INTRODUCTION
INTRODUCTION
E
very patient is a unique individual with different abilities and needs. 1 A compromised individual is a person who has one or more physical, medical, mental, social, or emotional conditions that result in a limitation of that person’s ability to function normally in fulfilling the activities of daily living (ADL). Four out of ten patients may require a modification in treatment plan at some point because of these conditions. These conditions may be transient, such as pregnancy or a bone fracture, or lifelong, such as chronic renal failure or mental retardation. 1,2,3
Most of us experienced temporary periods of being compromised, either through illness or an accident. During these times we encounter the same problems as someone who has a record of impairment, but our overall outlook is probably less pessimistic or guarded because of the temporary nature of disability. 4
objectives 5
▪ To promote maximum oral health for compromised individuals.
▪ To assure that all compromised individuals are treated with the same ethical, moral and professional standards for care as would be allocated to normal individuals within limitations that the disability dictates.
▪ To promote maximum comfort, quality of life, and independence for these same individuals.
▪ To assure that these individuals receive appropriate oral health care that is compatible with their medical, mental, physical, social, and emotional needs and desires.
▪ In addition to teaching the necessary clinical skills, to recommend that the training of family, caregiver staff and the dental care provider includes being empathetic to the needs of the patient.
▪ To acquaint physician and other health care professionals with the oral health care needs and recommendations for these individuals.
GENERAL CONSIDERATIONS
Incidence/Prevalence of Compromised Individuals. 1
▪ National statistics on incidence and prevalence figures are difficult to compile because of:
1. Unreliable reporting systems
2. Variable definitions of conditions
3. Differences between acute versus chronic conditions
4. Overlap in data when dealing with multiple conditions
▪ Estimated prevalence of selected disabling conditions is shown in Table 1
▪ Incidence, chronicity, and severity of health conditions is increasing with age
▪ Table 2 identifies the most common chronic conditions in the elderly population
-Table 1 Prevalence of selected disabling conditions –
|Estimated number |-CONDITION- |
|9 million |Mental illness |
|6.5 million |Mental retardation |
|6 million |Rheumatoid arthritis |
|4.5 million |Seizure disorders (including epilepsy) |
|1.7 million |Hearing loss (to the point of severe impairment) |
|1.4 million |Vision loss (to the point of severe impairment) |
|1.3 million |Emphysema |
|800,000 |Total paralysis |
|700,000 |Cerebral palsy |
|600,000 |Diabetes |
|450,000 |Multiple sclerosis |
|220,000 |Muscular dystrophy |
|121,000 |Cleft lip and/ or palate |
Modified from Robert Wood Johnson Foundation: Special report: dental care for handicapped Americans, Princeton, N.J., 1979, The Foundation.
- Table 2 Leading chronic conditions in the elderly population - 1
|NONINSTITUTIONALIZED |NURSING HOME RESIDENTS |
|Arthritis |Arthritis |
|Hypertension |Heart disease |
|Hearing impairments |Mental illness |
|Heart disease |Paralysis |
Dental Professional’s Role with Compromised Individuals 1
A. Recognize physical, mental, medical, social, and dental needs
B. Communicate with patients and caretakers in a positive, appropriate, and nondiscriminatory manner
C. Communicate with other professionals and team members to facilitate planning, implementation, and coordination of care
D. Plan, implement, and evaluate community-based and office-based programs
E. Adapt dental hygiene treatment plans, interventions, and evaluation to meet patients’ special needs, considering:
▪ Barriers to care
▪ Resources
▪ Personal skills and disabilities
F. Identify and eliminate potential barriers to care
G. Assess one’s own attitude, values, and commitment to provision of oral health services to these patients
H. Evaluate local, state, regional, and national trends for their potential impact on the provision of oral health care
I. Advocate preventive oral health programs, full use of dental hygienists, and development of a sound research base for use in oral health programs
General Definitions 1,5
These tend to change frequently and often overlap
▪ Labeling – process of classifying people for educational, medical, or financial reasons
▪ Barrier-free environment – facilities that are physically accessible to people with all types of disabilities
▪ Normalization – making available patterns and conditions of everyday life that are as close as possible to the norms and patterns of the mainstream of society
▪ Mainstreaming – integration of people with special needs into regular communities and services
▪ Access to oral health care – opportunity for each individual to enter into the oral health care system and make use of all available services
Goals of Normalization for People with Special Needs 1
A. Ensure legal and civil rights
B. Guarantee appropriate education for continued learning
C. Increase or maintain social skills and problems solving abilities
D. Increase employment options and decrease employer discrimination
E. Ensure comprehensive network of community resources
Factors contributing to Dental disease in Compromised Individuals 6
1. Tooth anomalies including the size, shape, and texture of teeth
2. Variable patterns of tooth eruption
3. Salivary flow and consistency
4. Oral microflora present
5. Diet and feeding practices
6. Oral hygiene habits
7. Use of fluoride supplement
8. Effect of medications such as anti-convulsant drugs
9. Related systemic diseases
10. Oral motor dysfunction
11. Occurrence of accidents or abuse or both
12. Degree of professional care provided, if any
13. Degree of dependence on others and for what
14. Type of disability
Components of a Preventive Program for Persons with Disabilities 6
Dental Professionals have a significant role in planning and conducting preventive oral health programs for individuals and groups of people in the private and public sectors. In developing such programs for disabled persons, several factors should be given consideration. These are:
▪ Understanding the psychosocial and medical issues affecting the individuals
▪ Alteration of mechanical plaque removal techniques to accommodate disabilities
▪ Use of chemical agents to promote optimum oral health
▪ Providing in-service presentation for those caregivers responsible for oral health care of disabled individuals
▪ Providing appropriate patient education so patients can increase their ability to perform oral care techniques
▪ Cooperation and working with other health professionals to achieve oral health for disabled persons
▪ Program should provide for frequent recall
▪ Program should provide for frequent therapeutic intervention such as periodontal scaling, pit and fissure sealants, and fluoride therapy to maintain health
▪ Preventive program must be individualized. It’s more than likely that patient education and oral physiotherapy aids will have to be modified for the handicapped patient
Types of Disabilities 3
1. Developmental disabilities may be present at birth (as a result of a genetic defect, brain damage, or a nutritional or other deficiency during prenatal development) or they may occur before adulthood; are considered permanent conditions.
2. Acquires disabilities are obtained from external forces during adulthood, such as those related to illness or injury.
Classification of Disabilities 3
Developmental Disabilities
▪ Are present from birth
▪ Include mental retardation, autism, epilepsy, cerebral palsy, and muscular dystrophy.
Communication Disabilities
▪ Often are related to neurologic damage to parts of the brain responsible for language or speech development.
▪ Include aphasia, apraxia, and dysarthria.
Cognitive Disabilities
▪ Are associated with reduced mental capabilities
▪ Include mental illness, Alzheimer’s disease, eating disorders, and Cerebrovascular disorders.
Medical Disabilities
▪ Are associated with conditions that affect major organs of the body.
▪ Include arthritis, heart disease, cancer, diabetes, drug and alcohol abuse, respiratory disease, kidney disease, endocrine disease, and blood disorders.
Orthopedic Disabilities
▪ Are conditions associated with use of the legs and arms
▪ Include paralysis and loss of limbs.
Sensory Disabilities
▪ Are conditions associated with the senses
▪ Include varying degrees of blindness and hearing loss.
Nervous system Disabilities
▪ Commonly involve degeneration of the nervous system
▪ Include disorders such as myasthenia gravis, Parkinson’s disease, Alzheimer’s disease, Bell’s palsy, and multiple sclerosis.
Levels of function 3
The assessment of a patient’s functional level involves an evaluation of the patient ‘s ability to perform activities of daily living (ADL) such as bathing, eating, dressing, speaking, and walking. The higher the functional level the greater a patient’s ability to take care of him/herself. ADL assessments have different rating scales and levels.
High Functional Category
▪ Is limited to individuals who are able to attend to most of their ADL needs with some supervision or encouragement.
▪ Patients typically require a daily reminder to brush the teeth and encouragement to go slowly and thoroughly; may require assistance with transportation.
▪ Is typically categorized as level I or II
▪ Patients typically are capable of giving informed consent.
Moderate Functional Category
▪ Is limited to individuals who need supervision or assistance with some of their care.
▪ May require the use of gesture of demonstration, or the use of adaptive equipment for communication.
▪ Is typically classified as level III
▪ Patients typically are unable to give informed consent; power of attorney or guardianship documentation must be obtained to determine with whom to discuss patient treatment.
Low Functional Category
▪ Is limited to individuals with little or no ability to perform ADLs themselves.
▪ Patients require a second or third party to provide daily care.
▪ Patient typically homebound.
▪ Is typically classified as level IV.
▪ Patients typically are unable to give informed consent; power of attorney or guardianship documentation must be obtained to determine with whom to discuss patient treatment.
Potential Barriers to Oral HealthCare 1,3
3 Communication Barriers
▪ Include attitude of health care workers about treating and communicating with compromised individuals, and patient and family attitude toward dental care.
▪ Involve hearing and visual losses and speaking difficulties
1. Always talk directly to the patient, even when the caregiver is present, unless the patient is unable to communicate.
2. Patient consent is required (when the patient is cognizant) before patient care can be discussed with caregivers or others.
Physical Barriers
▪ Include:
1. Stairs
2. Small-print signs
3. Narrow doorways
4. Heavy doors
5. Distant parking
6. Area rugs or other floor coverings that cause tipping
7. Lack of elevators
8. Narrow rest room stalls
9. Restricted access to drinking fountains, telephones, and rest room.
▪ Are addressed by the Americans with Disabilities Act, which requires dental office to have:
1. Ramped access to the office building
2. Room for wheelchair transport in the waiting room, operatory, and rest rooms
3. Parking spaces for disabled individuals
Transport Barriers
▪ Are common for disabled individuals
1. Many of these individuals prefer the safety of their homes to the problems associated with public or private transportation
▪ Related to public transit include:
1. Difficulty accessing public transit, include:
i. Reading time schedules
ii. Finding the appropriate bus or train
iii. Getting to and from the station
▪ Can be eased through:
1. Senior citizen buses similar transportation
2. Private transportation
i. Requires reliance on family members or friends to provide rides to appointments or stores.
ii. Can influence a disabled person’s ability to reach important destinations
Economic Barriers
▪ Are the greatest limitations to receiving necessary dental care
1. Many disabled people have only Social Security or other governmental programs as a means of economic support
2. Those who are employed typically earn low wages
3. Any money received is needed for primary needs such as shelter and food
4. Medical and dental care often are relegated to the bottom of the list of needs
5. Those on Medicaid or Medicare have difficulty finding providers who are willing to accept less than customary fees for their services
▪ Make paying for dental services difficult because most are paid out of pocket and are not covered by insurance
Motivational Barriers
▪ Are the common among the disabled, who rely on others for partial care
▪ May be complicated by communication difficulties.
1. Although cognizant, disabled individuals may be unable to communicate their needs to caregivers
2. Some disabled individuals also may be forgetful; written instructions in addition to verbal instructions should be given to both patient and caregiver.
