10: Special Care Patients

CHAPTER 10

Special Care Patients

Allen Samuelson

CHAPTER OUTLINE

Identifying the Patient With Special Needs
Role of the General Dentist in the Management of the Patient With Special Needs
Patient Evaluation

Chief Concern and History of the Chief Concern
General Health History and Review of Systems
Oral Health History
Psychosocial History
Functional History
Obtaining Additional Information From Other Health Care Providers
Physical and Oral Examination
The Actively Cooperative Patient
The Passively Cooperative Patient
The Actively Uncooperative or Combative Patient
The Passively Uncooperative Patient
Imaging
Special Diagnostic Tests
Diagnostic Casts
Arriving at a Diagnosis
Treatment Planning

Unique Aspects of Treatment Planning for the Special Care Patient
The Importance of General Health Issues
The Importance of Functional and Behavioral Issues
Levels of Care
Treatment Plan Content
Sequencing the Plan
Preventive and Maintenance Services
Referral Options
Phasing Treatment
Systemic Phase
Acute Care Phase
Disease Control Phase
Holding Phase
Definitive Phase
Maintenance Phase
Informed Consent
Planning for Specific Conditions

Patients With Developmental Delay or Cognitive Disorders
Traumatic Brain Injury
Multiple Sclerosis (MS)
Severe Coagulopathies
Acquired Immunodeficiency Syndrome (AIDS)
Hospice Patients
Access to Care

Transportation
Residency
Office Accommodations
Delivery of Care

Patient Positioning and Transfer
Patients Who Are Gurney-Bound
Patients Using Wheelchairs
Precautions With Transfers
Supports
Posture
Restraints
Communication With Special Care Patients
Role of the Family
Role of the Patient’s Caregiver
Other Professional Resources
Social Workers
Physician Assistants
Registered Nurses
Licensed Practical Nurses
Nurse’s Aides/Assistants
Pharmacists
Audiologists/Speech and Language Pathologists
Appointment Scheduling
Funding Sources
Private Pay
Medicare
Medicaid
Other Sources
Ethical and Legal Issues
Conclusion

The topic of dental care for patients with special needs addresses “the improvement of the oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional, social impairment or disability, or, more often, a combination of a number of these factors” (Training in Special Care Dentistry, Joint Advisory Committee, Sept. 2003). The U.S. government defines persons with disabilities as individuals who have a physical or mental impairment that substantially limits one or more major life activities. Census 2000 identified 49.7 million individuals in the United States with some type of long-lasting condition or disability. In 1993 the U.S. Centers for Disease Control and Prevention (CDC) reported that 1.5 million Americans had been diagnosed as suffering from mental retardation.1 Nursing home residents usually have one or more disabilities. In 1999, the United States had 18,000 nursing facilities with approximately 1.88 million beds. The average facility has 104.5 beds and an 86% occupancy rate.2

Typically the oral health needs of these populations are underserved and such patients often have limited access to oral health care3,4 (see the What’s the Evidence? box). For many, a caregiver must play a central role in taking care of their daily needs. Patients with special care needs provide the dental team with unusual and significant challenges in both planning and delivering dental treatment. The dental team’s consistent focus should be to provide these individuals with a complete range of preventive services and their caregivers with relevant information and support. Such patients deserve optimal care that is consistent with their dental treatment goals and with their cognitive and physical capacity to maintain a healthy oral condition. At the same time, treatment goals must be realistic, taking into account the patient’s temperament, social circumstances and support systems, and mental and physical abilities. Optimal treatment for these patients can range from simple pain relief to complete oral rehabilitation. In some situations, it may be appropriate to provide a complete range of definitive restorative care (with some treatment modification). Optimal care need not always involve a surgical intervention, however, and in some cases may be solely psychological and educational in nature. For instance, many caregivers feel guilty that their loved one’s dentition has deteriorated and feel powerless to help remedy the situation because of the patient’s resistance or lack of cooperation. Indeed, the state of debility for such a patient can be so severe that it may be inappropriate and virtually impossible to provide anything other than palliative care and education. Nevertheless, although the dental team may be unable to provide any treatment, the interpersonal situation may be improved by affirming the caregiver and his or her efforts, and the individual worth of the patient. In short, the responsibility of the oral health care team to these patients and their caregivers goes far beyond the provision of restorative dental treatment.

 

What’s the Evidence?

Are the Oral Health Needs of Patients With Disabilities Being Met?

