Transportation

Many modes of transportation can be used to bring a patient to a dental appointment, including personal conveyance, public transportation (bus or taxi), ambulance, or van (sponsored by social services, government, transit authority, or private enterprise). Often a personal friend or relative will offer to bring the patient in the patient’s or the friend’s or relative’s own vehicle. The mode of transportation may have an effect on the appointment scheduling for a patient. For instance, the dentist may try to provide more treatment or an extended appointment time for an individual conveyed by ambulance.

Residency

Many patients with special needs live in facilities other than a private home, apartment, or condominium. Such facilities include rest homes, nursing homes, and continuing care retirement centers. Several approaches to delivering dental care to these individuals are available.

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  In-house dental unit. The facility may have a fully equipped dedicated dental operatory permanently on site or may share a room equipped for dental care that is also used at other times by a hair stylist or podiatrist.

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  Comprehensive mobile dental operatory. This can be a complete dental operatory with all the amenities, including a full-sized dental unit with wheels built into the chair base. All equipment, materials, and supplies are packaged and transported by truck. Typically, the mobile operatory is delivered to the facility and set up to be fully operational on the same day. This format allows the dentist to provide a complete range of oral healthcare services on site.

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  Portable units. Portable dental units are easily transportable “fold-up” units stored in cases/containers and assembled on site by the dental team. These self-contained units typically include their own sources of water, suction, and compressed air. If electricity is not available, a portable generator can provide power. Designed primarily to serve in the mission field or at temporary military installations, this type of setup is adaptable to a wide variety of settings. Although in theory, a full range of services can be provided, the limited suction and air capacity, less ergonomic chair, and lack of many of the comforts and amenities of a fixed base setting make it difficult for the dentist and staff to carry out extended or complex procedures day after day.

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  Vans or buses with dental facilities on board. In this type of installation, a complete dental operatory with dental chair, x-ray head, sources for compressed air and suction, and a complete array of dental equipment, instruments, and supplies is housed and ready for use in a fully functioning van or bus. Using this mode of operation, the dental team drives to a convenient parking area, hooks up to an existing electrical and water supply, if available, and is prepared to see patients who need only to be brought to the van to receive dental treatment.

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  Delivery to the dental office. In some cases, patients living in nursing homes or continuing care facilities are transported to a dental care facility. Often it is a caregiver, family member, or friend who brings the patient in, or it may also be someone on the dental team.

Additional information on alternative modes of care delivery is provided in Chapter 17 .

Some of the options described previously (portable units, dental van or bus, delivery to the dental office) can be implemented for the home-bound patient. In addition, the dental team may provide in-home rudimentary dental services, as described in Chapter 17 .

Office accommodations

If the dental team elects to treat special needs patients in the dental office, the facility must be properly designed and equipped to deliver care in a manner that is comfortable and safe for the patient, and efficient for the dental team ( Box 12-1 ). ( See Video 12-1, Tour of an Operatory for Special Needs Patients on Evolve.)

American dental offices must comply with standards established in the Americans with Disabilities Act. Some state and local jurisdictions may also have laws or ordinances that are relevant. The dentist who anticipates seeing patients with disabilities should consult the document “Americans with Disability Act Standards for Accessible Design”.

Funding sources

As with all other patients, the dental team must establish with the patient and/or caregiver how dental treatment will be paid for. Several potential funding sources can be considered.

Private pay

Many special care patients have their own or family financial resources with which to pay for oral health services. If a designated power of attorney or legal guardian has taken over financial responsibilities, costs of treatment and financial resources will be discussed with this individual.

Medicare

In the United States, Medicare is a health insurance program for persons 65 years or older, some individuals with disabilities who are younger than age 65, and individuals with end-stage renal disease requiring dialysis or renal transplant. There are strict limitations as to the types of dental treatment covered by Medicare, however. For example, Medicare does not cover routine dental treatment, such as cleanings, restorative treatment, dentures, or extractions. However, Medicare Part A (hospital insurance) will pay for certain dental procedures performed while a patient is in the hospital. As of 2013, Medicare will pay for the following:

• 1.

  Comprehensive examination in a hospital inpatient setting preceding kidney transplantation or heart valve replacement.

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  Extractions in preparation for radiation treatment for oral cancer. (The patient is responsible for the cost of any prosthetics, however.)

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  Dental services that are an integral part of a medical procedure, such as reconstruction of the jaw after an accident or facial tumor removal.