Provider philosophy / provision of care
▪ Surveys indicate that about 20% of dental professionals are willing to treat persons who are physically or mentally challenged
▪ Reasons for not treating individuals with special needs include:
1. Inadequate facilities and equipments
2. Inadequate training (therefore, knowledge and skills)
3. Not wanting to expose “normal” patients to “special” patients
4. Inability to collect adequate fees
5. Additional effort and time required
6. Personal discomfort about perceived “differences” of special patients
Psychosocial Concern
▪ Over 50% of Americans express positive attitudes towards the elderly and people with disabilities, yet most really perceive them as different and inferior
▪ Society perceives disabilities, differences, and disease states before recognizing similarities
▪ Feelings of guilt, anxiety, apathy, inadequacy, embarrassment, depression, anger, and resentment about their special needs interfere with attempt to seek care
▪ Fear of or inability to comprehend dental procedures, antisocial or atypical behavior, or over dependency on oral health care providers interferes with provision of care
▪ Basic daily needs and activities are often overwhelming and can determine priorities for oral healthcare
▪ Preparation of self-image and worth can affect treatment planning
Medical Concern
▪ Situations compromising the provider or patient
1. Inadequate infection control procedures
2. Inadequate or inaccurate health histories
3. Inadequate precautions for potential emergencies
▪ Type of treatment / conditions
1. Medication
2. Therapies that compromise oral health
3. Conditions or situations that contraindicate treatment
4. Terminal illness or the aging process may change treatment planning or the prognosis of treatment
5. Medical problems or disabilities may necessitate provision of care in a setting other that the office
Mobility / stability concerns
▪ Impaired ambulation or use of a wheelchair may hinder access to care
▪ Uncontrolled or sudden movement may interfere with home care or dental hygiene intervention s
▪ Uncontrolled or aggressive behavior may endanger the care providers and the patient
▪ Spatial disorientation may interfere with patient relaxation in the dental chair or performance of oral care procedures
individual’s capacities and capabilities
Causative factors for compromised individuals, such as trauma, birth defects, or adult onset diseases, allow impairment pattern to appear along stratification line, the age of the individuals per se must not be the main determining factor in deciding the quality and quantity of preventive dental instruction provided for that person. Instead, this decision should be made after consideration of a number of other factors, including the individual’s sensory perception, cognitive abilities, functional expertise, and oral hygiene condition. 2
Sensory Capabilities
To communicate ideas and instructions successfully, the patient and the practitioner must first be able to see or hear each other. Communication channels are impeded if the patient’s hearing or vision is significantly impaired, in which case a modification in communication modalities must be made. Otherwise recommendations for an oral health home care program will not be understood, much less carried out.2
Visual Deficits
What are your feelings when you meet or observe a person who is blind? Concern? Pity? Amazement they can maneuver by themselves? Have you ever wondered whether you should offer assistance? Many people do not know how to respond to such situations or know enough about blindness or visual impairment to be comfortable. As a result, the true abilities and talents of blind and visually impaired persons often are underestimated. An understanding of the abilities and limitations of those suffering from this handicap will help to facilitate the provision of quality dental care. 4
Often a staff member sensitized in the skills of observation can easily identify visual impairment before the patient reaches the operatory. For example, a staff member may observe that the patient is unable to read and respond to the medical history questionnaire without assistance. 2
Instructional materials to be used with patients who have decreased visual acuity could include selective use of commercial products that have been developed for pediatric dentistry programs. Routinely, such products have large pictures. Custom-made instructional sheets may be produced by the dental office using large black letters of at least 12-point type on off-white or white paper. Cassette tapes for recording personalized hygiene instructions are also recommended. Chair side instructions of tooth brushing and flossing should be demonstrated on oversized models of the dentition with a giant- sized toothbrush (Fig1). 2
[pic]
Fig.1
To demonstrate brushing and flossing techniques in the office, all inexpensive magnifying mirror should be employed to assist the patient in observing his or her own performance. Many patients with visual problems experience an increased sensitivity to light or glare. Indiscriminate positioning of the dental light so that it shines in the eyes of a patient can result in significant discomfort for such a patient. Careful focusing and positioning the operatory light can avoid this.2
Hearing Disabilities
Individuals with hearing impairments face a number of problems unique to this handicapping condition. Ironically, perhaps the most significant and socially devastating problem arises from their normal appearance. Hearing-impaired persons are usually not distinguishable from others around them until communication is attempted.4 The commonest problem in communicating with the hearing disabled, however, is that the speaker does not sit directly in front of the patient, at the same eye level, and speak face to face. 2
Most patients with hearing disabilities do some lip reading to augment their hearing, but even the best lip reader is able to decipher only 26% of a message conveyed entirely through this method. The hearing disabled patient relies heavily on the communicator's facial expression and body language to understand the message. Do not speak to the patient with any equipment running. Similarly, it is not desirable to speak while performing other functions, such as writing with your head down, looking at radiographs with your face turned from the patient, or while entering or exiting the room. If preventive instructions are to be given to a patient with a hearing aid, be sure the Patient's aid is in place and turned on. 2
For patients with Visual or hearing deficiencies, keep distractions to a minimum (It is advisable to have office background music turned off at this time). This includes any interruption of the clinician at chairside as well as the distraction created by auxiliary personnel entering and leaving the room. 2
Speech and Language disorders 2
One cannot discuss the role of communication between the patient and the dental care provider without considering speech and language. With practice, a clinician who listens carefully and patiently to such speech can become adept at understanding much of it. This is the same sort of technique many dental providers have already achieved in learning to understand patients who attempt to speak with a rubber dam in place.
The substitution of written for verbal communication is a possible option for individuals in whom the recognition of language is still intact. Unfortunately, many of the causes of speech disorders result in slight or pronounced paralysis, or tremors that prevent the patient from writing legibly. One solution is to provide the patient with a lapboard containing preprinted letters, common words, or pictures.
In summary, both verbal and nonverbal techniques play roles in the communication process between a dental care provider and a compromised dental patient. Speaking directly to the patient from a sitting position in front of the patient in a well modulated, well-articulated voice and reinforcing each step of the communication with nonverbal cues are all techniques that should be used to produce a successful relationship with a patient who has impaired communication skills.
Cognitive Capacities 2
The functional capacity of a patient is of far greater importance than that person's intelligence quotient (IQ) test results in determining his or her capacity to benefit from preventive dentistry instructions. For example, a cognitively impaired individual is expected to have low IQ, short attention span, and difficulties in understanding oral hygiene instructions. Yet many of these patients, when properly taught and motivated can successfully perform oral hygiene procedures. To attain this success the dental care provider must first determine the patient's level of cognitive ability and then direct all instruction to that level. Often clinicians in their diligence to get their message across to the cognitively or intellectually impaired patient tend to do and to say too much. It is important to keep these instructional periods short with frequent repetition of the information. Use a level of language that is readily comprehended by the patient without being insulting. Written or tape recorded reminders can be given for homework. At each appointment the individual should be requested to state or show what he or she has been doing since the last visit.
Family members or guardians, teachers, or other caregivers must assume responsibility for oral health care programs of patients with little cognitive ability. The selected individuals should be thoroughly instructed by the dental staff in the proper techniques for that patient's oral health.
Functional performance 2
Tooth brushing and flossing require not only the fine motor skills or dexterity of the small muscles of the fingers and hands but also the gross motor skills of the larger muscle groups in the upper extremities. Numerous muscles and nerves of the head, neck, and upper extremities are all involved, as is the range-of-motion capability of the joints, especially the shoulders and elbows. In many disabilities one or more of these elements may be adversely affected or limited.
An accurate assessment of a patient’s expected functional performance depends on evaluation of each task necessary to perform the oral hygiene. Once a difficulty has been identified, either a device or a person is needed to compensate for the patient’s inadequacy. Gross motor skills such as grsping a toothbrush handle can often be improved by orthotic appliances (Fig2).
[pic]
Fig.2
Dexterity such as is necessary for the production of the small vibratory strokes recommended in toothbrushing usually cannot be enhanced through medical or orthotic techniques, although for certain patients, appliances specifically the electric toothbrush may serve as a highly effective substitute for this lack of dexterity.
SPECIAL NEEDS CONDITIONS 1,3,5
Individuals with special needs include the developmentally disabled, the communication disabled, the sensory disabled, the elderly, the patient with an eating disorder, the medically disabled, the patient with cancer, the patient with an orthopedic disorder, the patient with nervous system degeneration, the patient with cleft palate or Bell’s palsy, the abused patient, and the pregnant patient.
The Patient with Developmental Disabilities
Developmental disabilities are those that a person is born with. Common disabilities include mental retardation, cerebral palsy, autism, epilepsy, and cleft lip or palate.
I. Mental Retardation
Is the most common developmental disability
A. Is below average intellectual functioning (IQ below 70 to 75)
Oral manifestations
1. Delayed or irregular toot eruption
2. Small, cone-shaped, fused, or missing teeth
3. Malocclusion
4. Repercussion of mouth breathing and tongue thrusting
5. Cracked lips
6. Increased risk of gingivitis and periodontal disease
7. Caries
B. Barriers to care include:
1. Dependence on the caretaker to make and keep appointments
2. The cost of dental care
3. Mental limitations
i. Build patient’s trust
ii. Communicate at his / her developmental level
iii. Speak simply
iv. Reward good behavior; restrain and sedation to manage behavior are recommended only when absolutely necessary
C. Professional and home care includes:
1. Frequent oral prophylaxis to reduce the risk of periodontal disease
2. Lubrication of lips to reduce the risk of cracking
3. Awareness that the gag reflex may be strong
D. Patient / Caregiver education emphasizes:
1. Repetition of simple, demonstrable home care procedures with the patient and caregiver
i. The caregiver supervises and/or performs oral hygiene procedures depending on the abilities of the patient
2. Discussion of periodontal risk and the need for excellent daily home care, frequent progressive oral prophylaxis, and examination
II. Cerebral Palsy
A. Is a developmental, neuromuscular disorder that results in an inability to control muscular movement (spasticity); limitation ranges from mild to severe
B. Oral manifestations of the condition include:
1. Lack of control of facial muscles, which makes speech (dysarthria), chewing, and swallowing (dyphagia) difficult
2. Difficulty keeping mouth open during dental appointments
3. Tempromandibular dysfunction (TMD)
4. Tongue thrusting
5. Mouth breathing
6. Bruxing
7. Attrition
8. Caries and periodontal disease related to the inability to practice good oral hygiene measures because of limited coordination
9. Gingival hyperplasia in those talking phenytoin
C. Barriers to care include:
1. Communication difficulties between patient and dental professional; low self-esteem may influence desire to communicate also.