Although the evidence is sparse, epidemiologic studies have shown that individuals with disabilities have more oral health problems than individuals in the general population.15 There is also agreement that individuals with special needs are more likely to have gingivitis, periodontitis, and poor oral hygiene.6,7 Small scale studies have shown that such individuals are more likely to have higher caries levels,5689 more missing teeth, and fewer fillings1011 than the general population. Such individuals also are often less likely to visit a dentist.6

Studies comparing individuals with special needs have found that institutionalized individuals are less likely to have untreated caries lesions, whereas those living in the general community are more likely to have untreated decay.5101214 Individuals with special needs living in the community are significantly less likely to have a dentist of record and fewer dental visits than comparable individuals living in residential institutions.10 Individuals with special needs living in the community have more difficulty accessing dental care on a regular basis and are more likely to visit a dentist only when they have a problem.51013 The higher caries rate among such individuals may be the result of greater access to unhealthy foods, resulting in poor choices for meals or snacks,15 whereas institutions usually have strict dietary controls.12

Interestingly, studies have also shown that individuals with special needs living in residential institutions have significantly fewer teeth than their counterparts who live in the community.101315 Histories of more extractions may be the result of an inability to tolerate dental treatment delivered with local anesthetic only.61013 Institutionalized individuals may also present more behavioral challenges and are therefore less accepting of restorative treatment.1016 This may account for the fact that when they do receive care, those living in the community are more likely to have teeth filled than those in institutions.15

Greater caries experience among patients with special needs may be the result of medications (xerostomic or sweetened), poor diet (sweet snacks and soft drinks), and poor oral hygiene.317 Individuals with special needs report low access to primary dental care.151720 Many individuals with learning disabilities may have oral health problems that go unnoticed because of communication or behavior problems.31821 Also, individuals with disabilities report that many dentists are reluctant to provide the necessary care.21 Most often it is the pediatric dentists who treat patients with special needs, regardless of the age of the patient.6

Although oral health care for individuals with special needs is being provided to a limited extent,22 improvement is needed.3,15 To reduce unmet oral health care needs among this group, both increased funding and further training for dentists in the treatment of individuals with disabilities are necessary, including training in the provision of care under general anesthesia.23

 

1. Beck, JD, Hunt, RJ. Oral health status in the United States: problems of special patients. J Dent Educ. 1985; 49(6):407–426.

2. Brown, JP, Schodel, DR. A review of controlled surveys of dental disease in handicapped persons. J Dent Child. 1976; 43(5):313–320.

3. Desai, M, Messer, LB, Calache, H. A study of the dental treatment needs of children with disabilities in Melbourne, Australia. Austr Dent J. 2001; 46(1):41–50.

4. Nunn, JH, Gordon, PH, Carmichael, CL. Dental disease and current treatment needs in a group of physically handicapped children. Community Dent Health. 1993; 10(4):389–396.

5. Tesini, DA. An annotated review of the literature of dental caries and periodontal disease in mentally retarded individuals. Special Care in Dent. 1981; 1(2):75–87.

6. Waldman, HB. Special pediatric population groups and their use of dental services. J Dent Child. 1989; 56(3):211–215.

7. Nowak, AJDentistry for the handicapped patient. St Louis: The C. V. Mosby Co., 1976.

8. Nowak, AJ. Dental disease in handicapped persons. Special Care in Dent. 1984; 4(2):66–69.

9. U. S. Department of Health and Human ServicesThe prevalence of dental care in United States children, 1979-1980. Washington, DC: Government Printing Office, 1981. [NIH Pub. No. 82-2245].

10. Tiller, S, Wilson, KI, Gallagher, JE. Oral health status and dental service use of adults with learning disabilities living in residential institutions and in the community. Community Dent Health. 2001; 18(3):167–171.

11. Kelly, M, Steele, J, Nuttall, NAdult dental health survey; oral health in the United Kingdom 1988. London: The Stationery Office, 2000.

12. Brown, JP. The efficacy and economy of comprehensive dental care for handicapped children. Intl Dent J. 1980; 30(1):14–27.

13. Gabre, P, Gahnberg, L. Dental health status of mentally retarded adults with various living arrangements. Special Care Dent. 1994; 14(5):203–207.

14. Kendall, NP. Differences in dental health observed within a group of non-institutionalised mentally handicapped adults attending day centres. Community Dent Health. 1992; 9(1):31–38.

15. Lindemann, R, Zaschel-Grob, D, Opp, S. Oral health status of adults from a California regional center for developmental disabilities. Special Care in Dent. 2001; 21(1):9–14.

16. Pratelli, P, Gelbier, S. Dental services for adults with a learning disability: care managers’ experiences and opinions. Community Dent Health. 1998; 15(4):281–285.

17. Stiefel, DJ, Truelove, EL, Persson, RS, et al. A comparison of oral health in spinal cord injury and other disability groups. Special Care Dent. 1993; 13(6):229–235.

