Special Carefor Special Patients

Caring for the medically compromised patients in your practice.

• Mary-Ellen Cascone BSc, DDs

• Staff dentist, Mount Sinai Hospital and Toronto Rehab (UHN)

• Co director of the Hospital Dental Residency Program, Mount Sinai Hospital

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Many of the people we see, so can you!

• Will review some of the medically compromised groups and some of the unique issues related to that condition, which will often impact the dentistry we do one them. Hopefully, you will take away from this talk, that you can keep many of these patients in your own practice, patients you have had for years and I would suggest that there is no one better to treat them, than the dentist they have trusted for years.

• Being mindful of the condition the patient has, and the unique factors related to it, we can educate the patient and families, clean up trouble, be preventive, and treat these patients routinely, so as to maintain a quality of life, dignity…

• As the complications related to neglect in the face of a patient being “more difficult” is much harder to treat down the road.

SPECIAL CARE PATIENTS

• STROKE• GERIACTRIC (FRAIL)• HEAD INJURY (TRAUMATIC, NON TRAUMATIC)• DEMENTIA• DEVELOPMENTALLY AND/OR INTELLECTUALLY

DISABLED

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Stroke: emotional changes

Cognitive changes/emotional changes/outbursts.Re emotional outbursts- give them a moment and then move on (if fuss about it, only embarrasses them).

Lack of motivation and often depression in the early stages after a stroke, which can affect oral hygiene-encouragement and 3 month cleanings, and hopefully time will sort it out (often very different people a year after the stroke, don’t give up on them!).

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Stroke: Motor changes

When it affects the patients dominant side and they are now using a new hand to brush with- will have to relearn, but having many aids to help them such as electric toothbrushes and interproximal tools on the market…

Muscles of the affected side are weaker- source of many consults re “change in fit of denture” after the stroke.The denture didn’t change, the patients muscles supporting it did! Ask the question “how was the denture fitting before the stoke?”. If it was good, don’t touch it, if not, then can discuss relines…..

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Stroke : Speech changes (dysphasia/aphasia)

Often difficult for the patient to articulate their concerns/needs (which frustrates them),so keep questions simple so that a yes or no reply is required.

Patients that are frustrated or embarrassed, are reluctant to come back!

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• Decrease function of swallowing muscles on affected side• A deterrent for the patient to go to the dentist, is the fear

they will choke (includes their own saliva, and water..).• Need to reassure the patients that the airway is one of

your primary concerns.• Patient upright and head postured forward (block the

airway).• Can use cavitron, just use with head forward to block the

airway and with both suctions on (plastic bib is useful).• Stand up dentistry (not a reason to refer to the hospital!).

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Stroke: dysphagia (trouble swallowing).

Stroke: attention deficit disorder

• Why I think patients need to be seen ASAP after stroke, to ensure they don’t have an attention deficit disorder

• If they do, they will be unaware of one half of the mouth, they won’t brush it, as it is not there to them (one side perfectly clean, one side untouched).

• This must be reviewed, not only with the patient, but with the care giver/family member, as this side most likely will break down…

• Show them with a mirror, show the family, have someone help if necessary

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Stroke: new medications

• Many now anticoagulated-educate them.• Medication will depend on the etiology of the stoke.• If coumadin- INR of 3 or less required for treatment.• Low molecular weight Heparins are considered “non-

measurable” medications (no bloodwork required).• New drugs such as Xarelto, confer with MD, but often will

just take the dose after the procedure (if bleed, bit on gauze for a day if need be and miss next dose).

• If told to stop them- they are put at risk for a thromboembolic event up to 30 days later- they are on these drugs for a reason! (Robert Henry, 2007 SCDA )

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Stoke:

• Don’t delay treatment after strokes - not the same as MI 6M wait unless urgent care.

• Important to see these patients as soon as possible, to avoid trouble -as attention deficit is a big problem in many of these folks!

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FRAIL GERIATRIC PATIENTS

• Geriatric patients/patients of advanced age that are well…are treated no differently that any other patient (may be dry, with recession/roots….educate…) , but ageism has no place in dentistry (or anywhere else).

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Frail Geriatric Patients:

This patient population is often in and out of hospital frequently. Someone may call to cancel an appt re a loved one in hospital. The front desk staff can let them know you will want to see the patient as soon they are up to it, once back home, to:

1) ensure they are back to their usual standard/back on track, as oral hygiene is often not at the top of their list when in hospital, which is understandable, but don’t want it to fall apart.