2. Unfamiliarity of dental office; causes emotional distress and thereby increases spastic movement
3. Dependence on caregiver
4. Lack of mobility
5. Inability of the dental professional to provide thorough treatment because of the patient’s physical limitations
D. Professional and home care include:
1. Building a trust
2. Desensitizing the patient to dental routine
3. Encouraging complete communication
4. Avoidance of injury to the patient or operator from uncontrolled movements of the patient during instrumentation (fulcrums are a must)
5. Protecting the patient during from aspiration of water or other materials placed in the oral cavity
6. Assisting the patient during seizures (during seizure activity, the patient should not be moved; the area should be cleared of items that may hurt the patient during convulsive movement)
7. Wheelchair transfer
8. Realizing that communication barriers don’t indicate incomprehension
9. Involvement of the caretaker
10. The use of an assistant during treatment to avoid injury and to expedite treatment
11. The use of sedation and general anesthesia
12. Consultation with a medical physician regarding a change in medication if hyperplasia is a concern
E. Patient / caregiver education should emphasize:
1. Adaptation of toothbrushes or floss handles as needed
2. Evaluation of the need for mechanized cleaning devices (toothbrushes and oral irrigators)
3. Explanation and demonstration of all home care procedures; great patience may be necessary but most patient are willing to learn
4. Daily disclosing of plaque
5. Assistance with daily plaque removal if the patient is unable to thoroughly cleanse own mouth
6. The use of fluoride and chlorhexidine to control disease as needed; chlorhexidine gluconate sprays effectively reduce plaque when they are used twice daily
7. Explanation of the need for frequent oral prophylaxis
III. Autism
Is a lifelong, behavioral developmental disability of unknown cause
A. Oral manifestation includes:
1. Typically are no different for these patients than for others, unless patient has received insufficient care
2. May include a tendency for oral trauma because some patients may be aggressive or injure themselves when brushing
3. May include an increased risk of caries if patients has a high carbohydrate intake
B. Barriers to care include:
1. The stress of the dental visit
2. Communication difficulties because of poor behavior control (caregivers may be embarrassed about child’s behavior)
i. Managing behavior may include:
a. Desensitization over multiple appointments
b. Reinforcing good behaviors
c. Using physical restrain when safety is a concern
d. Sedation and/or general anesthetics (if other methods fail)
e. Reliance on the caregiver to make and keep appointments
Professional and home care includes
3. Consistency in care and among care providers; the patient’s preference for routine dictates that the same dental team member should see the patient at each visit
4. Shorter, more frequent appointments in a quiet, calm environment are preferable to longer, infrequent visit; noises, movement, and other changes are disconcerting to the patient and should be avoided or introduced slowly as needed
5. Involving the caregiver in preparing the child for the dental visit
i. Procedures should be explained to the caregiver so that some can be practiced at home in preparation for the dental visit
ii. Home care instruction should be performed consistently on daily schedule
C. Patient/Caregiver education should emphasize:
1. The use of both verbal and nonverbal techniques of communication to demonstrate simple oral care instructions
2. Discussion with the caregiver about the patient’s need to eat fewer cariogenic foods
3. The need for frequent preventive dental visits to create routine and avoid the need for extensive treatment
IV. Epilepsy
A. Is a central nervous system disorders; convulsions and/or loss of consciousness are common symptoms
B. Oral manifestations include:
1. Gingival hyperplasia secondary to phenytoin use; plaque control is vital to the prevention and limitation of gingival overgrowth
2. Trauma from seizure activity such as cheek, tongue, or lip-biting, falling and tooth chipping (from biting instruments or clenching)
C. Barriers to care include:
1. Economic cost; particularly if the disability affects employability
2. Lack of transportation, if the patient is unable to drive
3. Lack of communication, if fear of embarrassment about having a seizure in public is strong
D. Professional and home care includes:
1. Frequent (even monthly) oral prophylaxis, depending on the severity of the gingival condition
2. A calm atmosphere
3. Careful preparation for dental appointments; a medical kit or medical consult may be necessary
4. Demonstration and explanation of thorough home care procedures; should include sulcular brushing and flossing
5. Consulting with physician regarding medical change if gingival overgrowth is excessive or uncontrollable; surgical excision of gingival overgrowth may be required
E. Patient/Caregiver education should emphasize:
1. Discussion of oral health and the need for excellent plaque control
2. Repetition of instruction if patient’s memory is impaired by medication
3. Positive reinforcement to bolster self-esteem
V. Muscular Dystrophy (MD)
Is an inherited, progressive skeletal muscular disorder
A. Oral manifestations are related to a loss of muscle control and may include injury or infection. Irritated gingival may be caused by an open mouth; poor oral hygiene may occur because of a reduced ability to provide self-care
B. Barriers to care include:
1. Economic issues; caregivers are needed to provide full care as the disorder progresses
2. Dependence on the caregiver to make and keep dental appointments
3. Lack of communication; speech difficulties occur as muscle weakness affects muscle of the head and neck
4. Immobility or difficulty controlling movement
Professional and home care includes:
5. Frequent oral prophylaxis to reduce the risk of infection
6. Short dental appointments
7. The use of a bite-block to keep the mouth open after muscle loss prevents it
C. Patient/Caregiver education should emphasize:
1. Supervision and/or performance of oral hygiene procedures by the caregiver if the patient is unable
i. Power-assisted devices enable the patient to continue self-care
ii. Adaptive aids accommodate muscle weakness
2. Discussion with the patient and/or caregiver about the risk of infection and the need for excellent daily home care, frequent professional oral prophylaxis, and examination
3. The use of petrolatum on lips and oral tissues irritated by open mouth
VI. Cleft Lip and palate
A. Is a craniofacial deformity that range from a mild unilateral clefting of the lip to a wide, bilateral clefting of the lip and palate; typically is not life threatening but requires much care (minor clefting associated with the uvula and soft palate requires little if any medical care); defect is associated with inadequate fusing of the lip, palates, or uvula during the 4th to 12th weeks of gestation
B. Oral manifestations include an increased risk of oral infection (including periodontitis and dental caries) from malpositioning of the teeth, wearing of a dental appliance (obturator), mouth breathing, and oral deformity, which also make oral hygiene procedures more difficult
C. Barriers to care include:
1. Economic issues; multiple oral and facial surgeries and care by professionals from different disciplines are required to correct the defect and associated conditions
2. Difficult communication, because of inadequate speech production, hearing loss related to the defect, or self-consciousness
D. Professional and home care includes
1. Frequent oral prophylaxis (3 to 4 times annually) to reduce the risk of infection
2. When the premaxilla is unfixed or immediately after surgical procedures, fulcruming in the site should be avoided or limited
3. Fluoride treatment to reduce the incidence of dental caries
E. Patient/Caregiver education should emphasize:
1. Caregiver supervision and/or performance of oral hygiene procedures, depending on the age and abilities of the patient
i. Care of the teeth and gums involves the use of a soft-bristled toothbrush and dental floss to remove plaque
ii. Care of the dental prosthesis is similar to care of the partial denture; involves removal after meals to cleanse thoroughly and reduce halitosis
2. Discussion with patient or caregiver about the risk for infection and the need for excellent daily home care, frequent professional oral prophylaxis, and examination; a daily fluoride rinse or gel is recommended
The Patient with Communication Disorders
Patient with communication disorders are either unable to make speech sounds, because of structural disease or damage, or unable to understand language or form thoughts into words.
I. Types of Communication Disorders
A. Aphasia
1. Is the inability to put thoughts into words or to understand language
2. Is caused by neurologic damage or an organic brain disorder such as dementia
B. Apraxia
1. Is an inability to properly form speech sounds because of a CNS lesion or organic brain disorder such as dementia
C. Dysarthria
1. Is a motor speech disorder that often is associated with cerebrovascular accident (CVA), cerebral palsy, or Parkinson disease
2. Result in the slurring of speech pattern as a result of damage to the CNS or PNS
I. Oral manifestation depend on the severity of the condition and the loss of muscle control; difficulty in clearing food and an inability to adequately clean the teeth may cause an increased risk of caries and periodontal disease; difficulty swallowing and an inability to perform or understand the need for good oral hygiene also may complicate oral health
II. Barriers to care include economic cost, if the disability affect employment, transportation if the patient is unable to drive, and communication when speech making or comprehension is difficult
III. Professional and home care should include maintenance of adequate home care, with assistance as needed
IV. Patient/Caregiver education should emphasize discussion about oral health and the need for excellent plaque control. Caregivers who provide oral care should hear instructions
The Patient with Sensory Impairment
The patient with sensory impairment has loss of sight or hearing that makes communication and other daily living issues difficult. Sensory impairments often occur as result of infection, trauma, or disease but some may be inherited.
I. Types of Sensory Impairment
A. Hearing impairment
1. Can occur as a result of infection, trauma, disease, medication, or hereditary
i. In adults, is commonly noise-induced
ii. In children, is associated with hereditary, pregnancy or birth complications, or meningitis
2. May be indicated by inappropriate responses to questions or lack of interest in verbal communication
3. Hearing aids may help restore some hearing acuity
B. Visual loss or blindness
1. Few legally blind individuals are totally blind
2. Blind individuals may exhibit sensitivity to light
II. Oral manifestations are not directly associated with visual or hearing impairment; poor oral hygiene and accompanying oral disease are common and may occur because of inadequate presentation of oral hygiene instruction
III. Risk factors
A. For the visually impaired, include an inability to see objects in their path or to visualize instructions
B. For the hearing impaired, include an inability to understand instructions or fear or shock in response to unexplained procedures
1. The patient may feel discomfort when hearing aids are on during noisy procedures
2. Patients should be asked to turn off hearing aids during the use of powered devices such as a high-speed handpiece or an ultrasonic scaler
IV. Barriers to Care
A. Physical obstacles such as doorways and stairs; finding one’s way in new surrounding is particularly difficult for the blind individual
B. Lack of communication, which is more difficult for sensory-impaired individuals; health care workers may be apprehensive about communicating with sensory-impaired individuals
C. Lack of transportation; arranging transportation and/or relying on a caregiver for scheduling and transportation is cumbersome
D. Economic issues; good employment opportunities may be more limited for the sensory-impaired person
V. Professional and home care
A. For the visually impaired individual includes:
1. Positioning of caregivers and others to the visual advantage of the patient (typically directly in front of the patient)
2. The use of large visual aids and materials
3. Avoiding shining of operatory lamp in the patient’s eyes
B. For the hearing impaired individual includes:
1. Elimination of loud or background noises when attempting to communicate
2. If some hearing is present, directly speech to the ear
3. Positioning of caregivers and others so that the patient can see the facial features (particularly the lips and tongue) of the person speaking
4. The use of sign language, a message board, or an interpreter if the patient is unable to read lips (speech)
VI. Patient/Caregiver Education
A. For the visually impaired
1. Extremely descriptive explanations are important because they make use of other senses (particularly hearing), which are better developed
2. Use appropriate changes in tone of voice when providing information since facial expression may not be seen
3. Involves explanation and demonstration (on the hand) of each procedure; the patient should handle visual aids to improve understanding; the caregiver should be involved as needed
B. For the hearing impaired
1. The use of demonstration is particularly effective when explaining techniques or oral care
2. May involve the use of an interpreter, sign language, or a message board to explain things that are not easily demonstrated
3. Includes take-home written instructions for effective reinforcement
The Geriatric Patient
AGING BABY BOOMERS AND AN INCREASED LIFE EXPECTANCY WILL GREATLY EXPAND THE PROPORTION OF ELDERLY INDIVIDUALS BETWEEN THE YEARS 2010 AND 2039. PROJECTIONS INDICATE THAT THE PERCENTAGE OF AMERICANS WHO ARE OLDER THAN 65 YEARS OF AGE WILL INCREASE FROM 13% TO MORE THAN 21% OF THE TOTAL POPULATION BY THE YEAR 2030.
I. Medical manifestations include several chronic diseases. The occurrence of chronic diseases and multiple disease processes increases with age. Diseases in the elderly can include:
A. Cardiovascular diseases
B. Dementia/Alzheimer disease
C. Arthritis
D. CVAs
E. Diabetes Mellitus
F. Sensory defects
G. Oral adverse drug reactions
H. Osteoporosis
II. Oral Manifestations
A. The prevention of disease during the past three decades has resulted in an increasing number of older adults retaining their natural teeth. Many oral conditions once believed to be a normal part of aging currently are recognized as sequela to disease.
1. Age-related oral changes (normal)
2. Disease-related oral changes
i. Drug-induced oral conditions
ii. Dental decay, particularly of root surfaces
iii. Periodontal disease
iv. Oral cancer
III. Barriers to care
A. Income limitations are an obstacle to dental care for seniors.
1. Few seniors have dental insurance.
2. Medicare does not reimburse dental services; typically discretionary income is used to cover the cost of dental care.
B. Education is positively correlated with seeking adequate dental care.
1. As a general rule, older populations have less formal education than younger populations
2. The young old (ages 65 to 74) are better educated and are more likely to demand quality health care than the old old (ages 85+).
C. Residential status affects an older individual’s ability to seek or receive dental care.
1. The majority (67%) of the elderly live in family settings (are homebound).
2. Approximately one in four seniors can expect to spend some time in a nursing home.
3. Some seniors are homebound but continue to live at home with assistance.
D. The use of dental services varies among the elderly.
1. An estimated 40% of all seniors visit the dentist annually.
2. Individuals with natural teeth are more than four times as likely to seek dental care.
The Patient with an Eating Disorder
Patients with serious eating disorders typically are classified as anorexic, bulimic, or bulimorexia. Adolescents and young adult females are primarily affected, although men and adults of all ages can be afflicted. Serious cases require psychiatric treatment.
