Oral Healthcare for People with Physical and Learning Difficulties Flashcards
categories of barriers to care for special care pts
4
user/carer
professional services
physical barriers
cultural barriers
user/carer barriers for SC pts
7 main types
Physical, mental and cognitive ability to carry out effective oral hygiene, diet, decisions and tx
Diet
* High calorie food
* Dry mouth
* Sugar based liquid medications
* Laxatives
Fear and anxiety
* Irregular attendance
Greater need for behavioural management, sedation and general anaesthetic services
Require support to attend dental appointments
Transfer of responsibility to adult and carers despite high level of support from dental teams
Knowledge, skills and attitudes of carer
Training required
professional services barriers for SC pts
5 main types
Low confidence in the management of people with LD by new graduates
Inadequacies in professional training for dentists and therapists
Dentists lack experience
Financial constraints due to NHS renumeration
carers belief dental services would prefer to see no-troublesome pts
physical barriers for SC pts
2 main types
access
* physical
* emotional
* cost
travelling distance for speciliast services
culutural barriers for SC pts
5 main types
Black and minority groups are subject to the same barrier but their experience is exacerbated by ethnicity
Language
Different attitudes to oral health
Gender sensitivities
communication of need
oral disease experience for people with a mild learning disability
Less research available as generally managed within the primary care setting
Those with mild learning disabilities are more likely to have filled teeth, fewer extractions and more untreated active decay than adults with more profound disabilities
Dental care received appears to be related to the individual’s ability to comprehend or co-operate with treatment
Fewer dentures provided
* Increased burden of denture related problems, when they do have them
COMMON RISK FACTOR approach
what is the common risk factor approach
group of people experience poor oral health, but there is common risk factors across many conditions and diseases.
Multiple factors involved – more likely to be in lower socioeconomic background therefore have more barriers to healthcare services
disability and oral health
link
**Disability exerts an indirect effect on oral health by increasing people’s risk for developing dental disease. **
Examples:
* People who take multiple medications may experience a dry mouth that increases cares risk
* People with physical impairment may find it hard to clean their teeth or go to the dentist regularly
Oral health issues are often overlooked in health and social care planning for disabled people, because of lack of awareness amongst teams of how to protect oral health or the potential impact on oral health of medications prescribed or dietary advice given.
factors to consider when delivering oral healthcare to ensure to get it right
3
place
time
person
factors in deciding right place for delivery of care
3
Where and when is assessment appropriate?
What tx is safe and feasible in different care environments?
What if a medical emergency or complication arises?
options for care setting
4
Own Home,
Hospital Ward (e.g. multiple medical issues making them ASA III),
Primary Care,
Secondary/Tertiary Care
access details to ensure known before SC pt comes in
barriers and facilitators
3 categories for access
Location of site
* Distance and safety of transport
Moving and handling
* Training and equipment e.g. hoist (let trained individuals do it)
Medical support available
* Accessing the right facility
facilitators for access to dental setting
6
- Ground floor access
- Suitable car parking
- Elevators
- Hand rails
- Wide corridors
- Disabled toilets
3 facilitators for access to dental chair
- Banana board
- Wheelchair chair
- Hoisted in – if they cannot weight bear themselves – do not attempt to lift/aid them
6 facilitators for access to the mouth
- Bedi shield
- Open wide mouth rests
- Toothbrush – can be good aid initially to build up rapport, as they’ll likely recognise what a toothbrush is
- Mirror (ensure non shattering)
- Good light
- Head support – ask consent
factors to consider it is the right time for delivering dental care
5
- environmental
- medical disease
- social context
- transport
- dental disease need
person options for delivering of dental care
GDP - primary care
dental officer (commplex)
specialist/senior dental officer (very complex)
consulanat (most complex)
clinical holding
*assist or support a pt to receive clinical dental care or tx in situations where their behaviour may limit the ability of the dental team to effectively deliver tx, or where the pt’s behaviour may present a safety risk to themselves, members of the dental team or other accompanying persons
Gradient control
* Nature of hold applied should be proportionate to the actions / behaviour of the person and the risks associated with the behaviour
* If too forceful, too restrictive or sustained for extended period of times the person is likely to become distressed
* If not supportive enough the person may become anxious or unsafe
Consider care and support
Record keeping
engagement and learning
ask consent first
not commonly done in UK
7 things to assess gage indivduals learning disability level
- Level of understanding and intellectual function
- Communication
- Physical and emotional access
- Co-operation
- Medical Status
- Social Status
- Dental Status
how to attain C/O and HPC
From the patient if possible
From the carer if not possible to gain
Remember symptoms and signs which maybe indicative for people who cannot reliably report or communicate
* Sleep interruption
* Changes in behaviour
* Rubbing of an area
* Pulling at an area
common medical conditions in SC pts
9
- GI cancers
- Epilepsy
- GI problems
- Anxiety disorders
- Respiratory disorders
- Sensory impairments
- Obesity
- Diabetes
- Coronary heart disease
things to check when getting medical hx of possible SC Pt
Intellectual Impairment
As part of a syndrome with other associated conditions: Down syndrome, Fragile X, Williams syndrome, Autistic Spectrum Disorders ( not all people have a L.D.)