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Frail Geriatric Patients:

2) educate them re any new medical condition/medication which may impact their oral condition

3) to ensure nothing intraorally can be contributing to the overall decline in health (or that a dental finding was not the original cause of their medical problem!)…they (no one) can’t afford an oral sources of systemic infection. If they are so frail and considered unstable, they may need to be considered a palliative patient, but many are stable and treatable.

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Frail Geriatric Patients:

4)Dentures left at home during prolonged hospital stay, often don’t fit when they try them in after a few months (re tooth movement..) so educate them ahead of time (and if they do take them with them, careful re not losing them!).

• These folks are often in and out of hospital, and if they have dentures, you can suggest name tags be placed in them, if not already done so (will help if misplaced and found, won’t help if in a tissue on their tray and thrown out).

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Head Injury/Aquired Brain Injuries:

• Often in acute care for months, including ICU…

• Oral hygiene not a priority (saving their life is!)

• Screen to assess hygiene (often lacking or non-existent)

• Get them back on track - “REBOOT THE COMPUTER”

• Often asked look for the dental source of brain abscess

which cultured oral bacteria!

• If cognitively unable, or motor skills unable, find out who

will do the hygiene….get family involved (as they will

either do it or pass on the info to the PSW, who will do the

hygiene). (re oral hygiene- see slides 40/41).

HEAD INJURIES: if ACCIDENT RELATED:

• If an accident, are the dental treatment needs related to the accident, or unrelated to the accident? IF related to the accident…think down the road when doing a medical legal report. If oral hygiene is compromised, add that to the report, as will affect long term prognosis.

• (ie if a tooth cusp fractured, now a filling, down the road possible endo and crown, if fails, an extraction and implant…..).

Head injuries:SWALLOWING ISSUES (as with strokes…)

• Aspiration risks: saliva, plaque, grossly mobile teeth!• Aspiration pneumonia and oral bacteria - why good oral

hygiene and regular cleanings are so important!• Re grossly mobile teeth,… if cognitive or motor function is

compromised-remove these teeth!• Re restorative-good suction and rubber dam.• Re cleanings-can carefully a use cavitron (as will see a lot

of calculus in this patient population), with patient upright and head is postured forward to block airway, and high and low volume on at all times (and plastic bib!!)- operator stands-care with back! (I put my foot up on a stool!).

“DEMENTIA” patients (Geriatric psychiatry)

• Pain and infection can contribute to negative behavior (often behavior better, without adjusting meds, after an extraction!).

• Goal for advanced dementia: pain free, infection free (many have lost their verbal skills, so can’t tell you if something is troubling them, will act out in lieu). QUALITY OF LIFE issue! Treat these patients while you can!

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Dementia continued:

• Long term prognosis in the face of poor cooperation and lack of hygiene, is very poor….think down the road, can they maintain it? If it fails in 5 years, they will be 5 years older, more frail, often more aggressive- so deal with it now while can. Later, often must leave and observe… (if can get out most of caries and seal it for comfort measure, most likely will stabilize the area..).

• Early stages: frequent recalls, fluoride…keep trouble away, as often too hard to address/fix when behavior is an issue. (easier to prevent than fix!).

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How to treat an uncooperative dementia patient safely:

• Short term memory issues: explain often, when treating-”restart” the appointment as soon as feel their agitation start to rise.

• Be on guard: stand at side of patient (never directly in front) (Non violent crisis intervention course recommends)

• Arm posture - protecting myself (“on guard”)• Don’t hold them – they will fight you! (hands hover over

their arms to block, vs hold).• Explain (even if they have reverted to their mother

tongue!).

How to treat uncooperative dementia patients safely:

• GENDER PREFERENCES!

• “Cute” patients…may not help you, but they won’t hurt you.

• They often don’t like to recline back too far (breathing, control...) (again, stand up dentistry).

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How to treat uncooperative demenita patients safely:

Many will tolerate hand scaling i.e. 204S sickle and a curette and prophy or tooth brush..but not the cavitron(same with dd patients)- if you use the cavitron, you may get a flare up of poor behavior often).