18. Cumella, S, Corbett, JA, Clarke, D, et al. Primary healthcare for people with learning disability. Mental Handicap. 1992; 20:123–125.

19. Howells, G. Are the medical needs of mentally handicapped adults being met? J Royal Coll Gen Pract. 1986; 36(291):449–453.

20. Martin, DM, Roy, A, Wells, MB, et al. Health gains through screening. Users, and carers, perspective of healthcare. Developing primary healthcare services for people with an intellectual disability. J Intell Dev Disability. 1997; 22:241–249.

21. Milnes, AR, Tate, R, Perillo, E. A survey of dentists and the services they provide to disabled people in the Province of Manitoba. J Can Dent Assoc. 1995; 61(2):149–152. [155-158].

22. Waldman, HB, Perlman, SP. Are we reaching very young children with needed dental services? J Dent Child. 1999; 66(6):366–390-394.

23. Curzon, ME, Toumba, KJ. The case for secondary and tertiary care by specialist dental services. Community Dent Health 15 Suppl. 1998; 1:312–315.

This chapter focuses on identifying and diagnosing the patient with special care needs and how to plan treatment and manage such an individual’s oral health problems for the short and long term. The scope of this chapter is intentionally broad, and will address diagnostic and management techniques and issues applicable to a wide range of patient conditions that can be considered to reflect special needs. The management of several particularly important special clinical needs is covered in greater detail in other chapters. Treatment planning for the financially or motivationally impaired patient, adolescents, the elderly, the anxious and phobic, the substance abusing individual, patients with oral cancer, and patients with psychological problems is covered in subsequent chapters in this third section of Treatment Planning in Dentistry. This chapter serves as an overview and an introduction to those chapters, and, in addition, discusses a variety of special needs conditions not specifically addressed elsewhere in the book.

IDENTIFYING THE PATIENT WITH SPECIAL NEEDS

The distinction between the patient who is designated “special care” or “special needs” and the more typical dental patient who may need small accommodations to be comfortable during a procedure or to facilitate efficient treatment may sometimes seem indistinct. Indeed, all patients deserve individualized and compassionate, and therefore special care. All patients have a right to expect the dental team to treat them as unique individuals. This may be manifested in many small but significant ways. It may include addressing the patient in a preferred manner, or the way the assistant holds the suction to avoid causing a gag reflex, or using a mouth prop to reduce strain on a sensitive temporomandibular joint. The patient with special needs, although typically seeking the same types of services and therapy, will require an even more intentional, strategic, and individualized approach to care. Broadly speaking, patients with special clinical needs are those patients who live with significant mental, physical, psychological, or medical challenges and who, as a result, require significant modifications to treatment planning and delivery. The following is a representative, although not necessarily all inclusive, list of conditions that can be categorized as representing “special care” or “special needs”:

• Autism
• Mental retardation (Down syndrome)
• Traumatic brain injury
• Cerebral palsy
• Mental illnesses (psychoses or neuroses of various diagnoses)
• Medically compromised conditions (congestive heart failure, unstable angina, cancer, transplant, human immunodeficiency virus [HIV]-acquired immunodeficiency syndrome [AIDS])
• Severe dental anxiety or phobia
• Craniofacial abnormalities (craniofacial syndrome, Apert’s syndrome, cleft palate)
• Certain congenital illnesses (hemophilia)
• Various dementias (Alzheimer’s, Parkinson’s, multi-infarct dementia)
• Severe depression or pseudodementia
• Physical disability, such as severe rheumatoid arthritis

The patient with special needs may require modifications in both the kind and scope of dental treatment. Certainly specific physical, medical, psychological, or psychosocial problems will have a bearing on the kinds of modifications to the dental treatment plan that will be necessary. Equally important, the severity of the disorder will have an impact on what the necessary modifications will be. For example, an individual with mild autism who can cooperate during restorative procedures and is responsive to preventive therapy may be treated with minimal or no modification to treatment. At the other extreme, a patient in the late stages of Alzheimer’s disease is a poor candidate for anything beyond basic preventive and acute care services.

ROLE OF THE GENERAL DENTIST IN THE MANAGEMENT OF THE PATIENT WITH SPECIAL NEEDS

Recognizing, managing, and treating all oral health care problems presented by individuals with special needs is within the scope of general dentistry. The general dentist has several roles to play in the management of the patient with special needs. Initially the dentist must recognize that a patient has special needs and make appropriate adjustments to the examination process. Often the dental team will need to elicit the help of the patient’s caregiver to negotiate the initial examination. Consultation with other health care providers may also be indicated. If, after completing the examination, the general dentist determines that he or she will be unable to provide comprehensive oral health care for the patient, then referral to another oral health care provider, a hospital dentistry unit, or an academic health center may be indicated.

