For the people with physical disability, mostly elderly, who are confined to their homes, feel less anxious in their own familiar surroundings.
More and more older people will have their own teeth and they do not want dentures!
Empathetic and compassionate approach is paramount, with well understanding patient’ non-dentally related problems and support.
Dental treatment plan needs to be ‘3D’ – Clear – Concise – Consistent.
What is more important, treatment plan has to REALISTIC, adequate to patient needs and available resources.
Age, general medical conditions, capacity to consent, prolonged pharmacotherapy – all of them have to be taken into consideration
Efficient communication with care homes staff and family members ! Carers/support workers know everything about patient (does patient eat well ?, dentures use, oral hygiene, dental problems, MH, medications, etc.)
Support of carers, family, key workers, support workers, care home staff invaluable.
Rise the tone of voice and speak slowly – often necessary as elderly patients may have hearing impairments
Risk assessment prior to domiciliary appointment and particularly invasive intervention (extraction) – essential
If the patient is unable to consent for proposed dental treatment – two pathways: – best interest meeting with patient’s family, relatives, medical/dental professionals, and best interest decision has to be made – in case of there is no person closely related to patient or next of kin, IMCA needs to be involved.
Car used for domiciliary visits must have business car insurance. Some NHS Trusts provides also dedicated dental vans.
Oxygen cylinder and emergency drugs box must be carry all the time.
Hand held x-ray equipment could be helpful following careful risk assessment (currently approved by NICE, UK, Jan 2016).
Hand held Nomad x-ray equipment is safe for using in exeptional circumstances (eg. domiciliary care), however the quality of radiographs is lower compared to in-office taken radiographs (JDOHC, 2016).
Common problems: indigestion disorders and dysphagia, missing teeth, high plaque index, poor oral hygiene, edentulism, ill fitted dentures, co-mobridities, self-inflicted injuries.
Co-operation with consultant geriatritian regarding bisphosponates prescribed for osteoporosis/breast and prostate cancer
Any invasive treatment should be completed prior bisphosphonates Tx
Lots of elderly patients are currently on bisphosphonates
If patient on bisphosphonates – warn the patient before extraction and provide all possible information regarding potential risk and complications
Increased risk of osteochemonecrosis if patient on both bisphosphonates and steroids
ONJ may also develop spontaneously without BP therapy
Cancer patients – better to avoid extractions, always liaise with consultant oncologist
Is substance abuse – full mouth examination including thorough soft tissues examination
Extractions during domiciliary care can be done if home facilities reasonably good and safe (health and safety and cross infection issue)
Good dental practice – to check blood pressure with BP monitor if any doubts, eg. elderly patient with history of uncontrolled hypertension
Oxygen cylinder has to be carried while providing doms sessions. Appropriate label on the car indicating for services that there is an oxygen inside the car (ideally magnetic pad outside, clearly visible). Oxygen supply and administration in case of patient has become unwell
Dental care restricted to relatively non-invasive treatment:
- dental check-ups/examination
- oral hygiene advice, prophylactic and preventative measures including prescription of specific highly-concentrated fluoride toothpaste
- oral hygiene procedures: scaling/polishing
- urgent dental care provision: antibiotics prescription, sedative dressings, treatment of acute oral mucosa conditions, antiseptic mouthwash recommendation, abscess drainage
- treatment of acute/chronic oral soft tissues conditions, eg. periodontal disease
- application of topical antiseptic measures
- dentures reline: immediate with tissues conditioners, cold or heat cured in lab
- dentures construction, denture replication
- crowns or bridges recementation
- simple fillings with the use of local anaesthesia
- simple extractions
Necessary portable equipment and consumables:
- dental mirrors
- electric motor/micromotor
- light source, ideally head light with sensor (cross infection issue)
- portable hand or ultrasonic scaler
- prescription pad
- self-curing or light-curing dental materials
- curing light
- impressions pastes
- shade guide
- time-consuming due to nature of the patients
- can be stressful due to different environment
- posture problem, lower back strain
- different set of health and safety hazards
- infection control can be a challenge
- medical co-morbidities very frequent
- quite often family requests dental treatment, not patient
- be aware of medical emergencies
Essential questions to ask the patient:
- how are you feeling today ?
- are you eating well ?
- do you have/wear any dentures ?
- are you happy with your dentures ?
- can you wear your dentures ?
- do your dentures cause any problems ?
- any problems with your teeth ?
- are you having any pain in your mouth ?
- do you have any ‘wobbly teeth’ ?
- would you like us to do a new denture(s) ?
- have you got any family ?
- is there anyone from your family who can help you ?