Cerebral Palsy ( not all people have a L.D.)
Epilepsy +/- neurological conditions Diabetes
SHx check
6
Smoking/alcohol
Living arrangements
Support
Transport
Access facilitators required
Consent and capacity
DHx check
6
Cooperation
Preventative regime (what? How much? When?)
Level of support
Diet and method of delivery (what? How much? Nil by mouth?)
Swallowing of thickeners if appropriate
Previous delivery of dental tx (sedation? GA?)
how to conduct an exam on SC pt
Extra-oral… if you can
Intra –oral
* May only be brief look
* Multiple looks for each quadrant
* Use counting
* Use access aids
* Use other people if possible
* If using supportive holding always gain consent and document it!
Look at soft tissues, caries and oral hygiene
If possible assess periodontal condition
* Likelihood of BPE?
* Mobility might be a more acceptable assessment
There is an element of compromise
Document everything that was assess and everything that was not! Justify
how to tx plan after exam of SC pt
Are special investigations required?
* Can you achieve them?
Findings will dictate what needs to be managed
**Prevention
Modification of risk factors **
Treatment
a. Emergency – if required
b. Short, middle and long term thinking
c. How, where and who?
d. Share care and modalities?
e. Role for hygiene/therapy in maintenance care
5 things to consider when tx planning SC pt
a. Emergency – if required
b. Short, middle and long term thinking
c. How, where and who?
d. Share care and modalities?
e. Role for hygiene/therapy in maintenance care
to demonstrate capacity indivduals should be able to
4
Understand in simple language what the treatment is, its purpose and nature and why it is being proposed
Understand its principle benefits, risks and alternatives
Understand in broad terms what will be the consequences of not receiving the proposed treatment
Retain the memory of the decision
2 principles of the Adults with Incapacity Act
2000
Principle 1 – Benefit
Principle 2 - Least restrictive option
Principle 3 - Take account of the wishes of the person
Principle 4 - Consultation with relevant others
Principle 5 - Encourage the person to use existing skills and develop new skills
principle 1 of the Adults with Incapacity Act
2000
benefit
principle 2 Adults with Incapacity Act
2000
least restrictive option
principle 3 Adults with Incapacity Act
2000
take account of the wishes of the person
principle 4 Adults with Incapacity Act
2000
consultation with relevant others
prinicple 5 Adults with Incapacity Act
2000
encourage the person to use existing skills and develop new skills
augmentative communication aids examples
4
picture boards - allows them to show what they feel about things, point to pictures
social stories
talking mats
makaton
ask them to bring any aids they use with them to appt
multidisciplinary care for SC pts
Pt in centre
* Carer
* Oral health team
* Dietician
* Speech and language therapist
most common in oncology, but used in other areas of care too
Work with colleagues to target that oral health care is not in isolation
Common risk factor approach for other medical conditions
how to use the fact an individual is independent to your advantage
2
Maximise existing skills
Establish a routine
how to use the fact pt is dependent on others to your advantage
4
Who is responsible
Can you engage them
Provide appropriate education
Facilitate support
what can be the cause of a pt drooling
5
- Developmental disability
- Cerebal palsy
- Progressive neurological conditions
- Parkinson’s disease
- Motor neuron disease
Rare to that they are producing excess saliva
how can drooling be managed
3 pathways
Head Positioning and Posture
* Neuromuscular
* Try and correct forward positioning where possible
Speech and Language Therapy:
* Behavioural techniques
* Oral Sensory –Motor Intervention
Medication and Surgery (extreme measure)
dysphagia is
difficulty in swallowing
issues due to dysphagia
affects pt ability to maintain good OH effectively
Hospitalisation
Dependency can affect stroke patients’ ability to maintain oral hygiene effectively
Increased exposure to antibiotics
Dehydration and xerostomia can be a particular problem because of:
* Oxygen therapy
