.com/
- Mughal S, Azhar Y, Mahon MM, et al. Grief reaction. National Library of Medicine. January 2022. Updated March 24, 2022. https://www.ncbi.nlm.nih.gov/books/NBK507832/
- Peña-Vargas C, Armaiz-Peña G, Castro-Figueroa E. A biopsychosocial approach to grief, depression, and the role of emotional regulation. Behav Sci (Basel). 2021;11(8):110. doi:10.3390/bs11080110
- Matsuyama Y, Jürges H, Dewey M, Listl S. Causal effect of tooth loss on depression: evidence from a population-wide natural experiment in the USA. Epidemiol Psychiatr Sci. 2021;30:e38. doi:10.1017/S2045796021000287
- National Cancer Institute. Grief, bereavement, and loss (PDQ)-patient version. Accessed June 1, 2022. https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/bereavement-pdq
- PDQ supportive and palliative care editorial board. Grief, bereavement, and coping with loss. December 3, 2020. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK66052/
- Osterweis M, Solomon F, Green M, eds. Bereavement during childhood and adolescence. In: Bereavement: Reactions, Consequences, and Care. National Academies Press; 1984. https://www.ncbi.nlm.nih.gov/books/NBK217849/
- Head Start Early Childhood Learning and Knowledge Center. Trauma and adverse childhood experiences. Accessed June 01, 2022. https://eclkc.ohs.acf.hhs.gov/publication/trauma-adverse-childhood-experiences-aces
- O'Connor MF. Grief: A brief history of research on how body, mind, and brain adapt. Psychosom Med. 2019;81(8):731-738. doi:10.1097/PSY.0000000000000717
- Centers for Disease Control and Prevention. Grief and loss. Accessed June 01, 2022. https://www.cdc.gov/mentalhealth/stress-coping/grief-loss/index.html
- Kutscher AH, Schoenberg B, Carr AC. Death, grief, and the dental practitioner: thanatology as related to dentistry. J Am Dental Assoc. 1970;81(6):1373-1377.
- More than 140,000 U.S. children lost a primary or secondary caregiver due to the COVID-19 pandemic. National Institutes of Health. October 2021. Accessed June 1, 2022. https://www.nih.gov/news-events/news-releases/more-140000-us-children-lost-primary-or-secondary-caregiver-due-covid-19-pandemic
- Butler SA, Panzer AM, Goldfrank LR. Preparing for the psychological consequences of terrorism: A public health strategy. Institute of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK221638/
- Albuquerque S, Teixeira AM, Rocha JC. COVID-19 and disenfranchised grief. Front Psychiatry. 2021;12:638874. doi:10.3389/fpsyt.2021.638874
- Uziel N, Meyerson J, Giryes R, Eli I. Empathy in dental care–the role of vicarious trauma. Int Dent J. 2019;69(5):348-353. doi:10.1111/idj.12487
- Gustafsson A, Skogsberg J, Rejnö Å. Oral health plays second fiddle in palliative care: an interview study with registered nurses in home healthcare. BMC Palliat Care. 2021;173:20. org/10.1186/s12904-021-00859-3