It is important to note that, according to cms.gov, coverage of dental care is not determined by the necessity of the dental care but by the type of service provided and the anatomic structure involved in the procedure. Therefore it is important to verify with Medicare which dental procedures are covered before initiation of treatment.

Medicaid

In the United States, Medicaid is the federally sponsored, state and/or county-administered insurance program for blind, disabled, and indigent individuals. Medicaid dental coverage for both adults and children varies from state to state. For the patient to benefit from this form of assistance, the dental team must be knowledgeable about and comply with all the rules and restrictions, as well as with the fee schedule for the Medicaid plan in the patient’s jurisdiction.

Other sources

Other possible sources of financial support for the special care patient in the United States include Supplemental Security Income (SSI), pensions, and religious or other nonprofit groups. Social workers and case managers are well trained in optimizing federal, state, and community-based resources for clients under their care.

Throughout the world, there is great variability in the level of governmental support for oral healthcare. Western European countries have traditionally placed a high priority on the provision of basic dental services both to their general population and to special needs populations, such as the elderly, infirmed, and impaired. Programs and benefits are determined for the most part by national policy.

Patients with developmental delay or cognitive disorders

At the outset, the patient’s level of cooperation must be diagnosed to help the dental team determine which treatments can be performed and in what setting. Prevention is of paramount importance. Oral home care coaching and dietary analysis and counseling are extremely important. The caregiver must be heavily involved in providing the patient’s oral home care and maintenance of the patient’s oral health. If the patient is fully cooperative, routine dental care can be provided in the office setting. If the patient is combative or uncooperative, however, the decision needs to be made as to the setting in which care will be provided. Alteration or modification of the treatment goals from the ideal is often necessary. If a complete examination, radiographs, and treatment are necessary, then general anesthesia is usually indicated. When the patient is partially cooperative, the decision becomes more difficult. If the patient is not both clinically and legally competent, then treatment goals, risks, benefits, and limitations of each mode of treatment must be explained fully to the caregiver.

Traumatic brain injury

Patients with a history of traumatic brain injury may be treated similarly to individuals with cognitive disorders. The level of potential cooperation must be assessed as noted previously. Similar decisions regarding setting and extent of treatment will be made for patients with head injuries. It must be recognized, however, that the functionality of the patient with traumatic brain injury can change dramatically over time. The patient may progress from an uncooperative, combative individual to one who is fully cooperative. The dental treatment plan can be changed, sometimes drastically, with changes in the patient’s physical ability and cognitive function. Although initially, dental treatment may be limited to palliative and acute care, with full recovery, the patient may become an ideal candidate for comprehensive definitive treatment. From the time of the injury and throughout the recovery phase, the caregivers often must be intensely involved in providing for the general and oral healthcare needs of these patients.

Severe coagulopathies

Hemophilias A and B and von Willebrand’s disease are three well-known disease-induced coagulopathies requiring specific management plans. If invasive therapy is anticipated (including mandibular blocks), then factor replacement is necessary. Postoperatively, an antifibrinolytic agent may be prescribed to assist in stabilizing the initial clot. There are instances of hemophiliacs with inhibitor to the very factor they require for coagulation. For example, the hemophilia A patient with inhibitor will exhibit an immune response to the administered factor and will thus require a continuous infusion to clot properly. Discussion with the patient’s hematologist, describing the nature of planned dental procedures, should take place before dental treatment. These patients often require infusion of coagulation factor before dental procedures.

Additionally, several anticoagulant medications that are frequently prescribed to prevent thrombi, strokes, coronary artery occlusions, and/or myocardial infarctions may have implications for the provision of some dental procedures. For example, patients who take warfarin (Coumadin) on a daily basis may need to discontinue or decrease the dose 2 to 3 days before invasive treatment. A current international normalized ratio (INR) value (preferable to a prothrombin time) is an important preoperative measure. The INR provides a standard measure of coagulability. However, the patient who requires oral surgery or any dental treatment likely to cause bleeding (including uncomplicated tooth extractions) typically does not require alteration of Coumadin dosage unless the individual’s INR is greater than 3.5 to 4.0, provided that local hemostatic measures such as gel foam and primary closure are used. High-risk patients may need to be admitted and heparinized after discontinuing Coumadin. The heparin is then discontinued 4 to 5 hours preoperatively and resumed soon after surgery. The half-life of heparin is approximately 4 to 6 hours, and that of Coumadin is 3 to 4 days. Low-molecular-weight heparins can also be used to anticoagulate a patient and can be administered at home by the patient. This medication typically need not be discontinued before invasive treatment, because the half-life is approximately 24 hours. Discussion with the patient’s physician, including a thorough explanation of the planned dental procedure, should take place before invasive dental treatment. Furthermore, risks and benefits to discontinuing or decreasing the dosage of Coumadin should be discussed.