I. Types of Disorders
A. Anorexia nervosa
1. Oral manifestations include dental caries, xerostomia, and oral lesions from malnutrition.
2. Barriers to care include lack of communication because of patient denial, guilt, fear of gaining weight, and lack of compliance; may include economic barriers because of the cost repairing damage caused by the eating disorder.
3. Professional and home care includes multidisciplinary care (dental, medical, and nutritional consultations) because of the severity of the disorder. Fluoride in a custom tray is recommended if xerostomia or vomiting is a problem.
4. Patient education should be based on the prevention of further damage to the teeth. Should involve discussion of the influence of diet on caries; daily fluoride use (rinse or gel) should be recommended.
B. Bulimia nervosa
1. Oral manifestations include:
i. Enamel erosion (perimolysis) on maxillary anterior teeth from vomiting (restoration margins appear raised), dishing of lingual surfaces, and the appearance of an anterior open bite.
ii. Dental caries from stomach acids.
iii. Dry mouth from diuretic use.
iv. Salivary gland enlargement.
v. Palatal trauma lesion from forced vomiting.
vi. Sensitivity to temperature changes and acids if dentin is exposed.
vii. Square appearance of the jaw from enlargement of the salivary glands; a round appearance is caused by parotid gland enlargement.
viii. Xerostomia from prescribed antidepressant.
2. Barriers to care
i. A lack of communication because of patient denial, guilt, fear of gaining weight, and lack of compliance; also results from an inability to gain the patient to a physician or psychiatrist.
ii. Economic barriers may be involved because of the cost of repairing damage caused by the eating disorder
3. Professional and home care should include the restorative (to leach fluoride ions) where possible, sealing of eroded areas with composite resins, and assessment of the progression of erosion (whether by study models or intr-aoral photos).
4. Patient education should emphasize:
i. Discussion of oral and medical problems associated with purging, diuretics, and laxative use.
ii. The need to neutralize vomit acid by rinsing with tap water, a sodium bicarbonate, or a magnesium hydroxide and water rinse.
iii. Discouragement of toothbrushing immediately after vomiting in order to reduce abrasion.
iv. The use of saliva substitutes or sugarless gums to increase salivary flow.
v. The daily use of fluoride supplements in rinse or gel form
vi. Daily vitamin and mineral supplementation may be recommended when gingival tissue appears unhealthy or when angular cheilitis is present.
C. Bulimorexia
1. Is a combination of anorexia and bulimia (binge eating followed by starvation); involves signs and symptoms of both anorexia and bulimia.
2. Medical manifestations, oral manifestations, risk factors, barriers to care, professional care, and patient/caregiver education are the same as for anorexia nervosa and bulimia.
The Patient with a Medical Disability.
I. Arthritis, a common disorder of the musculoskeletal system that causes painful swelling of the body joints, affects 14% of Americans. Approximately half of older Americans have some form of arthritis. The disorder may be caused by infection, allergy, trauma, drug reactions, or heredity; it results in fatigue and the loss of mobility and hand strength. Common forms include rheumatoid arthritis, juvenile rheumatoid arthritis, and degenerative joint diseases (osteoarthritis).
A. Oral manifestations include an increase in bleeding and oral infection from the use of anti-inflammatory drugs; temporomandibular joint pain may be present.
B. Barriers to care include transportation difficulties because of a loss of mobility; log appointments and keeping the mouth opened can be uncomfortable; irritability is common in those with chronic pain.
C. Risk factors include the effects of medications and difficulty with motor activities.
D. Professional and home care considerations include assessing the need for antibiotic premedication in cases of joint replacement, the need for short appointments with frequent opportunities to close the mouth, and the patient's need shift positions in the chair to relieve discomfort.
E. Patient/Caregiver education involves discussion of the oral side effects of arthritis medications; recommendation of powered toothbrushes and other adaptive aids (enlarged toothbrush handles, floss holders) as needed; and recommendation of frequent recall so that appointments are quicker and easier on the patient.
II. Alcoholism is a chronic but treatable disease that involves the compulsive abuse of ethanol-containing substances. Causes of the disease may include genetic, psychological, and environmental factors. An estimated 43 million Americans are considered binge or heavy drinkers.
A. Oral manifestations include:
1. Xerostomia.
2. Reduced ability to taste.
3. Glossitis.
4. An increased risk of both dental caries and periodontal disease from poor oral hygiene.
5. Leukoplakia.
6. Odor of alcohol on breath.
7. Enlargement of the parotid gland and the tongue.
8. An increased risk of oropharyngeal cancer.
9. Facial and dental trauma from falls and injuries.
B. Risk factors include nutritional deficiencies, infections, trauma, and oral cancer (especially if tobacco is also used); caution should be used when administering amide local anesthetics and nitrous oxide sedation.
C. Barriers to care include:
1. Communication difficulties; patient may not appear for appointments when actively drinking.
2. Transportation problems, if the alcoholic does not drive or has lost driving privileges and must rely on others.
3. Economic problems, if the patient is unable to hold a job or is on a fixed income.
D. Professional and home care involves:
1. The use of nonalcoholic mouth rinses.
2. Possible bleeding problems from liver damage.
3. The need for oral cancer evaluation.
4. Fluoride treatment and daily supplementation as needed.
5. Dealing with patient's intoxication and difficulties in keeping appointments.
E. Patient/Caregiver education should emphasize the need for frequent recall, fluoride supplementation, saliva substitutes, and the need for practicing good home care because of the risk of infection.
III. Blood disorders include anemia, leukemia, and hemophilia and are caused by inadequate numbers of specific blood parts or components. The disorders range from mild and easily treatable to severe and incurable
A. Anemias are disorders of red blood cell production, hematocrit, or hemoglobin concentrations. The limited number of cells or blood parts results in inadequate oxygen delivery throughout the body.
1. Oral manifestations include pallor of the oral mucosa, glossitis or burning tongue, and angular cheilitis. In cases of sickle-cell anemia, the gingiva may have a yellow tone and individuals may be prone to bleeding and periodontal disease.
2. Risk factors include excessive bleeding and trauma
3. Barriers to care may be nonexistent; in sever cases, fatigue may discourage patients from keeping appointments.
4. Professional and home care should focus on observation of the signs and symptoms of anemia and appropriate referral; for sickle cell anemia, consultation with a physician and antibiotic premedication is recommended.
5. Patient/Caregiver education should emphasize the appropriate care of anemia through following physician's orders and the practice of good oral hygiene to decrease the risk of infections.
B. Leukemias are malignant overgrowths of immature white blood cells that are most likely caused by viral infection, ionizing radiation, chemicals, or heredity. Leukemia can be acute or chronic in nature.
1. Oral manifestations are more common in acute than in chronic cases and include:
i. Susceptibility to bacterial, viral, and fungal infection.
ii. Gingival bleeding, bluish-red gingival color, and gingival hypertrophy (see cancer section for effects of cancer therapy).
iii. Full-body lymphadenopathy.
iv. Toothaches.
v. Changes in maxillary and mandibular alveolar bone.
2. Risk factors include susceptibility to infection, bleeding, and risks associated with cancer therapy.
3. Barriers to care include the need to schedule appointments during periods of remission.
4. Professional and home care involves:
i. Scheduling dental appointments during periods of remission.
ii. Consultation with the oncologist.
iii. Frequent prophylaxis and oral examination as per consultation with oncologist.
iv. Treatment of acute problems (e.g., bleeding, candidiasis, inflammation) as they occur.
5. Patient/Caregiver education should include discussion of:
i. Preventive procedures.
ii. The need for meticulous home care to prevent infection.
iii. Meticulous cleaning of dental appliances.
iv. The use of antimicrobial rinses as needed.
v. Fluoride rinses or gels
vi. Pit and fissure sealants.
vii. The need for frequent dental evaluation especially during active treatment.
C. Hemophilias are inherited, congenital disorders of the blood clotting mechanism. There are three distinct versions of hemophilia: A and B (which affect only males) and von willebrand's disease (which affects both sexes).
1. The primary medical manifestation is difficulty with uncontrolled bleeding (varies in severity with extent of disease).
2. Oral manifestations include gingival bleeding associated with poor oral hygiene (because of fear of causing bleeding during home care procedures) or caused by trauma.
3. Risk factors include susceptibility to bleeding and potential for acquiring infectious disease (AIDS, Hepatitis) from blood transfusions
4. Barriers to care include.
i. Communication difficulties, if the dental professional has fear regarding treatment of a patient with hemophilia or if the patient has suffered mental or intellectual impairment from bleeding or from the stresses of dealing with the disease.
ii. Economic difficulties because of the lifelong cost of infusions, laboratory tests, and physician consultations.
5. Professional and home care should include:
i. Consultation with a physician regarding the severity of the disease and medication use.
ii. Preparedness for potential bleeding (including treatment with factor replacement immediately before any dental procedures that may cause bleeding).
iii. Prevention of infectious disease transmission.
6. Patient. Caregiver education should include discussion of the need for frequent recall, procedures to prevent infection and associated bleeding, and the need for soft-bristled brushes, gentle flossing, and antimicrobial rinses.
D. Cardiovascular disease comprises a variety of diseases of the heart and the blood vessels and affects an estimated 17% of the US population. 18 These include congenital heart diseases, heart valve diseases, cardiac dysrhythmias, hypertension, ischemic heart disease, and congestive heart failure.
1. Types.
i. Hypertension
ii. Congenital heart disease
iii. Heart valve disease
iv. Cardiac dysrhythmias
v. Ischemic heart disease
vi. Congestive heart failure
2. Oral manifestations of cardiovascular diseases typically are no greater than for other patients, unless the patient is severely debilitated; some medications (calcium channel blockers) are associated with the development of gingival hyperplasia
3. Risk factors include infection (rheumatic heart disease and congenital heart disease), side effects of medication, and vasoconstrictors (should be used with caution).
4. Barriers to care include transportation difficulties when the condition restricts the patient's mobility; patient may need to rely on others. Economic barriers may be present if income is restricted because of disability or fixed income.
5. Professional and home care should include:
i. Consultation with a physician regarding the need for antibiotic premedication and care fully documented medication needs.
ii. Caution when administering local anesthetics because of possible interactions with medications.
iii. Adjusting chair appropriately because some patients are unable to recline in a supine position.
6. Patient/Caregiver education should include emphasis on daily meticulous home care, frequent dental recall, and the need to take antibiotic premedication and heart medications as prescribed.
E. Cerebrovascular accident (stroke) is a temporary or permanent loss of brain function caused by a loss of blood flow to the brain via a clot, constriction, or rupture of a blood vessel supplying the brain. An estimated 2% to 3% of Americans have had a stroke.
1. Oral manifestations of cardiovascular diseases typically are no greater than for other patients, unless the patient is severely debilitated
2. Risk factors include continued high blood pressure and receiving dental treatment within 6 months of a stroke.
3. Barriers to care include transportation difficulties, when the condition restricts the patient's mobility, and economic problems, if income is restricted because of disability or fixed income.
4. Professional and home care should include:
i. Consultation with physician regarding the need for antibiotic premedication and careful documentation of medication needs.
ii. Caution when administering local anesthetics because of possible interactions with medications.
iii. Adjusting the chair appropriately for patients unable to recline in a supine position.
5. Patient/Caregiver education should include emphasis on daily meticulous home care, frequent dental recall, and the need to take antibiotic premedication and heart medications as prescribed.
F. Diabetes is associated with inadequate insulin production or utilization, which causes glucose intolerance. These diseases have a hereditary basis and are related to a reduced production of insulin, hyposensitivity to insulin, and / or excessive glucose production. When blood sugars are uncontrolled, oral insulin or injectable insulin may be needed.