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How to treat uncooperative dementia patients safely:

Quiet environment, with exception of music appropriate for the patient (I have CD’s for each era, I know if I am ever in the same situation, I will be happy if they play the music of my youth!).

limit talking, unless to patient, as confuses the patient.

Keep the focus on the patient, not the family member in the room.

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DEMENTIA and DENTURES

Dentures rely on cognitive and motor factors in order to succeed.Do they need dentures? Most likely, the diet already has been modified due to change in motor function and compromised swallowing (regardless of having dentures or natural teeth).If lost, should we remake them?.Could you make them if you wanted to? (should you try so as not to close doors?) (document the limitations!!).Will they wear them (coping is poor)?Who are they for? The patient or the family?

DEMENTIA and DENTURES

If placing name tags on their own dentures - do same day, as often out of sorts without them.

If early in dementia and appropriate, consider implant supported dentures? Whether retrofitting existing or new…as will be one less thing to frustrate the patient.

MY RULE IS: if they can’t manage dentures on their own, we do not recommend they use them, as they now become an airway risk! I will not be bullied into making dentures when I feel it is inappropriate for the patient.

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CONSENT with DEMENTIA (from POA)

• Need re care/treatment and $ (often different people).

• Often write on the consent form (after I have verbally explained it to them) that if I am not able to take an x-ray of the tooth to be removed, I will remove it, even without the x-ray (as it is easier to take out a tooth than do an x-ray on patients with cooperation issues!)

Consent with Dementia patients (from POA)

Remind them we are doing the best we can, and may not get all treatment completed…(windows of cognition- when it opens, jump in, when it closes, get out!).

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Dementia patients:

These patients may resist care in other areas such as eating, clothing, bathing…(ADL’s)….yet we can do dentistry on them…so don’t give up! (they never did their own dentistry, and they will remember that when you start to work...)

Remind them often what you are doing, and why.

There is no one better to treat them, than their dentist they have known for years!

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Dementia patients re active treatment:

• If a dementia patient needs work, I will try with whatever prn agitation sedation they have already ordered by the MD, and that is often all I need.

• If unable with this, I consult the MD to see what they would like to happen, a different sedative…remember, this is an out patient and they need to go home (don’t overdo it, have to worry re recovery, respirations…).

• If need treatment and fit for a GA, then that may happen.• If need treatment and not fit for a GA, then will see patient

every 3 months….this is….

PALLIATIVE CARE RE DENTISTRY:

• I will clean, as best I can (to decrease the bacterial load, and thus a possible source of an aspiration pneumonia), often with the help of the family. Also, ensure there is no need for an antibiotic re an acute infection, which will push an acute infection back to chronic, and hopefully keep them comfortable.

• This is dental palliative care- the goal is that the patient is pain free and acute infection free (re improved quality of life).

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ACCESS DIFFICULTIES- patients hard to get to the office

• Difficult getting some of the frail folks around. If they come, I want to know I can treat them that day, since they are usually coming because there is a problem.

• A referral/check list must be completed before I will see someone - so as not to waste the patients, their family member’s, and my time!

TRANSFERS: does this patient come to you in a wheelchair

• If in a wheelchair, I ask, “can you transfer” – NOT ” can you walk?”.

• If they say no, I ask “how did they get into the chair?”• They just need to weight bear in order to transfer • For hemiplegic patients, if able, transfer in and out on

“good” side• Consider having a transfer board in your office.• If something very quick, I will leave them in their chair-

otherwise transfer them (for your backs sake).• If not transferring -use your legs/foot up/protect your

back.. and protect/stabilize the patients neck/head as well.

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“DEVELOPMENTALLY AND/OR INTELLECTUALLY DELAYED” (dd) patient

• Physically: such as cerebral palsy• Mentally: such as downs, autism• Good behavior - private setting• Moderate to poor (aggressive) behavior - specialist or

hospital• Adult special needs clinic at MSH

When treating dd patients:

• Keep it simple • Show tell do• Movement of patients ie CP, move with them! (stabilize to

protect). • Often must hand hold, get care givers, family involved (if

allow).• Sedation when appropriate (ie higher functioning and

anxious).

When treating dd patients:

• For the more profound dd and aggressive- most likely sedation won’t help (not anxious patients) and hard to monitor recovery in non verbal, non ambulatory patients!

• General anesthetics: indication –uncooperative and a clinical need- often get nothing but a screening done, to look for an indicaton for a GA.