If the general dentist is able to provide all, or a portion of, the oral health care for the patient, then a plan of care will be generated. The complexity of this plan will depend on many factors, including the patient’s dental needs, the anticipated level of cooperation, the patient’s ability to carry out effective oral self care, and the availability and extent of support from a caregiver. When completed, the general dentist and the dental team will carry out the plan in a compassionate, humane, efficient, and professional manner. Long-term maintenance services will necessarily be provided, taking into account that, in many situations, the patient’s oral and general health may deteriorate. Engaging the assistance of caregivers and health care providers in providing dental therapy and long-term oral health maintenance to the patient is important. Throughout the treatment process, every effort will need to be made to preserve the dignity of the patient and to affirm and encourage the efforts of the caregivers and family.

Educating the patient and caregiver is an important role for the dental team. Patients with special needs and their caregivers should be informed of the importance of oral health and its relationship to systemic health. Involving the patient in the decision making will encourage the individual to assume responsibility for his or her own oral self-care to the extent possible. Beyond what the patient can do alone, the caregiver will need to be actively involved in this process. Often the dentist will need to provide the caregiver with detailed information about the nature, scope, and demands of dental treatment; and to educate the caregiver on how to assist the patient, and the importance of that activity.

 

Dental Team Focus

The Oral Health Team and the Patient With Special Needs

The oral health team plays a critical and invaluable role in the care and treatment of the patient with special needs. Notable benefits of the team’s assistance include increased efficiency in the delivery of treatment and an overall higher quality of care. The administrative assistant may need to:

• Schedule patients at the specific time of day that works best for their needs.
• Schedule longer appointments to meet the additional challenges that can be expected.
• Communicate with caregivers concerning changes in the patient’s general or oral health, or other physical or behavioral changes. Ongoing communication with a responsible family member or caregiver can be helpful both to the oral health team and the family member or caregiver.

Strategies that team members should adopt include:

• At team meetings, discuss and plan provision of any special emotional and physical support that may be helpful at a prospective dental visit.
• If the practice has many patients with special needs, it may be useful to identify some member in the office to regularly serve as liaison with family members, care providers, and other medical support personnel.
• Provide physical comfort for the patient who has a chronic or acute disease.
• Provide reassurance and familiarity throughout the treatment process.
• Be prepared and able to assist in transferring a patient from a stretcher, gurney, or wheelchair.
• Accommodate the special needs of patients with hearing, vision, or other physical impairments (e.g., rearranging the operatory, employing appropriate educational techniques, using physical supports or other devices).
• Anticipate patient needs; be flexible, resourceful, patient, and compassionate in the delivery of care.

Frequently, physicians refer patients with complex conditions to the general dentist for evaluation, treatment of oral infection or disease, or oral rehabilitation so the individual can eat and chew more effectively. A physician or surgeon may also refer the patient to a dentist for oral disease prevention before major medical or surgical interventions. Such referrals would include patients who are scheduled for chemotherapy, organ transplantation, major joint replacement, or radiation therapy. In such situations, it is critical that the dentist diagnose and treat any current or potential source of oral infection before, during, and after the medical intervention.

The dental team has the responsibility to help the patient with special needs maintain a functional, healthy oral condition (see the Dental Team Focus box). For such patients, this can necessitate considerable time, effort, and creativity. The ultimate goal is to help the patient to achieve an optimal state of oral health consistent with what his or her mental and physical condition will allow.

PATIENT EVALUATION

Ideally the patient with special needs will be identified at the time the initial appointment is made through a matter-of-fact query by a member of the office staff: “Do you have any physical or other limitations that we can assist you with upon your arrival?” If the patient answers affirmatively, he or she should first of all be assured that he or she will be welcomed to the practice and that any necessary effort to provide accommodation will be made. The patient should be asked to bring any available medical records and names and contact information for other health care providers; a list of all medications; and any available dental images or records. An effort should also be made to learn whether the patient has a guardian or caregiver, in which case that person should be invited to attend at least the initial visit. Some dental offices find it useful to develop a specific form or questionnaire for such patients, which helps to characterize the special needs and individual expectations. Upon arrival, the patient should be greeted warmly and given an explanation of what to expect at this first visit. If the patient has brought any documentation, forms, questionnaires, or images, these need to be received, recorded, and copied, and returned to the patient (or caregiver) as appropriate. If a caregiver or family member comes with the patient, he or she should be recognized and thanked for any assistance with providing care for the patient in the dental office setting.