1. Oral manifestation severity is related to the level of control of the blood glucose; common conditions include:
i. Dry or cracked lips.
ii. A mild increase in caries because of decreased salivary flow or high carbohydrate intake.
iii. Periodontal disease because of poor healing.
iv. Parotide gland enlargement
v. Ulcerated and reddened mucosa.
vi. Candida.
2. Risk factors.
i. Poor healing, which results in an increased risk of bacterial, viral, and fungal infection.
ii. Local anesthetics with vasoconstrictors are recommended for all but the most complicated procedures
iii. A disturbance in the balance between glucose and insulin: occurs when the diabetes is uncontrolled or if dental procedures are major and require large amounts of anesthetics.
3. Barriers to care are no greater than for unaffected patients unless complications exist.
4. Professional and home care includes:
i. Scheduling
ii. Thoroughly assessing oral health.
iii. Preparing for diabetic emergency (sugar, glucose gel or tablets, or orange juice must be available).
iv. Consultation with the treating physician is necessary and prophylactic antibiotics are advised in cases of uncontrolled diabetes or extensive infection.
5. Patient/Caregiver education should emphasize:
i. Preventive oral health procedures.
ii. The need for frequent recall.
iii. The need for frequent recall.
iv. Control of infection.
G. Substance abuse is the use of illegal or prescribed drugs for nonmedicinal purposes; abuse can lead to psychological, chemical, or physical addiction to a drug.
1. Alcohol abuse affects approximately 7% of Americans, and drug abuse affects approximately 5% of the population.
2. Examples of abused drugs include heroine, marijuana, nitrous oxide, LSD, cocaine, and amphetamines, (Alcohol abuse is also in the section on alcoholism).
3. Oral manifestations any include trauma, mucositis, xerostomia, extrinsic stain, high rates of dental caries, gingival lesions, and periodontal disease, often from poor oral hygiene.
4. Barriers to care.
i. Communication problems related to denial of drug abused and disordered behavior (careful attention to behavior and physical appearance any help identify the condition).
ii. Transportation problems, if patient is unable to drive.
iii. Economic problems related to drug habit costs and possible unemployment.
5. Professional and home care includes:
i. Careful assessment of patient behavior and appearance (needle marks, sniffing, agitation, dull expression, careless dress and hygiene, dilated/constricted pupils, bloodshot eyes).
ii. Through intraoral examination.
iii. Awareness that patient may request pain or nitrous oxide sedation because of a drug habit.
iv. Caution with the use of local anesthetics to prevent reactions with illegal drugs.
6. Patient/Caregiver education should emphasize:
i. Responsibility for maintaining good oral hygiene and for keeping scheduled recall appointments.
ii. That prevention of oral infection is particularly important in IV drug users because of the risk of bacteremia
H. The HIV-Positive/AIDS patient.
1. HIV infection affects more than 600,000 individuals in the United States. HIV refers to the human immunodeficiency virus, which infects human T-helper lymphocytes and CD4 lymphocytes and causes acquired immunodeficiency syndrome (AIDS), a usually fatal disease.
2. Oral manifestations include:
i. Persistent and generalized lymphadenopathy.
ii. Candidiasis.
iii. Hairy leukoplakia (which is strongly associated with HIV infection).
iv. Angular cheilitis.
v. Recurrent and severe aphthous and herpetic infections.
vi. Severe and chronic gingival and periodontal infection.
vii. Oral warts.
viii. Kaposi sarcoma.
ix. Tooth erosion from frequent vomiting (a side effect of AZT use).
x. Xerostomia (medication-induced) and caries.
3. Barriers to care include:
i. A lack of communication; the patient may be afraid to provide accurate or thorough medical information; the attitudes and fears of dental professionals who work with AIDS patients also may interfere with communication.
ii. Transportation problems, if the patient is debilitated.
iii. Economic difficulties, because of the high costs of medication, medical visits, and hospitalizations; also may be caused by loss of employment.
4. Professional and home care should include:
i. Consultation with the patient's physician regarding blood counts and the risk of bleeding.
ii. Careful oral examination for signs for infection and a focus on maintenance of oral health.
iii. Frequent professional oral prophylaxis and dental examination to reduce the opportunity for secondary infections.
iv. Avoiding the creation of aerosols during instrumentation.
v. Diet counseling, if xerostomia and vomiting occur, should emphasize adequate nutrition with noncariogenic foods to reduce the risk of dental caries.
vi. Tobacco cassation counseling, as needed, to reduce the risk of periodontitis.
vii. Treating the patient and caregivers with respect, kindness, and compassion.
viii. Providing literature regarding AIDS and the importance of good oral care
5. Patient/Caregiver education should emphasize:
i. Meticulous, frequent daily home care, including flossing and brushing; self-care may be impossible during later stages of the disease.
ii. Prevention of dental disease to promote oral and systemic health.
iii. The use of daily chlorhexidine rinse and systemic antibiotics if sever gingivitis or periodontitis is present
I. Renal disease is disease of the kidney, which alters the kidney’s filtering ability and is caused by infection, autoimmune disease, or a developmental disorder. It affects approximately 3% of Americans
1. Oral manifestations include:
i. Mucositis
ii. Candidiasis.
iii. Hemorrhage and petechiae.
iv. Halitosis.
v. Enamel hypocalcification.
vi. An increase in dental caries and periodontal disease if oral hygiene is poor.
vii. An increase in calculus development.
2. Barriers to care are economic; finances may be limited because of high medical costs and the patient’s inability to maintain employment.
3. Professional and home care should emphasize:
i. The need to check vital signs and prevent drug interactions.
ii. Consultation with a physician to determine the need for antibiotic or steroidal premedication (patient may have arteriovenous shunt or organ transplant).
iii. The tendency for bleeding.
iv. Possible interactions with local anesthetics.
v. Slow healing.
4. Patient/Caregiver education should emphasize:
i. Meticulous oral hygiene to reduce the incidence of infection.
ii. Frequent recall appointments for examination and prophylaxis.
iii. Daily fluoride supplementation.
iv. Toothpastes with antigingivitis, anticaries, and anticalculus properties, unless mucosal irritation results.
J. Chronic respiratory diseases include chronic obstructive pulmonary disease, active tuberculosis, and lung cancer. These diseases may have a variety of causes, including allergy, cigarette smoking, infection, pollutants, and heredity.
1. Types
i. Chronic obstructive pulmonary disease (COPD)
ii. Active tuberculosis
iii. Lung cancer
2. Oral manifestations may include xerostomia and candidiasis from inhalants or the use of other medications, ulcerations, and lymphadenopathy.
3. Barriers to care
i. Lack of communication because of patient’s embarrassment about the condition (e.g., TB, emphysema).
ii. Transportation difficulties, if the patient has difficulty walking even short distances.
iii. Weather may exacerbate certain respiratory conditions and may require the rescheduling of appointments
4. Professional and home care involves:
i. Recognition of the communicability of tuberculosis and the need to avoid aerosol production.
ii. Awareness of and the ability to deal with respiratory difficulties associated with asthma and COPD.
iii. The need for a relaxed dental environment to prevent asthmatic or other complications.
iv. The placement of medications and bronchodilators in close proximity to the patient.
v. The avoidance of vasoconstrictors in local anesthetics.
5. Patient/Caregiver education should emphasize the need for meticulous oral hygiene, daily fluoride supplementation as needed, and the use of saliva substitutes for patients with xerostomia.
K. Thyroid Disorder
1. Hyperthyroidism
i. Oral manifestations include:
a. In children-premature loss of primary dentition and eruption of permanent dentition accompanies premature physical maturity
b. In adults-rapidly progressing periodontitis, dental caries, osteoporosis, and a burning sensation of the tongue; salivation may be increased.
ii. No barriers to care are specific to the condition.
iii. Professional and home care involves thorough extraoral and intraoral inspection for increases in thyroid gland or lymph node size; the use of home and professional fluoride to reduce the incidence of decay; and frequent examination and oral prophylaxis to manage bone loss, caries, and periodontal infection.
iv. Patient/Caregiver education should emphasize instruction in plaque removal methods to prevent periodontitis; adequate diet to reduce the risk of osteoporosis; and the use of home fluoride gels or pastes.
2. Hypothyroidism
i. Oral manifestations include:
a. In children-enlarged tongue and lips and delayed tooth eruption.
b. In adults-enlarged tongue; and slow, hoarse speech.
ii. Professional and home care involves thorough extraoral and intraoral inspection for increases in thyroid gland or lymph node size and frequent oral examination and prophylaxis.
iii. Patient/Caregiver education should emphasize instruction in thorough plaque control and the need for frequent oral prophylaxis to reduce the incidence of periodontal destruction.
The Patient with Cancer
Approximately 40% of Americans will develop cancer in their lifetimes. Each year, approximately 30,000 individuals develop oral cancer.
I. Types of Cancer
A. Oral and pharyngeal carcinoma
B. Non-Head and Neck Cancer
II. Dental Hygiene Care
A. Before cancer treatment:
1. Assess condition of teeth, periodontal structures, oral hygiene, previous interest in dental care, and psychosocial factors.
2. Patients scheduled for radiation therapy to the jaw bones.
i. Teeth can never be extracted safely from irradiated bone
ii. Determine, with the dentist, which can be maintained for the life of the patient.
3. Oral hygiene education should emphasize bacterial plaque control and the use of oral rinses
4. Nutrition and dietary counseling are essential.
5. Tobacco cessation counseling is recommended.
6. Fluoride
i. Patients scheduled for radiation therapy to the salivary glands need daily prescription-strength fluoride gel in brush-on form or in custom fluoride trays.
ii. Patients with temporary xerostomia during chemotherapy may benefit from an over-the-counter fluoride rinse or gel.
7. Instrumentation should include scaling, root planning, removal of overhangs, and smoothing of rough restorations.
B. During cancer treatment:
1. Design alternative plaque control measures for patients with mucositis and for patients forbidden by a physician to use a toothbrush and floss.
2. Encourage continued fluoride application.
3. Suggest measures to relieve xerostomia, and topical anesthetics/coating agents for mucositis.
4. Assist with the selection of nonirritating and noncariogenic foods.
5. Counsel patients with dentures on daily cleansing and removal before sleep.
6. Continue to assist with tobacco cessation
C. After cancer therapy:
1. For patients who receive radiation therapy to the salivary glands and jaw bones
i. Encourage frequent recalls, scheduled according to individual patient need, for prophylaxis and home care evaluation.
ii. Encourage excellent home care.
iii. Encourage palliative measures for xerostomia and stimulation of saliva.
iv. Recommend daily jaw exercises to prevent trismus.
v. Provide tobacco cassation counseling.
vi. Caution patient to avoid all future surgical procedure to irradiated bone.
2. For patients who receive chemotherapy or bone marrow transplantation
i. Monitor blood counts until patient recovers from immunosuppression; subsequently place patient on regular dental hygiene recall.
ii. Encourage excellent oral hygiene
iii. Consider fluoride rinse or gel until xerostomia is resolved.
iv. Provide tobacco cessation counseling.
Patients with Spinal Cord or Limb Disorders
Patients who have suffered damage to the limbs or spinal column may have difficulty caring for themselves because of their injuries. Teaching self-care techniques is particularly important to their dental health
I. Types
A. Amputation is the removal of a lamp or an appendage either through accidental injury or surgical procedure. The amount of functional disability is dependent on the type and extent of amputation.
B. Paralysis is the loss of motor, sensory, and autonomic function of parts of the body located below the area of the spinal cord injury.
1. The paralysis may be caused by trauma, congenital defect, infection, hemorrhage, or infarction.
2. Approximately 0.7% of Americans have some form of paralysis.
C. Spinal cord injuries typically result in partial or complete paralysis from trauma to the spinal or complete paralysis from trauma to the spinal cord.