• Typically done q3-5 years –risk of GA vs treatment…• Often cleanings only are done, no decay – DIET!

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TYPICAL NOTE to a group home re dd patient with poor behavior (use layman’s terms).Date: 3m recallLIMITED/CURSORY exam, secondary to POOR cooperation

Update med history: no significant changesCC: none (ask re change of behavior…often an indication of pain or infection)

E/O no obvious gross asymmetries

I/O gross plaque, gross calculus, no OBVIOUS caries, no OBVIOUS swellings or fistulas, moderate motilities generalized (none at risk of aspiration), severe gingivitis. Dx: severe gingivitis secondary to poor oral hygiene. Prognosis fair to poor. Treatment, limited tooth brushing of bucal surfaces. Reviewed tb at gum line with small tooth brush, in a gentle manner, and diet, with PSW. No indication for GA at this time. RTC 3M recall. (care, history of pinching, 3 operator). (which means your assistant and the family or PSW). Sign.

Within the DD population:

•Increase incidence of bruxism? Bruxism appliances with good oral

hygiene only, or caries rate increases!

Increase incidence of GERD, advise family so MD can prescribe medication if they deem it appropriate

•Often poor oral hygiene, so diet discussion very important.

•Can pre-d ODSP re cleanings q3ms, good for 5 years.

•Prescribing of CHX, fluoride …with care as many will only swallow anything put in their mouths.

•Consistency of provider helpful- same hygienist so can bond!

•Reminders in the bathroom (and for memory issue patients as well)

Advice re providing oral hygiene to patients(whether from DD or head injury or dementia)

• Everyone is worried about being bite- my mantra to the students, family and PSW’s: if you get bit, it is your own fault- don’t put your fingers between unpredictable patients teeth!!

• Most of the trouble is on the bucal surfaces, look there and clean there (if they are very vocal…can look on palatal side!). (PSW’s often say can’t brush as they won’t open- no worries, brush the bucal, tongue will self clean the inside).

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Advice re providing oral hygiene to patients(whether from DD or head injury or dementia)

• Gentle but thorough.No scrubbing- the patient will resist as it hurts! (I offer to

clean the PSW’s teeth and see how they like it!).• “You can’t clean it if you can’t see it” (to the students or the

psw)• Hypertonic lips, finger in mucubucal fold, small

toothbrush…or will miss the gum line• From behind the patient, so sweeping motion same as the

one we do in our own mouth, and gives a “birds eye view”• Do the best you can, not a perfect situation, but try (if

never try, never will desensitize the patient…gets harder)

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RESTORATIVE SUGGESTIONS:

In the face of poor oral hygiene, amalgam in the posterior and glass ionomer in the anterior (as many are class V lesions.Rubber dam is a must, especially with swallowing disorder patients (for fillings, crowns, bridges…) (of course if able).For patients difficult to treat who have caries- try and leave the nerve undisturbed if able, place a sedative dressing and restore it so it is sealed, most likely will arrest the process and you can call it a day (vs flare up and need endo or exo…). (try not to open cans of worms!!!).

PREVENTIVE SUGGESTIONS:

In office:clean q3m and neutral fluoride in trays

At home: Magnifying mirror in the bathroom +/- note on mirrorChlorohexidine (swallowing?)/non alcohol based rinsesWeekly use of a high fluoride toothpasteSips of water to spread their own salivaElectric tooth brush, small headXylitol gum

PREVENTIVE SUGGESTIONS:

NEW:-a clear coating of chlorohexidine applied professionally to adult teeth- excellent results re caries prevention being noted (I have not done this yet myself). (research ongoing re use on the special needs population).

-Silver diamine fluoride applications re arresting active caries (again, I have not done this yet, but the 2017 Special Care Dental Association Conference talk had very good outcomes with its use-careful, turns everything black!).

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• Difficult situations often: lots of STRESS in general, coping mechanisms are taxed (for the patient, the care-givers and the family) - try not to overwhelm, but also they should not be neglected.

• BUT, we need to be realistic-often dealing with issues related to hygiene, dexterity, cognition, diet, dryness…Everyone is doing the best they can!

If you are able to, and it is appropriate, try and keep these patients in your practice. Patients are very appreciative that they, or their loved ones, are able to be seen by the dentist they have known, and trusted, for years.

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• QUESTIONS?

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