Chapter 24

At-risk and special-care patients

WHO ARE AT-RISK PATIENTS?

When talking about at-risk patients in the context of giving oral health education, we mean people who are at higher risk than the general population of developing dental disease, or who find it difficult to manage oral health procedures.

Patients in this group include certain people covered in other target groups in this section, plus others who fit into the at-risk groups below:

• Medically compromised patients (those with chronic, systemic disease, and those on continual medication).
• People with physical or mental impairment.
• People of low socio-economic status.
• Dental phobics and those who never visit the dentist unless in pain.
• Severely compromised patients.
• People who smoke and/or misuse alcohol and other drugs.

Medically compromised patients (see also Chapter 8)

Medically compromised patients include people with systemic conditions that have oral implications, such as:

• Lichen planus (skin condition).
• Diabetes (particularly periodontal disease).
• AIDS (including gingivitis, necrotizing ulcerative gingivitis [NUG], oral thrush).
• Epilepsy (the drug phenytoin can cause gingival overgrowth).
• Crohn’s disease and colitis (gingivitis and ulceration).
• Rheumatoid arthritis (xerostomia).

Many of these patients will be on continual medication, and may find it difficult to adhere to an oral health regimen because of how the drugs need to be taken (e.g. with food, after food, early morning or last thing at night). Some drugs may have side effects such as nausea and vomiting, which can lead to dehydration and xerostomia (see Chapter 7).

Also, in some of these conditions, such as those with rheumatoid arthritis (see under ‘Patients with physical impairment’ heading), epilepsy and diabetes, the condition itself can cause problems in maintaining oral health or present difficulties in the surgery.

Patients with diabetes (see also Chapter 8)

For patients with diabetes, observe the following guidelines:

• Keep to time with appointments, as the patient may have to eat at regular intervals to avoid hypoglycaemia.
• Be aware for signs of impending coma (the patient may become confused or irritable).

Patients with epilepsy (see also Chapter 8)

An empathetic and tactful approach is necessary as certain patients may be sensitive about the stigma attached to this condition. Some epileptic patients have their condition well controlled by drug therapy, others less so. Patients may also require encouragement to keep regular dental/hygiene appointments because they need excellent plaque control.

Epileptic seizures

Epileptic seizures can range from a temporary loss of awareness to loss of consciousness, body functions and uncontrollable shaking/jerking. After a minute or two, the jerking movements should stop and consciousness may slowly return.

In the event of a seizure, follow these guidelines [1]:

• Protect the person from injury (remove harmful objects from nearby).
• Cushion the head.
• Look for an epilepsy identity card or identity jewellery.
• Aid breathing by gently placing them in the recovery position once the seizure has finished.
• Stay with the person until recovery is complete.
• Be calmly reassuring.

Do not:

• Put anything in the person’s mouth.
• Try to move them unless they are in danger.
• Give them anything to eat or drink until they are fully recovered.
• Attempt to bring them round.

Call for an ambul/>