1. Occur in 8% of Americans. Victims often are children or young adults.
2. The amount of injury is related to the location and extent of the injury. Generally, all motor, sensory, and autonomic function is lost below the point of the injury.
II. Oral manifestations are related to the patient’s ability to care for his or her own oral health; may include dental caries and periodontal disease if oral hygiene is poor or if diet or motor function is restricted.
III. Barriers to care include:
A. Lack of communication, when learning disabilities (spina bifida), depression, and poor self image (paralysis) are present.
B. Transportation difficulties because of ambulatory disability.
C. Economic loss from reduction in or loss of employment because of severe disability
IV. Professional and home care involves:
A. Providing though dental hygiene care in a comfortable, relaxed environment.
B. Antibiotic premedication is required for the patient with a shunt.
C. Awareness of the risk for respiratory difficulty from accidental airway blockage when motor dysfunction such as spasticity and tremor occur.
D. Familiarity with wheelchair transfer procedures is essential.
E. Maintenance of good oral hygiene and the use of fluorides to prevent dental caries.
F. Encouragement and empathy, which are extremely important to developing patient rapport.
V. Patient / Caregiver education should emphasize:
A. Adaptive equipment and aids, including powered toothbrushes and oral irrigators.
B. Emphasis on self–care, although assistance of caregivers may be sought when efforts to maintain good oral hygiene are not feasible.
C. The need for fluoride supplementation.
The Patient with Nervous System Degeneration
Nervous system degeneration is caused by a variety of diseases and often has devastating consequences. Common diseases of this type include Alzheimer’s disease, multiple sclerosis, myasthenia gravis, and Parkinson’s disease. Bell’s palsy, which typically is a temporary disorder, is also discussed
I. Types
A. Alzheimer disease
1. Oral Manifestations include speech difficulties and poor oral hygiene because of a loss of cognitive abilities; may include trauma from falls or elder abuse.
2. Barriers to care include:
i. Difficult communication because of cognitive difficulties.
ii. Lack of transportation; patient must rely on others when unable to transport self
iii. Economic obstacles, because of an inability to hold a job or because of a fixed income.
3. Professional and home care involves:
i. Scheduling short, relaxed appointments during the patient's most alert times.
ii. Reintroducing staff and procedures to enhance familiarity.
iii. Home care instructions that are concrete; must be repeated because of patient's memory and behavior difficulties.
iv. Reminders to brush and/or assistance with oral care tasks as the dementia increases
4. Patient/Caregiver education should emphasize:
i. Gaining assistance of caregivers when the patient is unable to maintain appropriate oral cleanliness
ii. The importance of frequent dental recalls.
iii. Empathy with the difficulties the caregiver faces in caring for a loved one.
B. Multiple sclerosis
1. Oral manifestations include facial pain, speech disorders, and facial paralysis in severe cases.
2. Risk factors include:
i. Physical or emotional stresses, such as infections, emotional stress, inadequate rest, and excessive exercising.
ii. Side effects of medications.
iii. Diet restrictions caused by muscle dysfunction.
3. Barriers to care include:
i. Communication difficulties, from dysfunction of the muscles of speech.
ii. Transportation difficulties, because of ambulatory problems and the need to use canes, walkers, or wheelchairs; patients eventually must rely on others
iii. Economic issues, when income is restricted because of reduction in or loss of employment
4. Professional and home care involves:
i. Scheduling short, relaxed appointments for the patient, preferably during times of remission.
ii. Keeping the patient at comfortable temperature.
iii. Attention to proper cleansing when facial paralysis and weakness reduce the patient's ability to cleanse the cheeks and tongue.
iv. Home care instructions related to frequent cleansing of the oral cavity; powered toothbrushes, adaptive aids, and oral irrigators may be recommended for those who have difficulty manually cleaning the oral cavity.
5. Patient/Caregiver education should emphasize:
i. Family assistance in maintaining good daily oral hygiene after the patient is no longer able to do so.
ii. Daily fluoride supplementation.
iii. Maintenance of an adequate diet.
C. Myasthenia gravis
1. Oral manifestations include effects on the facial and cervical musculature, which lead to a loss of control of facial muscles and result in smiling, eating, swallowing, speaking, and vision difficulties; when severe can cause respiratory distress.
2. Barriers to care include:
i. Communication difficulties, if patients experiences facial weakness or paralysis (patient may hold chin with hand to speak).
ii. Transportation difficulties; generalized fatigue affects the patient's ability to get to the dental office.
iii. Economic issues for those on fixed incomes.
3. Professional and home care involves:
i. Scheduling appointments during the patient's most active periods of the day-generally soon after medication is taken and after a good night's sleep.
ii. The availability of emergency equipment for respiratory distress during appointments.
iii. Home care instructions related to preventing oral infections, which are risk factors for crisis development. Powered toothbrushes and oral irrigators are recommended for patients who have difficulty manually cleaning the oral cavity.
iv. Careful attention to proper nutrition, which becomes more important when food selections are limited by an inability to chew.
4. Patient/Caregiver education should emphasize keeping the oral cavity in excellent condition to reduce the risk of crisis. Family members may be enlisted to assist in frequent, daily oral care procedures and transport of the patient to the dental clinic when the patient is no longer able.
D. Parkinson's disease
1. Oral manifestation include drooling, difficulty swallowing, tremors, and a reduced ability (or inability) to properly care for the mouth because of motor dysfunction, which may result in oral infection; speech may be stammered and monotone; xerostomia is a common side effect of medication
2. Risk factors include difficulty in swallowing, a restricted diet because of eating difficulties, and difficulty in walking.
3. Barriers to care may include:
i. Communication difficulties, because of the patient's embarrassment about the condition; slurred speech from motor dysfunction occurs later in the course of disease.
ii. Transportation difficulties, including ambulation problems and the need to rely on others as the disease progresses.
iii. Economic difficulties associated with the loss.
Patient during Pregnancy
Full-term pregnancy is defined as the 40-week-long developmental period of the fetus
I. Pregnancy is divided into first, second, and third trimesters; each has its own focus.
II. Medical manifestations
A. The pregnant patient undergoes system-wide changes during pregnancy; may have difficulty with nauseas and vomiting (typically first trimester) that predispose the patient to malnutrition because of appetite loss; caries also may result from acid in vomit contacting teeth and oral structures; is the best period for preventive dental examination.
B. The second trimester typically is the best time to schedule routine dental care appointments for several reasons; the patient typically is over morning sickness, the risk for developmental disturbances of the fetus is lower, and the fetus is small enough that the patient can still sit comfortably in the dental chair.
C. The third trimester is undesirable for treatment only because the patient may have difficulty sitting or lying in the dental chair for the entire appointment.
III. Oral manifestations
A. Erosion of enamel may occur in response to frequent vomiting, which accompanies severe morning sickness; small, frequent meals of healthy. Noncariogenic foods should be recommended; the mouth should be rinsed thoroughly with water after vomiting and fluoride should be applied daily; frequent intake of fermentable carbohydrates for nausea puts the patient at high risk for carries; gagging and nausea may lead to inadequate performance of home care.
B. Tetracycline and its derivatives are contraindicated during pregnancy and early childhood to avoid staining effects during mineralization the teeth
C. Inadequate oral home care can predispose the patient to gingival inflammation; although pregnancy itself does not cause the inflammation, the elevated hormonal influences of estrogens and progesterone during pregnancy can exaggerate the gingival response to microorganisms; the inflammation abates somewhat after the pregnancy terminates. Proper plaque removal can prevent inflamed tissues.
D. Recent research has found a relationship between periodontal disease and low-birth-weight infants. It is believed that some periodontal pathogens stimulate uterine contractions and may cause premature labor.
IV. Barriers to care
A. During pregnancy: including morning sickness (gagging, nausea, lack of appetite); inability to sit comfortably for long periods (backache, frequent urination, fatigue, dizziness); and economic difficulties because of increased medical costs
B. After pregnancy: include lack of time (return to work, family obligation) and economic difficulties because of increased costs associated with child rearing.
V. Professional Care
A. Should be based on the patient’s needs, in terms of both frequency of care and level of care; more frequent care (every 3 months) may be necessary for those with less-than-desirable home care, those with periodontal disease, or those whose morning sickness results in frequent vomiting.
B. Should include routine oral prophylaxis and root planing; avoid taking radiographs or giving medications
C. Should be provided in limited, shorter appointments as required for patient comfort. Allow patient to shift position as needed, preferably to the left side when orthostatic hypotension presents. Supine positioning must be avoided if hypotension persists
VI. Patient/Caregiver education should emphasize:
A. General health and well being during pregnancy and a well-balanced diet that meets the needs of both mother and fetus. Adequate consumption of protein, calcium, folic acid, and vitamin A, B-complex, C, and D is particularly important.
B. Plaque-induced and hormone-influenced inflammatory effects on gingiva and the effect of vomiting on enamel erosion; rinsing with water instead of brushing after vomiting should be recommended.
C. The dispelling of myths (e.g., about loosing a tooth for every child); when the diet contains inadequate amounts of minerals, calcium and phosphorus are removed from the mother’s bones (including alveolar and all other skeletal bones), not from the teeth. Nursing bottle syndrome and its prevention should be discussed
D. Meticulous plaque control; includes proper tooth brushing and flossing daily.
E. Fluoride application via dentifrices, gels, or rinses as needed, depending on the patient’s risk for the caries
F. Fluoride supplementation should be provided only for the benefit of the mother; no studies have found a link between prenatal fluoridation and a reduction in the rate of dental caries in children.
The Abused, Dependent patient
The dental professional should be aware of the signs of dependent abuse or neglect. Dependents include children, disabled adults, and the elderly-any person under the care of another. Abuse occurs in cases of physical neglect or abuse, emotional deprivation or abuse, and sexual abuse or exploitation. It is estimated that hundreds of thousands of elderly Americans and between 1 and 2 million children are abused or neglected each year.
I. Types of Abuse
A. Physical neglect is the failure to provide a healthy environment for a dependent. This includes the provision of adequate food, clothing, supervision, health care, living environment, personal hygiene, and education, Neglect can be either deliberate or the result of ignorance.
B. Physical abuse is nonaccidental biting, striking, burning, lacerating, or other type of conduct that results in injury.
C. Emotional deprivation is the failure to provide for the emotional needs of a dependent. It can include withholding love, lack of caring, alienation, and chronic criticism (is common in immature parents or caregivers).
D. Emotional abuse is the purposeful use of demeaning, vengeful, demanding, or aggressive behaviors to control a dependent. It can also include role-reversal, whereby the child or dependent controls the caregiver (is common in immature parents or caregivers).
E. Sexual abuse is the purposeful use of a dependent for nonconsensual sexual acts with a dependent that is unable to give informed consent.
F. Sexual exploitation is the purposeful use of a nonconsensual dependent or a dependent that is unable to give informed consent to provide some form of sexual act for the sexual or monetary gain of the caregiver.
II. Medical Manifestations of abuse
A. Signs of physical neglect may include:
1. An Unkempt appearance, which can include soiled clothing; dirty hair, hands, and skin; poor personal hygiene; inappropriate clothing or clothing in need of repair; and a lack of dental or medical care.
2. Lack of appropriate supervision, which can include allowing the dependent unrestricted freedom to roam the streets, leaving a dependent home alone, and failing to provide needed assistance in proper oral or personal hygiene.
3. Improper or inadequate nutrition, which can include: allowing indiscriminate eating and drinking of junk foods and beverages, restricting dietary choices, or providing too little food to give adequate nutrition.