After introductions, the patient is escorted to the operatory, and the examination process begins. The patient may be more comfortable if the caregiver or family member is also present during the examination and that should be encouraged. A patient with special care requirements is evaluated in the same basic manner as described in Chapter 1 of this text. An initial attempt should be made to complete the examination in a standard fashion. Depending on the level of the patient’s ability to cooperate, parts of the examination may not be completed effectively. For example, the patient with severe autism or delayed development may not even allow a team member to escort them to an operatory, much less perform an examination. Strategies for managing such a situation are described later in this chapter.

Initially the patient may have difficulty becoming acclimated to the new and strange surroundings. The dental team must be flexible and team members need to be accepting of the patient’s behavior and limitations. As the team converses and interacts with the patient in a kind, gentle, and caring manner, the patient will often lower defenses and allow anxiety to abate. The patient may become comfortable enough to allow at least a brief look, a moderately complete examination or, in a best case scenario, a complete oral examination. If the examination is not completed at the initial visit, the dentist (in consultation with the caregiver) may reappoint the patient, with the goal of completing the examination at a future date when the patient is less stressed and more comfortable with the dental office setting. If the patient is physically unable or mentally incapable of cooperating for a comprehensive evaluation, some form of sedation or general anesthesia may be necessary.

Chief Concern and History of the Chief Concern

It is critical to evaluate the patient’s chief complaints or concerns to properly address specific needs that the patient or the caregiver perceives to be important. Characterization of the chief concern often gives the dentist a sense of the patient’s or caregiver’s oral health philosophy and knowledge. If the patient is unable to articulate his or her own wishes and concerns, the chief complaint can be derived from a variety of other sources, including family members, physician, caregiver, social worker, or case manager. If the dentist believes that addressing the chief concern is unrealistic or unreasonable, then the issues involved must be articulated to the patient, caregivers, or other family members or individuals who may be involved in the decision making. For example, if the family of an individual with dementia desires complex restorative treatment, but the patient appears uncooperative and lacking in the capacity for preventive care, then the family must be informed that this option is inappropriate and why this is the case. Addressing the chief concern is often the starting place for co-discovery of issues central to the ultimate management of the patient and a touchstone on which to begin the education of the patient and caregivers.

General Health History and Review of Systems

Although important as a baseline of information for all patients, obtaining a thorough and complete health history for the special care patient can be of life preserving significance. Answers to questions regarding hos-pitalizations, major illnesses, surgical procedures and complications, medications, and allergies are essential if the patient is to be treated safely and effectively. Because of the complex physical status of many of these patients, an exclusive use of only a standard health history form with close-ended questions is inadequate.5 Instead, an open format mode of questioning, or a questionnaire supplemented with follow-up questions, is frequently necessary to provide a complete history. In addition to the patient interview, the history can be taken from a variety of other sources, including family members, caregivers, nurses, physicians, case managers, and the patient’s medical records.

The phrasing of questions must be consistent with the patient’s level of understanding and education. Layman’s terms and colloquialisms can appropriately be used to take a good history. Even with this open format, however, it is imperative that the dentist use a standardized and consistent “branching tree” series of questions (Box 10-1).

 

BOX 10-1   Example “Branching Tree” Questioning Process

The branching tree questioning process refers to a method in which, after an affirmative response to a general question, more specific questions are asked to ascertain the dimensions of a particular condition, problem, or concern. For example, if the patient gives an affirmative answer to the question “Do you suffer from angina pectoris?” the following questions are commonly asked:

• What is the frequency of the pain?
• When does the pain typically occur? (after meals, related to exertion, specific time of day)
• What is the duration of the pain?
• What is the character of the pain? (sharp/dull/crushing)
• What is the severity of the pain? (mild/moderate/severe/intolerable)
• What exacerbates the pain? (exercise, position, or posture)
• What alleviates the pain? (rest, nitroglycerin)
• Does the pain radiate? If yes. Where?
• Do you take antianginal medication? (frequency, amount)
• Have you visited an emergency room for this condition? (frequency, treatment received)

The review of systems (ROS), an integral part of the health history, consists of a sequential series of questions about each organ system. Inherent in this process are checks and balances that prompt the patient to remember aspects of his or her history that may have been missed in the questionnaire or in previously discussed sections of the history. Key topics to be listed in a typical review of systems are included in Box 10-2.