- poor oral health condition
- poor oral hygiene
- poor denture hygiene
- chronic periodontal disease
- soft tissue lesions
- root caries
- retained root tips unreplaced missing teeth
- broken or failing existing dental restorations
- psychomotor dysfunction, hypotonia
- respiratory complications
- increased risk of aspiration pneumonia
Practical Tips and Advices:
- keep doms as simple and clear as possible
- do not make to much promises eg. regarding full denture work
- be realistic planning a prolonged dental treatment course
- be well organized for the whole day sessions
- be kind as well as assertive in making clinical decisions
- be assertive in communication with patient relatives
- be aware of existing co-morbidities ! is GA really justified ?
- always try to resolve dental problem; always worth to try to do denture work even though patient may not tolerate this
- in case of doubtful prognosis – start denture work (eg. impressions) with the presence of relatives to demonstrate patient’s compliance/non-compliance
- focus on major oral health problems: oral cancer screening, acute odontogenic problems, pain/swelling
- make a referrals eg. for susp. oral cancer second opinion as necessary
- at all times respect decisions of elderly patients
- do not automatically assume that patient is unable to make a consent for dental treatment
- capacity assessment may be often necessary
- always take into consideration medical conditions and underlying health problems
- always double check if any changes in patient medical history
- always check Medications Administration List (MAR list)
- always ‘give it a try’ and attempt denture work if clinically justfied even if predictable outcome may not be as expected
- bear in mind age factor, terminal stage of patient’s life and otweight prons and cons of invasive dental interventions
- always carry oxygen cylinder and oxygen mask for domiciliary care.
- elderly patients more often are on regular oxygen supply at home.
- if any signs of health deterioration during dental appointment (eyes rolling, “tiredness”) – be prepared to use oxygen
- remember about limitations of denture work provided for severely ill, elderly and dementia patients
- remember about variable patient cooperation; patient may allow initial impressions and then decline further denture work due to deteriorating dementia
- often patient is unable to indicate/express and dental problem due to severe heatlh condition (learning disability, dementia) – individual key support worker/carer knows patient’ much better than dentist and may indicate if patient has got any pain or any other odontogenic problems, by observing patient unusual behaviour: eg. poor eating, face hitting, constant cheek pressing by hand, agitation, sudden change in bahaviour, fingers putting into mouth
- dentures can be marked with patient’s initials/name (individual marking)
- ba careful re: the use of burner for denture work at care home – it may trigger a fire alarm due to fumes from melting down wax
- arrested and non active caries can be monitored
- retained roots, not causing and odontogenic infections, can be potentially left and monitored
- shallow, not progressing and cleansable root caries can be monitored for a a long period of time
- consider routine prescription of sodium fluoride 1.1% toothpaste for vast majority of dentate elderly patients (4-6 tubes at once)
- always stress the importance of regular toothbrushing and denture brushing to carers
- always contact elderly patients’s relatives and inform them about proposed dental treatment
- be carefull in terms of planning expensive denture work for eg. pensioners who are not exempt from payment, request denture work but their relatives are in charge of making financial decision
- do not force elderly patients for complex and prolonged dental treatment
- tongue strength can be a predictor of poor health condition in elderly people needing at-home nursing care
- the use of disposable dental kit usually made of plastic: mirror, probe, twizers, ideally duble ended with mixing spatula, ball burnisher, carver, etc) is very handy to manage efficiently nfection control issues during domiciliary care:
- cooperation with: auxillary staff, care home staff, carers, GP, managers is paramount
- PEG fed patients are usually resiliant to caries, but present with gross hard deposits (calculus) acculumation, particularly within posterior quadrants, sometimes covering the whole occlusal and buccal surfaces of teeth
- it is important to encourage carers/managers to arrange visit in clinic it patient require any invasive procedure
- some special needs patients may need full dental assessment under IV or GA if any symptoms which may indicate odontogenic problems
- some elderly patients with dementia can be agitated and even agressive, keep them calm, do not attempt any dental treatment if not really necessary and clinically justified
- elderly residents constantly losing their dentures at care homes and during staying at hospital are a significant group of domiciliary patients, reasons: patients throwing away dentures by mistake (eg. wrapped in paper towel or tissues), do not remember where denture has been left, sometimes other residents collect someone else denture(s), denture loss by hospital staff
- capacity assessment always necessary if any doubts re: patient capable/uncapable to consent
- best interest meeting can be necessary to proceed further with dental treatment
- USS scaling at care home or patient’s home only with the use of proper, high volume portable suction
- soft denture lining may work very well as a temporary solution (eg. Visco gel)
- ATR technique for restorative work can be feasible, acceptable and effective approach in elderly patients who have difficulty coping with conventional treatment.