B. Signs of physical abuse
1. Bruising
2. Lacerations tend to occur on the lips, eyes or face; a lacerated maxillary labial frenum can indicate forced feeding.
3. Bites
4. Burns that appear suspicious and have no reasonable explanation; often are made by cigarettes, immersion in hot water, or by rope (in cases of confinement).
5. Hitting
6. Hair pulling is indicated by bald patches or thinning hair.
7. Head banging may be evidenced by bruising of the back of the head, loss of consciousness, and retinal hemorrhage (as in shaken baby syndrome).
8. Inappropriate behavior is common in the abused. It may include:
i. Inappropriate fearfulness and crying.
ii. Abrupt changes in behavior when separated from a caregiver.
iii. Delays in language or growth development in infants and children.
iv. A withdrawn, unhappy character.
C. Signs of emotional deprivation or abuse
1. Improper behavior of a caregiver, including displays of anger, a condescending attitude, and criticism of a patient in front of others.
2. Improper behavior of the patient, including extreme displays of fear, dependence, and withdrawal.
D. Signs of sexual abuse and exploitation
1. Sexually explicit behavior in a child
2. Severe gag reflex
3. Oral lesions of sexually transmitted diseases
4. Refusal to allow clinician to enter mouth
5. Bruising of the palate not associated with accidental injury.
6. Discomfort of the genital-rectal area upon sitting.
7. Discomfort of the genital-rectal area when walking.
III. Oral Manifestation of abuse
A. Facial trauma, as evidenced by bruising, lacerations, bite marks, or burns in unlikely locations or associated with an unlikely cause.
B. A torn maxillary labial frenum, which often is associated with forced feedings.
C. Severe caries or oral infections that remain untreated after the caregiver is notified of need for treatment
D. Oral lesions associated with sexually transmitted diseases.
E. Palatal bruising, which is associated with forced oral sex
IV. Barriers to care include communication difficulties with both patient and caregiver. The dental professional may feel unprepared or uneasy dealing with abuse situations, the patient may be fearful of reporting abuse to any wrongdoing. An abusive caregiver who feels threatened with discovery may fail to keep appointments or may switch doctors.
V. Professional and home care involves:
A. Building trust with the patient by explaining all procedures and encouraging appropriate behavior.
B. Immediately reporting suspicion of abuse to supervising dentist or appropriate agency.
C. Discussing superficial treatment of injured areas; refer Patient to a physician as needed
VI. Patient /Caregiver education should include discussion of the need to reevaluate the injured area at a later date.
ATTENDANT CARE 2
TO ENSURE DENTAL CARE AND COMPLIANCE WITH HOME SELF-CARE PREVENTIVE PROGRAMS, COMPLETE COOPERATION MUST BE ESTABLISHED AMONG THE FAMILY OR CAREGIVERS, THE HEALTH PROVIDER, AND. TO THE EXTENT POSSIBLE, THE PATIENT. MANY COMPROMISED INDIVIDUALS ARE UNABLE TO HANDLE THEIR OWN HYGIENE DUE TO SENSORY, COGNITIVE, OR PHYSICAL DEFICITS. FOR THESE INDIVIDUALS AN ATTENDANT OR FAMILY MEMBER SHOULD BE INSTRUCTED IN THE PROPER ORAL HEALTH CARE FOR THE PATIENT.IF LONG TERM COMPLIANCE WITH INSTRUCTIONS IS THE GOAL, THE COMFORT OF BOTH THE CAREGIVER AND THE PATIENT IN PERFONNING THE ORAL HYGIENE PROGRAM IS PARAMOUNT. FOR THIS REASON A NUMBER OF POSITIONS HAVE BEEN RECOMENDED FOR THE CAREGIVER TO ASSUME WHEN PROVIDING ORAL HYGIENE CARE TO THE PATIENT.FACTS TO BE CONSIDERED INCLUDE THE PATIENT’S SIZE AND STRENGTH, THE ATTENDANT'S SIZE AND STRENGTH, AND THE AMOUNT OF CONTROL THAT NEEDS TO BE EXERTED OVER THE INTETIONA1 AND THE UNINTENTIONAL MOVERNENTS OF THE PATIENT.ONE POSITION THAT HAS PROVEN TO BE SUCCESSFUL IS FOR THE ATTENDANT TO STAND BEHIND THE PATIENT, WHO IS SEATED IN A STRAIGHT-BACKED CHAIR OR A WHEELCHAIR. IN THIS POSITION IT IS EASIER TO STABILIZE THE PATIENTS HEAD BY RESTING IT AGAINST THE BODY OF THE ATTENDANT. BRUSHING THEN PROCEEDS WITH THE ATTENDANT USING THE SAME KIND OF ARM AND BRUSH POSITIONING AS HE OR SHE DOES WHEN CLEANING HIS OR HER OWN TEETH. PERFORMING THIS OPERATION IN FRONT OF A MIRROR TAKES FURTHER ADVANTAGE OF THE ATTENDANT'S OWN BRUSHING HABITS, A1THOUG A MIRROR IS NOT A NECESSITY. OTHER RECOMMENDED POSITIONS INCLUDE HAVING THE PATIENT LIE ON A SUFA OR BED WITH HIS OR HER HEAD IN THE CAROGIVER'S LAP OR SIT ON THE FLOOR IN FRONT OF A CHAIR IN WHICH THE CAREGIVER IS SEATED.
SPECIALIZED EQUIPMENT
FOR PATIENT MANAGEMENT 2
Mouth Props
Several types of mouth props can be used to assist in opening and holding open the patient’s mouth for oral hygiene procedures. A simple, effective mouth prop can be easily fabricated with two or three tongue blades wrapped together, padded on one end with 2 x 2 gauze squares and secured in place with adhesive tape. This prop can be used with patients who are unable to understand or to cooperate due to decreased cognitive functioning. as seen in mental retardation, mental deficiency senile dementia, or in patients exhibiting neuromuscular dysfucntion, such as occurs in cerebral palsy or muscular dystrophy. The mouth prop is first placed in the buccal vestible and then slid to the posterior part of the vestible until it reaches the anterior border of the ascending ramus. Pressure applied against this anatomic area with the padded end of the prop causes a reflexive opening of the mouth. When this occurs the
mouth prop is immediately flipped over onto the occlusal surfaces of the teeth to maintain the opening. This prop may be used for the duration of the hygiene procedure, or it can be replaced by a commercially manufactured prop, which is placed on the opposite side of the arch. The original mouth prop is then removed with the new prop holding the mouth open.The two types of mouth props most commonly used are made of rubber or metal.
Headrests
There are numerous ways of supporting and stabilizing the head and neek of compromised dental patients. For those individuals who remain in their conventional wheelchairs throughout treatment, a commercially available wheelchair headrest may be purchased and kept in the dental office. This headrest attaches to the hand grips of the wheelchair and adjusts to compensate for different chair widths and sitting heights of the patients. Other types of head stabilizers can be attached to the headrest of the dental chair with velcro straps, which extend around the back of the chair to secure the stabilizing device. The cervical pillow is a welcome addition for patients who have cervical spine deformities, such as those present in severely involved arthitic patients. The cerebral palsy head support consists of a block of foam with a depression built in the center to stabilize the patients head.
Soft Ties
Soft ties, which are cloth or soft leahter straps may be used to support and stabilize any part of the body, including the head. Most commonly, soft ties are used to secure the upper and lower limbs to an appropriate arm or leg rest. This prevents the limb from spasming, flailing, or hanging ofthe edge of the rest, a position that can compress nerves and lead to neural damage. Soft ties are not meant to be punitive restraining devices but to provide positive support, stability and security to the patient.
Body Wraps
Full body wraps, such as pedi-wraps and papoose boards, are often used to immobilize smaller patients during dental treatment.These devices have limited usefulness in preventive programs where purposeful attempts are being made to actively involve the patient in his or her own oral hygiene. Body wraps should be considered only when an intraoral procedure needs to be accomplished and the patient is unable to cooperate. For some compromised patients unfamiliar with the dental environment, these full body wraps are welcomed as a souree of security and comfort. The provider who decides to use a body wrap should be aware that some communities frown on the use of restraints for any purpose.
ORAL HYGIENE DEVICES
MODIFYING TOOTHBRUSH HANDLES 2,7
In general the principles and techniques of toothbrushing used for a compromised population are the same as for anyone else. In comprornised individuals, however, good oral hygiene is much more difficult to achieve and rnaintain. If it has been determined that the patient has adequate dexterity to produce the small strokes needed to brush properly, a manual toothbrush may produce satisfactory results. Even if the patient has a weakened hand grasp or uses orthotic splints or other adaptive appliances, a manual toothbrush can be modified to facilitate usage. Figure 3 illustrates several different methods of quickly augmenting toothbrush handles from materials commonly found around the dental office or home. These include foam wrappings from packing materials, acrylic tray or bite registration material, the center foam piece from a hair curler, bicycle grip with plaster anchoring the toothbrush inside, or a juice can with a slotted ball inside to hold the toothbrush.
[pic]
Fig.3 Readily available foam tubes, bicycle handles, cans, or dental tray material can be used to modify the size of toothbrush handles.
Electric Toothbrushes 2
Electric toothbrushes are valuable aids in assisting compromised patient’s. They are especially useful when the patient has the strength to grasp the handle and place the brush in the mouth but does not have the manual dexterity needed to perfom the fine movements for the scrubbing function.The length and diameter of the handle of an electric toothbrush approxinlates those of manual toothlbrushes that have been modified for individuals with compromised hand function. These devices cannot, however be universally recommended for two reasons: (1) their increased weight, and (2) the difficulties in using their on off switch.
[pic]
Fig.4. An electric toothbrush being used by a severly disabled individual.
Floss-Holding Devices 2,7
Dental flossing is not recommended for all compromised patients unless the task of toothbrushing can be learned, it is useless to superimpose the more complex task of flossing. To do so can be so discouraging that all attempts at oral hygiene arc abandoned. This is true whether the patient or the attendant is performning the program. Therefore flossing should be introduced on a selective basis for those patients or attendants who have mastered toothbrushing and consistently show low plaque levels on tooth surfaces.
For some compromised patients, flossing can be performed regularly if a floss holding device is used. In a recent study, eight Such devices were evaluated by people with upper-extremity limitations.This group rated one device significantly higher for its handle dimensions, ease of threadings and ability to keep the floss taut. Although some compromised patients have learned to use parts of their bodies to assist in threading a floss holder, the majority of compromised patients have great difficulty in accomplislsing this procedure.
Interproximal Brushing 2
In older patients gingival recession is common expenence. Often the recessionis so pronounced that the use of regular dental floss is not effective in cleaning the long expanse of exposed root structure. In this Situation some recommend Super Floss, as it considerably thicker at one end. If the gingival recession has occurred to such an extent that the papilla no longer fills the interdental space, the use of an interproximal brush is often beneficial. Individuals who have never used floss or who have difficulty manipulating the dental floss or threading floss holder seem to adapt readily to the interproximal brush. The interproximal brush is also indicated for use in spaces where adjacent teeth are missing.
Disclosing Techniques 2
Whatever the patients age, disclosing pruducts should be suggested to visualize plaque when a patient has difficulty in plaque removal. Although disclosing solutions are readily available over the counter, the price is often prohibitive for daily oral health care. The cost factor can be minimized by purchasing commercial food coloring, usually available in the bakery section of any grocery store. The food coloring can then be used in place of the disclosing solution to stain dental plaque. The color should be chosen on the basis of which is easiest to see in the mouth. For example, yellow is difficult to detect on teeth because the color is too close to that of natural tooth color. Blue and green colors, although suitable for teaching plaque control to children, are more diffieult for the aging eye to visualize. Red food coloring is the easiest to visualize for all age groups.