Other oral anticoagulants, such as antiplatelet medications (e.g., dipyridamole, ticlopidine, aspirin, ibuprofen), direct thrombin inhibitors (dabigatran etexilate), or factor Xa inhibitors (rivaroxaban, apixaban, edoxaban, betrixaban, darexaban, eribaxaban, and idrabiotaparinux) may need to be discontinued or dosages decreased before surgery depending on anticipated blood loss and the planned extent of the surgery. Again, consultation with the patient’s physician concerning the planned dental procedures should take place before any invasive dental treatment. Risks and benefits to discontinuing or decreasing dosage of these medications should be discussed.

Acquired immunodeficiency syndrome

The dental team must be vigilant in recognition of the occurrence or progression of the oral manifestations of HIV/AIDS, including Kaposi’s sarcoma, candidiasis, oral hairy leukoplakia, HIV-associated periodontal diseases, or other opportunistic infections. Good oral hygiene instruction and oral home care are critical to managing the oral health of the patient with AIDS. If invasive treatment is planned, a complete blood count (CBC) must be evaluated. The platelet count should be at least 50,000, and the absolute neutrophil count should be higher than 1000. If the absolute neutrophil count is lower than 1000, antibiotic premedication is required. Physician consultation is always advisable when invasive treatment is planned. Viral load and CD4 counts are indicators as to the level of control of the illness.

Patients under hospice care

By definition, the patient in hospice care has an anticipated life expectancy of 6 months or less. Frequently, it is much less than 6 months, because hospice care is often called late in the disease process. Palliative care and pain control are of great importance. If invasive treatment is planned, depending on the diagnosis, a CBC may be necessary. Any patient-requested dental treatment that is not life threatening should be provided if feasible. For example, if the patient desires a reconstruction, and the dental team is capable of providing this care, then it is justifiable to proceed. Informed consent must be obtained, listing diagnoses, alternatives, and costs. Code status should be designated (e.g., Do Not Resuscitate/Do Not Intubate/Full Code [see the In Clinical Practice: Physician Orders Related to Resuscitation box later in this chapter]). Occasionally, the dental team may be called on to evaluate a patient who is losing weight because of a refusal to eat. In this situation, it is appropriate for the dentist to do a limited evaluation to discern whether the refusal to eat results from oral pain or, for example, an ill-fitting denture. Here, a comprehensive assessment is not necessary, and the dental treatment can be limited to strategic efforts to alleviate the pain or improve the functionality of the denture.

Chief concern and history of the chief concern

To properly address specific needs that the patient or the caregiver perceives to be important, it is critical to evaluate the patient’s chief complaints or concerns. 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 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 explained to the patient and caregivers or other 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 as to why this option cannot be implemented. Addressing the chief concern is often the starting place for identification of issues central to the ultimate management of the patient and will provide a touchstone from 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 hospitalizations, 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 will be inadequate. 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. Layperson’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 12-2 ).

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 12-3 .

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 will be helpful to learn the setting for past dental care (i.e., general dental office, hospital-based clinic, operating room [OR], or other). Did the patient receive 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 whether the patient’s mouth can be cleaned, and whether he or she is cooperative with such care. Important questions to be asked of the patient or caregiver include the following:

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  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?

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  Do you floss? How often and when? Do you use floss aids?

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  Do you use other cleaning devices?

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  Do you use mouth rinses? Gels? Other forms of fluoride?

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  Do you have plaque or tartar buildup?

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:

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  How much table sugar do you use?

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  Do you consume soft drinks or sodas? If so, how often? With meals? How quickly consumed (sip or gulp)?

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  Do you consume two or more fruit drinks or juice per day?

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  Do you eat hard candy or other sweets? If so, what type? How often?

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  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)?

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  How often do you consume snacks or baked goods?

An understanding of the nutritional intake and 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 caregiving 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 critically important to educate patients and caregivers about the hazards of a cariogenic diet and suboptimal oral home care.

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 relating to 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 12-4 ).

When the patient returns to the office, a member of the team reviews the diary in detail with the patient and caregiver when appropriate. 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 ( Box 12-5 ). After this review, it is often helpful to compose a follow-up 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 ( Box 12-6 ). Such a letter can be an important part of the process of educating, encouraging, and empowering the patient and/or caregiver.