Silicone Mouth Cleansers are the safest option
Swabs not recommended as risk of detachment and chocking hazard
- hand held, portable x-ray unit may be useful for doms following thorough risk and health&sefety assessment
- carefull planning for elderly and medically compromised patients (eg. severe heart failure, politherapy) – are multiple extractions under local anaesthesia clinically justified ?
- communication with patients can be difficult due to: hearing problems, lost hearing aid devices, mental health conditions, lack of understanding of specific dental terminology, etc.
- to help distinguish dentla pain from other types of pain in patients with dementia: changes in eating pattern, response to toothbrushing or oral care, refusing to wear dentures, not allowing people near their mouth, holding, touching or rubbing face or mouth, teeth grinding, drooling or excess saliva, changes in sleep patterns
- proper assessment and clinical decision re: no intervention, immediate reline with tissue conditioner, cold/heat cured reline, denture copy (replication) or new denture as a last resort(?)
- if any doubts re: patient may not tolerate new dentures – denture reline or copy
- if patient would not tolerate any impressions or risk of aspiration – immediate denture reline with tissue conditioner
- immediate denture reline, with the use of: Visco gel or GC Tissue conditioner – temporary solution up to a few months
- pre-assessment and risk assessment in elderly patients with swollowing and breathing difficulties before impresions
- be aware of potential problem with impression paste choking
- impression paste distribution towards front area while taking upper impresion, more pressure into posterior part of impression tray
- impression paste consistency as dense as possible, warm water to accelerate setting reaction
- careful check intraorally following impression if any remaining rest impression paste inside patient’s mouth
- route planning and logistic issue are important
- take into consideration patient’s BMI score and general well-being
- risk assessment often necessary
- emergency drugs box and oxygen must be available all the time.
- show carers how to brush teeth properly
- explain re: gentle cheeks retraction is not a acceptable for eg. dementia patients (carers are allow to do this)
- cooperation with patient’s GP, consultants re: underlying health conditions
- be aware that vast majority of domiciliary patients may be on prolonged (poly)pharmacotherapy ! eg. bisphosphonates (p.o. or i.v.) – increased risk of osteochemonecrosis
- flexible ‘fiberoscope-like’ intraoral camera can be extremely useful during performing a dental assessment for the eg. domiciliary elderly patient reluctant to mouth opening, or patient with trismus, muscles spasms, neurologicial problems, etc.
Be positive and creative, show own initiative !
CAMPING’ acronym describing dimiciliary care (BSDH Guidelines for Delivery of the Domiciliary Care, 2009)
- Manual handling and map reading
- Planning and the time management
Mnemotic ‘CHIN’ approach: C – Check patients mouth H – Help I – Inform patient and professionals N – Note findings
- patient are usually bedbound, wheelchair bound
- common symptoms: tremor, fatigue, spasms, facial pain, paraesthesia, numbness of hands, arms, legs, feet
- common dental problems: impaired manual dexterity, difficulty in teeth cleaning, parafunctions
- seamless care: regular dental hygienist visits, prenentive regime, medications without xerostomic effect, the use of wheelchair recliner, the use of mouth prop, oral health monitoring, long-lasting dental restorations including indirect onlays/inlays.
Clinical cases (examples):
Above 80 years old patient with early stage of dementia, care home resident. Wears old upper full denture with reasonably good fit, but retention and stability not great . Patient seems to be happy with F/-, eats well, no problems with food intake. Severe generalized horizontal bone loss within lower alveolar ridge. Family requested a new set of complete dentures. Capacity assessment – lack of capacity to consent for denture work, unable to understand and retain information, only partially cooperative. Discussion with family members, explanations re: new lower denture may not be successful and may cause discomfort. Option to make F/- heat cured reline following consideration of benefits for the patient and cooperation during upper impression for F/- lining.
Above 90 years old patient, vascular dementia, medically compromised, severe heart failure, recently resuscitated, polytherapy, bed bound, permanently on oxygen. Carers requested emergency appt. as patient indicates discomfort/pain originated from lower molar tooth. Lack of communication, lack of capacity to consent. On examination: lower first molar mild (grade 1/2) mobility due to bone loss and chronic periodontitis. Decision to make a second opinion from GP/consultant cardiologist. re: potential extraction under LA in future. Treatment postponed. Review in a month time.
Elderly patient with late stage of dementia who requires a simple restorative treatment of interproximal moderate (not too deep) carious cavities with GIC/amalgam. Asymptomatic at present, no symptoms of local odontogenic inflammation. Capacity short term and fluctuating, patient slightly agitated. Discussion with patient’s relatives, they declined dental treatment as they think this might cause a significant distress for patient. Options, long term prognosis and potential complications provided in detail. Decided to monitor and reassess in 3 month time. Sodium Fluoride 1.1% toothpaste prescribed.