 

BOX 10-2   Common Issues Included in a Review of Systems

Head, Eyes, Ears, Nose, Throat hearing, vision, glaucoma, sinus/allergies, mouth ulcers, oral cancer

Neurologic strokes, seizures, trauma, lightheadedness, Parkinson’s disease

Neck arthritis (spondylitis), trauma, subluxation, mobility, masses

Cardiovascular myocardial infarction, angina pectoris, valvular disorders/murmurs (nature of, how diagnosed), atherosclerosis, hypertension, peripheral vascular disease

Pulmonary tuberculosis exposure, asthma, smoking, emphysema, bronchitis

Gastrointestinal polyps, ulcers, reflux, indigestion, liver/gallbladder disorders

Genitourinary kidney/bladder disorders, incontinence, renal failure (dialysis and type)

Endocrine adrenal gland, diabetes, thyroid disorders, pituitary

Hematologic bleeding disorders, clotting problems, anemia (type)

Musculoskeletal weaknesses, prosthetic joints, arthritis

Other cancer, chemotherapy, radiation, metabolic disorders (for head and neck cancer need dosages and portals of radiation, history of hyperbaric oxygen)

Oral Health History

Many questions on the oral health history are the same as for all patients (for example: frequency of check ups and oral prophylaxis), but there are additional questions that have particular relevance and importance for the patient with special care requirements. It is helpful to know where past dental care occurred (i.e., general dental office setting, hospital based clinic, operating room, or other setting). Did the patient need sedation or general anesthesia? It is also important to learn what type of specialty care the individual has received and the nature of the treatment. The dentist should inquire about each of the dental specialties in an effort to gain a comprehensive understanding of the patient’s dental experience. The patient’s specific daily oral care regimen should be ascertained. It may be necessary to ask caregivers to describe their routines for cleaning the patient’s mouth. In fact, it is important to determine if the patient’s mouth can be cleaned, and whether he or she is cooperative. Important questions to be asked of the patient or caregiver include the following:

• How often do you brush your teeth? What times during the day? How much time do you spend brushing? Do you use a mechanical or a manual toothbrush? What type of toothpaste do you use?
• Do you floss? How often and when? Do you use floss aids?
• Do you use other cleaning devices?
• Do you use mouth rinses? Gels? Other forms of fluoride?
• Do you have a substantial plaque or tartar build-up?
• Caregivers should be asked whether a mouth prop is needed when assisting the patient with oral home care.

Also included in this section of the patient history is a dietary analysis. The patient or caregiver should be questioned about the following:

• How much table sugar do you use?
• Do you consume soft drinks or sodas? If so, how often? With meals? How quickly consumed (sip or gulp)?
• Do you consume 2 or more fruit drinks or juice per day?
• Do you eat hard candy or other sweets? If so, what type? How often?
• Do you ingest acidic foods or beverages (such as citrus fruits, vinegar, or artificially sweetened soft drink or soda) on a regular basis (especially between meals)?
• How often do you consume snacks or baked goods?

An understanding of the nutritional intake and the dietary history is important for any patient, but can be critical for the patient with special needs. Sugary “comfort foods” may be readily available and more appealing than healthier foods. Caregivers may use such foods to pacify their patients and reduce the required care-giving time or lessen caregiver stress. Especially when coupled with poor oral home care, such patients will often be afflicted with many active carious lesions and be at high risk for new caries development. It is therefore very important to educate patients and caregivers about the hazards of a cariogenic diet and suboptimal oral home care.

Impeccable home oral health care can sometimes mitigate the ill effects of a cariogenic diet, but this is often difficult for the special needs patient to achieve. Often the patient does not have the ability to carry out meaningful oral self-care procedures and is resistive to efforts by caregivers. When a patient needs assistance with oral home care and is not responsible for his or her own dietary choices, it may be easier and more effective for the caregiver to modify a cariogenic diet than to maintain good plaque control for the patient. Serious efforts should be made on both fronts, but of the two, diet may actually be the more important variable to control in the long run. See Box 10-3 for some common dietary tips that can be shared with patients and caregivers.

 

BOX 10-3   Dietary Tips for Special Needs Patients and Their Caregivers

• Limit consumption of refined sugars, especially between meals. Drinks such as pure fruit juice and fruit drinks, milk, and dietary supplements often contain large amounts of fermentable carbohydrates and can cause cavities particularly in the absence of good plaque control.
• Limit consumption of acidic substances and beverages especially between meals. Acidic substances, including carbonated beverages, can dissolve tooth structure and contribute to cavities. Diet sodas are particularly damaging.
• After consuming acidic or sugary between meal snacks, rinse the mouth with water to flush away sugars and dilute acids in the mouth.
• Do not brush for at least 30 minutes following acid exposures.
• Fresh fruits, vegetables, meat products, whole grains, cheeses, and water are generally good foods for oral health.
• Fluoride use should be encouraged fluoridated toothpaste, mouth rinse, gels, and varnish have all been shown to be helpful for patients who are at risk for cavities.