PREVENTIVE THERAPIES
DIETARY CONSIDERATIONS AND ALTERNATIVE REWARD SYSTEMS 2,7
For many compromised patients, foods high in sugar are distributed throughout the day as a reward to individuals who have been compliant. Such a reward system encourages between-meal snacking and increases the consumption of highly cariogenic foods. With patients who have a decreased neuromuscular coordination or decreased salivary flow, it is not possible to adequately clear the mouth. Food remains impacted in the buccal vestibule and between the teeth until the next time the patient brushes or is brushed. To reduce the cariogenic potential, it is necessary (1) to restrict between-meal snacking and (2) to limit the use of highly cariogenic foods. If sweets are to be consumed at all, they should be presented at mealtime and the teeth brushed
immediately after eating. Bedtime snacks should be discouraged
Sealants And Fluorides 2,7
The use of sealants and Fuorides should be considered important preventive techniques to assist in caries control for compromised patients. Sealant application may be more difficult in some compromised patients, because it may be more difficult to control intraoral moisture contamination. Salivray pooling is often seen in cerebral palsy and muscular dystrophy patients, because they have swallowing difficulties. For the short time needed to apply sealants, antisialogogue medications are usually not indicated. Instead, the sealant may be applied in the conventional manner using the techniques to control saliva flow. To aid in moisture control the patient should be seated upright rather than in a reclining position.
Regular topical fluoride applications by the dental staff are highly important for the compromised dental patient. For the younger patient water fluoridation or tablets are essential. Equally important for this population is a home self-applied fluoride program. Several effictive techniques are now available for home fluoride application, ranging from mouth rinses to fluoride gels applied with custom-made trays. Rinses are contraindicated for compromised patients who cannot effectively swish the solution around their mouths.
Fluorides have also been shown to effectively reduce demineralization and to enhance remineralization. Therefore brush on gel fluorides should be considered for use by elderly compromised patients, particularly those with gingival recession. Fluorides should not, however, be indiscriminantly given to patients for unsupervised use if some question exists as to the patient’s ability to understand and follow instructions. This is necessary to prevent accidental ingestion or misuse.
Chemical Plague Control 2
When a patient has difficulty removing plaque, even with a conscientiously applied toothbrushing program, a chemical plaque control agent may be introduced. The use of a 0.12% chlorhexidine gluconate (CHX) mouth rinse, twice daily, has been found to reduce plaque and gingivitis in handicapped patients, and CHX has been shown to be effective.
Chlorhexidine glucunate may be used as a mouthwash, a spray, or a gel. The gel, which has been shown to be the most effictive, requires a tray. For handicapped patients, especially those needing. Assistance with oral hygiene activities, this method may be difficult or impossible. For compliance, the form that is accepted by the user is best.
Review of Literatures
I- From 1990 to 1995
Long-term oral effects of manual or electric toothbrushes used by mentally handicapped adults.
In 1991 AD, Bratel-J investigated the long-term oral hygiene effects in mentally handicapped patients using an electric toothbrush as compared to manual brushing. Twenty-three moderately handicapped patients were selected and sampled into two control groups. The two study groups used electric toothbrushes, while the control groups used manual toothbrushes. When the study was completed, no significant changes were found in or between the groups regarding plaque scores. The gingival score of the unaided electric toothbrush group was significantly reduced after 16 months. This improvement was probably attributed to frequent recalls and a well-designed prophylactic program. The main conclusion of this study is that an electric toothbrush is not a superior to a manual toothbrush.8
B- Treatment accessibility for physically and mentally handicapped people.
In 1992 AD, Wilson-KI found that transport systems may severely limit the ability of some handicapped people to travel to accessible surgeries. Professional and societal attitude towards handicapped people are ambivalent. It has been shown that professional attitudes towards handicapped people, and willingness to treat them, increases with training in this field. At present, this training has a low priority in many dental schools.9
Enhancing the effect of oral hygiene with the use of a foam brush with chlorhexidine.
In 1994 AD, Epstien J et al reported that foam brushes with chlorhexidine have been recommended for the use in hospitalized patients, particularly medically compromised and immune compromised patients as an alternative to toothbrushes.10
Oral health needs of persons with physical or mental disabilities.
Tesini DA and Fenton SJ in 1994 AD, explained that dentists who examine the needs of their patients population will recognized that the oral health concern of persons with physical or mental disabilities demands more of their knowledge and skills than any other segment of their practice. And to deliver quality, comprehensive care, the dentist must be updated on prevention and treatment techniques.11
Ethical and legal issues in special patient care.
In 1994 AD, Shuman SK and Bebeau MJ concluded that special patients, particularly the frail elderly, are at increased risk to become victims of abuse, and dental professionals should be familiar with the warning signs and symptoms of such abuse and their obligation to take an action to end it.12
Comparison of the clinical effectiveness of a single and a triple headed toothbrushes in a population of mentally retarded patients.
In 1995 AD, Sauverte-E et al reported that tooth brushing is a very simple and effective method for removing daily dental deposits and for preventing dental and periodontal diseases. However, it can cause considerable manipulative difficulties among some populations, e.g., young children, physically handicapped and mentally retarded patients. In order to test and compare the efficiency of a newly designed toothbrush (Superbrush), they have performed a pilot study on 30 patients, aged between 18 to 40 years. They concluded that the easiness of manipulating this newly designed toothbrush renders it a useful tool for the dental hygiene for this special part of dental compromised population.13
From 1995 to 2000 AD
Chlorhexidine: is it still the gold standard?
In 1997 Jones CG stated that after 20 years of use by the dental profession, chlorhexidine is recognized as the gold standard against which other antiplaque and gingivitis agents are measured. Specifically, chlorhexidine would seem to be of most value to patients in whom the ability to perform adequate oral hygiene procedures has been compromised.14
The use of chlorhexidine as a preventive and therapeutic means of plaque control in the handicapped.
Martens L et al, in 1997 AD mentioned that most of the handicapped are very dependant. Moreover, it is shown that the higher the dexterity level, the poorer the oral hygiene. It is well documented that the use of 1% gel chlorhexidine in prefabricated trays is the most efficient. They also indicated that the choice of any device for chlorhexidine application depend on the handicapping condition and on the knowledge and motivation of educators, and medical care takers.15
Comparison of the Interplak and manual toothbrushes in a population with mental retardation/developmental disabilities (MR/DD).
In 1997 AD, Carr et al reported that a major dental problem confronting persons with mental retardation/developmental disabilities (MR/DD) is poor oral hygiene, which can result in an increased incidence of gingivitis and periodontal disease. Their comparison study concluded that there is a significant improvement in the Gingival Index over 12-month period with the use of Interplak compared with a manual toothbrush.16
Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs.
In 1998 AD, Gordon SM et al highlighted that persons with special health care due to physical and cognitive impairment can be at increased risk for dental disease which can be attributed to, as well as exacerbate, existing medical conditions. Their stud assessed the nature of perceived barriers to obtaining oral health care among a special needs population and the influence of these factors (in particular, fear and anxiety) on utilization of dental services. They concluded that the levels of self-reported fear/anxiety and the high proportion of respondents indicating an unmet need for adjunctive anesthesia services suggest that fear/anxiety acts as a barrier to dental care among this special-needs group which could be ameliorated with greater use of these services.17
Maintaining mutans streptococci suppression with xylitol chewing gum
In 2000 AD, Hilderbrandt GH and Sparks BS confirmed that xylitol chewing gum appears to have the ability to prolong the effect of chlorhexidine therapy on mutans streptococci. And it is feasible to maintain long-term caries-pathogen suppression with currently available commercial products and can be expected to result in significant caries inhibition.18
Xylitol candies in caries prevention
In 2000 AD, Alanen P et al concluded that not only xylitol chewing gum but also xylitol candies are effective in caries prevention, and that a school-based delivery system seems to offer a practical way to distribute and control the use of the xylitol products.19
SUMMARY2
Individuals with physical, medical, mental, or emotional problems often have a greater need for dental care than their healthy counterparts. This may be because the disability itself has oral manifestations, but more commonly, it is due to (1) the limited capabilities of the individual or the family members to understand and to perform important oral hygiene tasks, (2) a lack of understanding of the importance of preventive dental care, and (3) a lack of albilit to finance dental care. When compromised patient does present to a dental office, the clinician should develop a treatment plan that emphesizes prevetion. Assesments should be made of the patient'S sensory cognitives and functional abilities ,and be used to customize a preventive plan. When the patient is unabe to provide his or her own care, the family or an attendant needs to be taught the appropriate techniques. Specialized equipment and easy-to-accomplish modifications of conventional oral hygiene devices may be employed to provide oral hygyiene care. .Strategies such as substituting noncariogenic reward systems to decrease caries incicdence are often successful. Dental preventive procedures, such as sealants, fluorides, and chemical plaque control, should be considered for each patient as part of any treatment plan. For many compromised individulas the retention of teeth in a healthy mouth improves mastication and digestion, as well as helps maintain an adequate nutritional status. In addition, the pleasing esthetics afforded by good oral health helps people with disabilitics to be more welcomed by others. Good preventive care enhances one’s self-esteem. For some patients who are severely compromised, specially adapted appliances may be required to maintain a high level of oral health and may be the only way to keep the mouth intact and free of dental diseases. Many individuals, due to neuromascular problems, have difficulties functioning with any type of oral prosthesis. Because the natural dentition assumes such an important role in the total living environment of the compromised patient, it is of utmost importance that the patient, caregivers, and the dental clinician work together to achieve an effective preventive oral hygiene program for such an individual.
REFERENCES
Michele L. Darby, Eleanor J. Bushee. Comprehensive Review of Dental Hygiene. Ed 2. 526-570. Mosby Co. 1991.
Norman O. Harris, Arden G. Christen. Primary Preventive Dentistry. Ed 4. 477-507. Appleton & Lange. 1995.
Debralee McKlevey Nelson. Saunders Review of Dental Hygiene. Ed 1. 501-541. W.B. Saunders Company. 2000
Brian M. Lange, Beverly M. Entwistle, Laurette F. Lipson. Dental Management of the Handicapped: Approaches for Dental Auxiliaries. Ed 1. 1-38. Lea & Febiger. 1983.
ADA Council on Community Health, Hospital, Institutional and Medical Affairs. Oral Health Care Guidelines: Patients with Physical and Mental Disabilities. 1-77. ADA. 1991
Ellen Brownstone. Handicapped Dental Patients: Mechanical Methods and Modifications for Oral Hygiene Care. CAN. DENT. HYG. 1990 March; Vol. (24): 32-39.
Diane Albertson. Prevention and the Handicapped Child. Dental Clinics of North America. 1974 July; Vol. (18): 595-607.
Bratel-J, Berggren-U. Long-Term oral effects of manual or electric toothbrushes used by mentally handicapped adults. Clin-Prev-Dent.1991 Jul-Aug; 13 (4): 5-7.
Wilson-KI. Treatment accessibility for physically and mentally handicapped people. Community-Dent-Health. 1992 Jun; 9 (2): 187-92.
Epstein J et al. Enhancing the effect of oral hygiene with the use of a foam brush with chlorhexidine. Oral surg. Oral Med. Oral Pathol. 1994 March; 77 (3): 242-247.
Tesini Da, Fenton SJ. Oral health needs of persons with physical or mental disabilities. Dent Clin North Am. 1994 Jul; 38 (3): 483-498.
Shuman SK, Bebeau MJ. Ethical and legal issues in special patient care. Dent Clin North Am. 1994 Jul; 38 (3) 553-575.
Sauvetre-E et al. Comparison of the clinical effectiveness of a single and a triple-headed toothbrushes in a population of mentally retarded patients. Bull-Group-Int-Rech-Sci-Stomatol-Odontol. 1995 Sept-Oct; 38 (3-4): 115-119.
Jones CG. Chlorhexidine: is it still the gold standard?. Periodontal 2000. 1997 Oct; 15: 55-62.
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