Above 60 years old patient, dementia, MH non significant. Medications not influencing dental treatment plan. Husband requested domiciliary visit as patient expresses pain originated from front lower tooth. Difficulties with eating. Communicates well, capacity to consent maintained. On examination: lower incisors grade 2 mobile due to bone loss and chronic periodontitis. Husband is confident removal of ‘loose teeth’ would improve quality of life of his wife. Decision to extract with LA following topical anaesthetic.
Domiciliary visit (dental assessment) requested by key worker. Patient with MS, wheelchair bound, needs constant assistance, PEG fed, communication maintained. No particular complains of any dental problems. According to patient last dentla check-up was a year ago. General health conditions deteriorated since last year. Fairly adequate OH thanks to carers, uses ETB and additional hygienic measures. Small amount of hard deposits within lower anteriors. Small carious, open cavity by cervical area UL6. Patient fully able to consent for dental treatment. Treament plan: hand scaling and FM debridement with hand instruments as unable to use USS scaler (dystonia, inability to swallow).
Elderly patient with dementia set of F/F at hospital. Partially capable to consent for denture work (‘borderline’ patient regarding capacity to consent). MH non significant. Constant tremor, physical disability. Wants to go ahead with denture work. Poor muscle control. Decision to attempt prosthodontic procedure. Final outcome will depend on cooperation and practical ability to proceed with all stages of denture construction. Patient agreed.
Healthy pensioner, co: ‘sore corner of her mouth’. Dentures user. Extraorally: cracked RHS comissure, lacerated area with inflammatory fluid excretion. Diagnosis: angular cheilitis, poss. mixed bacterial and fungal infection (Candydiasis). Dentures cleaned with chlorhexidine gluconate 0.2%, applied Corsodyl gel onto affected area with cotton swab, 1% Miconazole oromucosal gel prescribed tds/ 7 days, adv not to wear dentures over the night time and to use diffrent towels to different parts of the body. Diet supplementation with vitamin B and iron (?).
Elderly pensioner, living with his wife. 92 years old. Early signs of dementia. Fluctuating and short term ability to consent. Reports some discomfort/sensitivyty comming from both lower remaining canines. intraorally: severe tooth wear, enamel and dentin loss, cavity proximity to pulp chamber, pulp not exposed. Capacity assessment performer, able to understand and retain information provided. Accepted more explanations and reassurane from his wife. Tx plan: direct GIC coverage. Consent signed. Next visit: patient fairly confused, said, he does not want any treatment as “it may interrfere with his dentures”. Thorough discussion about benefits and potential consequences with his wife involvement. Repeated capacity assessment. Patient suddenly changed his mind and willing to have dental treatment done straightaway. Valid and informed consent confirmed. GIC restorations performed.
Multiple sclerosis (MS) patient, bed bound. Stays in care home. Fairly adequate oral hygiene, however localized accumulation of subgingical calculus. Patient requires a regular, comprehensive perio debridement on regular basis as uses implant supported fixed suprastructures. Signs of initial periimplantitis. Portable electric suction arranged by care home staff. Thorough, subgingival debridement, one side per session, with additional use of non-metal scaler tips for peri-impants cleaning under LA as patient reported a ‘low pain threshold level’.
Elderly, frail and medically compromised patient with multiple complex and severe health problems, chronic unstable cardiovascular diseases. On poly-therapy, including new oral anticoagulants. To avoid a non urgent invasive procedures (extractions) on asymptomatic teeth/roots. If extraction necessary, to consider referral to oral surgery department (safe hospital setting), with access to intensive care unit/crash team. Problem: transport could be an issue.
Elderly (above 90 years old) patient, confined to wheelchair, very frail and not particularly medically compromised but permanently on oxygen at home. Some difficulties with swallowing, very dry lips. Capacity to consent as verified. Able to understand an retain information, however, speech very slow and slurred. Able to sign consent form with additional help. Needs repetitions and reassurance. Family requested full set of dentures as old ones went missing (damaged?). Long discussion about pros and cons, Decision about construction the upper denture only, patient and relatives agreed. Special caution re: avoiding Vaseline (oxygen), gentle approach, Corsodyl gel as lips moisturizer, thick consistency of alginate impression paste, avoid excessive amount of impr paste, reduce number of appointment to minimum., oxygen supply and emergency drugs easily available.
Elderly and very frail patient who lost weight recently (BMI very low) as eating difficulties, due to sharp retained roots edges and mild gingiva inflammation. Roots seem to be asymptomatic at the moment, no obvious signs of localized odontogenic inflammation, no sinus tract/swelling/TTP. Smoothed edges to ease discomfort, Chx gel 1% recommended to apply bd for 4 weeks.