Patients who are deemed to be at high risk for caries are good candidates for the use of a diet diary. Patients with active caries for whom the cause of the dental caries is not clearly evident can definitely benefit from the compilation of a comprehensive diet history. The diet diary can be used to identify hidden and overt sugar and acid sources and can serve as the basis for counseling the patient regarding dietary habits and those food items detrimental to dental and oral health. The patient is usually instructed to keep a diet diary for 5 to 7 days, writing down all food items and beverages consumed (Box 10-4).

 

BOX 10-4   Example of a Single Day From a Patient’s Diet Diary

Breakfast

Sugared cereal
Toast and grape jam
2 glasses of OJ
Cup of coffee with tablespoon of sugar and milk

Lunch

Meatloaf
Black beans
Fruit cup
Bread and butter
Candy bar
1 regular soda

Dinner

Hunan chicken and vegetables
Fried rice
1 regular soda
Pecan pie
Fruit Loops and milk (during evening)

When the patient returns to the office, a member of the team reviews the diary in detail with the patient. It is often helpful to circle those food items harmful to the patient’s teeth. Dietary recommendations are then made to the patient (and/or caregiver). At this point, it is often helpful to compose a letter for the patient and caregiver reviewing relevant dietary and oral home care issues, and formalizing the dental team’s recommendations and goals for the patient. (See Box 10-5 for an example.)

 

BOX 10-5   Example of a Follow-Up Letter to a Patient Regarding His or Her Oral Health and Recommendations for Oral Disease Prevention

May 1, 2006

Dear Mr. Smith:

My staff and I have appreciated the opportunity to work with you to improve your oral health during the past two appointments. I believe that we have made real progress in oral health promotion in preparation for restoring your dentition and getting you on the road to keeping your teeth for your entire lifetime! I hope that all your questions about brushing/flossing techniques and diet have been answered. If not, please do not hesitate to contact me or to bring them up at our next appointment.

As we discussed, several areas in your diet raise concerns relating to good oral health.

1. Fruit Loops and other sweet cereals are particularly devastating if oral hygiene procedures are not carried out soon after eating.
2. Sugar in coffee is acceptable, but again I recommend a quick brushing afterwards.
3. Regular sodas these are EXTREMELY detrimental to your dentition. It would be best to limit or discontinue their use. When you do consume them, be sure to rinse your mouth out with water and brush afterwards.
4. Any consumption of sweets should be followed up with oral hygiene procedures as soon after as feasible.
5. Considering your past caries activity, I recommend a thorough brushing and flossing 2 to 3 times a day. I also recommend use of an electric toothbrush as well.
6. Remember, preserving your teeth is primarily up to you with support from our dental team! I am very encouraged by your positive attitude and feel confident that you will follow through with our recommendations!

Thanks and please contact me if you have any questions or concerns. I know some of these changes may be difficult, but with you as a co-therapist, I think we can accomplish much.

Professionally,

Allen D. Samuelson DDS

Clinical Associate Professor

Such a letter can be an important part of the process of educating, encouraging, and empowering the patient and/or caregiver.

Psychosocial History

A psychosocial history, useful for any comprehensive care dental patient, often carries particular relevance and importance for the patient with special care needs. Information about basic issues, such as the patient’s ability to ambulate and get to the dental office, is essential to being able to provide dental care. Does the patient need an accompanying person? Who will that be? Does the patient need transportation? If so, how will that be arranged? It should not be assumed that because a patient is elderly or handicapped he or she is not employed. An understanding of the patient’s past and present career and employment can have a bearing on the nature and extent of dental treatment that may be desired or appropriate, the timing of dental visits (to accommodate the patient’s work schedule), and financial resources. An understanding of the patient’s support system, schooling, and domiciliary arrangements can give the dentist an idea of how well the patient may be able to follow through with a preventive and restorative plan.

Taking a good psychosocial history also tends to affirm the patient’s humanity and his or her integration into the family unit and society. Trust is gained with the patient and family by this affirmation. A thorough psychosocial history will also disclose relevant habits, including the use of alcohol, tobacco, and illicit drugs, which are discussed at length in Chapters 11 and 12. Oral habits can be commonplace in special needs patients and may impede the success of preventive therapy and negatively impact the outcome of dental treatment. Some common deleterious habits include fingernail or object biting; “doodling” with needles, nails, and other objects; obsessive use of oral health aids; bruxism; and mouth breathing.

Functional History

The functional history reviews the patient’s past and present ability to live independently and to function in society. Typically this includes an analysis of the patient’s capacity for the activities of daily living (ADL), which is important because it allows the practitioner to evaluate the patient’s physical and cognitive ability to follow through with a preventive, restorative, and maintenance plan of care. Activities of daily living are divided into two major groups; basic and instrumental. (See Box 10-6 for a listing and explanation of activities of daily living.)

 

BOX 10-6   Activities of Daily Living

A range of common activities whose performance is required for personal self-maintenance and independent community residence

Physical ADL (basic self-care activities)

1. Dressing
2. Toileting/continence
3. Transferring
4. Eating
5. Mobility
6. Bathing

Instrumental ADL (complex abilities needed for independent living)

1. Shopping
2. Traveling/transportation
3. Using the telephone
4. Preparing meals
5. Housework/laundry
6. Taking medicine
7. Managing money

Depending on the level of function that the patient exhibits, treatment planning may need to be altered. An analysis of the patient’s ability to perform ADL is predictive of how well he or she may be able to perform oral hygiene. For instance, if the patient has limited mobility (e.g., severe arthritis), he or she may not be able to get to a lavatory to perform basic oral hygiene, and modifications such as basins and towels brought to the bed may be necessary to facilitate daily oral care.

Obtaining Additional Information From Other Health Care Providers

For the typical dental patient, the dentist completes all parts of the patient evaluation and, if warranted, a physician consultation is obtained. In the case of patients with complex health concerns and multiple medications, however, this sequence may need to be modified. If the individual comes to the office unattended, he or she may have some difficulty communicating all the necessary health and drug information to the dental team. If the individual comes with an attendant or family member who is not the primary caregiver, the attendant may not have the necessary information either. If the patient lives in a residential care facility, the medical record (or a general health problem list and summary of current medications) can be requested and brought with the patient on the initial visit. It still may be necessary to consult with the patient’s primary care physician, pharmacist, primary caregiver, close family member, or other responsible party who is knowledgeable about the details of the patient’s general health. In many cases, it may be prudent to do this before initiating invasive portions of the clinical examination. This is usually accomplished most effectively by making an immediate telephone contact. Where this is not possible, follow-up contact via phone, fax, or e-mail can be made (with the patient’s permission) before the next visit. Otherwise, arrangements can be made to have other medical records or documentation brought to that next visit. A copy of a recent medical history and physical examination, any recent (less than 12 months ago) hospital discharge summaries, and laboratory reports, such as an EKG (electrocardiogram), CXR (chest x-ray), echocardiogram, and a CBC (complete blood count) with differential are relevant examples of useful documentation. A typical situation in which a consultation with the physician is appropriate is when the patient has an equivocal history of a “heart click” or heart murmur (Box 10-7).

 

BOX 10-7   Example of a Typical Referral Letter to a Physician for Evaluation of a Reported Heart Murmur

Dr. Jim Smith

Division of Internal Medicine

Department of Cardiology

Re: Mrs. T. Brown

Dear Dr. Smith,

I would like to introduce Mrs. Johnson to your service for evaluation of a reported heart murmur. Mrs. Johnson is a very pleasant 78-year-old African American female. She reports that she has been diagnosed with a murmur and states that she “needs antibiotics” for this. She says her “old dentist” stated that she needed to take the antibiotics before dental treatment. She does not remember how the murmur was diagnosed and I see nothing in her medical record regarding a murmur. She has been taking antibiotics (according to the AHA guidelines) for several years. Mrs. Johnson is healthy otherwise and reports no other medications and no allergies. She reports having had only two surgeries in her lifetime (C-sections).

Our team plans to perform 2 to 3 dental extractions, clean her teeth, and construct partial dentures for Mrs. Johnson. I anticipate minimal blood loss, relatively short appointments, and the use of roughly 108 mg lidocaine and 54 mcg epinephrine with each appointment.

Please evaluate Mrs. Johnson for the presence of a murmur and the need for antibiotic prophylaxis. I appreciate your assistance. If you require further information please feel free to contact our office.

Professionally,

Allen D. Samuelson DDS

Although in many cases a physician consultation is warranted, it is usually not necessary that it occur before the clinical examination. Often the dental team can complete the portions of the intraoral and extraoral examination and the noninvasive portions of the clinical examination that the patient is able to cooperate with, make a general determination of what dental treatments may be recommended to the patient, and then obtain a medical (or other related) consultation. The procedure and documentation for a referral to a medical provider follow the guidelines discussed in Chapter 1. If a patient with special needs presents for dental treatment and has no established or current relationship with a physician or medical practice, then a referral to a physician for a complete evaluation is necessary. Other cases in which referral to a physician or medical clinic may be warranted include when the dental team believes that they have not obtained a complete or accurate health history, or when the patient exhibits signs of an emerging health problem or signs that a preexisting condition is not under adequate control. Generally, referral should be to an internal medicine physician. A referral letter should be sent along with the patient or care provider giving a brief explanation of planned treatment, anticipated blood loss if any, time in the chair, and medications to be used. The physician should be queried about the diagnosis and management of any health problems that are relevant to den/>

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 10: Special Care Patients
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