* Mouth breathing
* Side-effects of medications
* Reduced food and fluid intake
pouching
what is it
impact
Food or medicines are kept in buccal sulcus
* Check on examination if anything there – can cause cervical/root caries, ulceration due to medication (aspirin, alendronic acid)
Moderation of consistency of foods and liquids
Nutritional changes and sip feeding (inc caries risk)
Risk of aspiration
altered texture of foods indicates
ability to swallow
position to perform OH/support someone with OH
sitting upright
NOT TILTED BACKWARDS, less likely to inhale
oral care and dysphagia
Support from carers and nursing staff
If possible sit the patient in an upright or semi upright position for toothbrushing
If the patient is able to spit out following mouth care this should be encouraged
Hand-over-hand technique with the patient
Regular dry mouth care
Use the handle of a second toothbrush to improve access to the whole mouth.
A mouth guard or finger prop may also be useful
Consider adaptations to toothbrush handle
Use suction if you are trained to do so
PEG fed, do they still need OH?
YES
Tube direct to stomach
Still have biofilm development in mouth
* Can additionally still get tasters/drinks etc
* Still a risk for dysphagia as well
caution with tasters
Taster tends to be sweet
Likely also have dry mouth
Discuss what they have and when
possible modfications to the handle so the pt can be part of their OH routine
- Ball ended
- Putty grip (or heat cure acrylic)
- Toothbrush with multiple heads
toothpaste options
Level of fluoride as per risk assessment
If suggesting foaming toothpaste assess ability to swallow
Non-foaming toothpastes better for risk of aspiration or pt dysphagic (SLS free)
Unflavoured toothpastes – Oranurse (sensory issued)
what is Open Wide
public health improvement project, for middle part of life (broad – stroke, LD)
- Patient centred / Client centred
- Tailored to each individual’s needs
- Maximising the capabilities of the individual
- To provide support where required in the most appropriate way
A training resource and manual for the delivery of oral care for people with additional care needs
Open Wide consists of three units:
* Unit 1 – Core Oral Health Knowledge
* Unit 2 – Practical Oral Care
* Unit 3 – Oral Health Documentation
communication skills for SCpts
- Be caring, calm and friendly. Smile.
- Talk clearly, at the individual’s pace.
- Use the communication technique that works for the person
- Explain in short sentences and in simple terms what you are doing.
- Use reassuring and appropriate body contact and gentle touch.
- Consent before – ‘if its alright with you can I perform check you cheeks and necks to see if how it feels?’
- Remain positive and try not to show any frustratio
basic guide to support OH of SCpt who able to perform
Discuss at eye level from in front of the person
Pea-sized amount of toothpaste on small headed toothbrush
Access to the mouth
Systematic approach:
Outside surfaces,
Inside surfaces
Chewing surfaces
Mucosa
Counting, singing
Timing
* Best time of day
* Same time of day to develop a routing
* Predictable
* Routine can be positively reinforced
Environment
* Dignity / embarassment
* Light to be able to see
bridging
behavioural strategy
- This helps to engage a person with the task through their senses and helps them to understand the task.
- Describe and show them the toothbrush, then mimic brushing your own teeth.
- Give another toothbrush to the individual. They may mirror your behaviour and brush their own teeth.
chaining
behavioural strategy
involves gently bringing the person’s hand to their mouth while describing the activity. The carer starts the activity and the individual finishes it .
hand over hand
behavioural strategy
chaining is not successful, then place your hand over the individual’s hand and gently brush their teeth together
distraction
behavioural strategy
Distract the individual by placing a familiar item in their hand while you brush their teeth.
Other distraction such as music may be helpful.
* Brush DJ – song whilst performing OH can be useful
rescuing
behavioural strategy
- If attempts are not going well, the carer can leave and a ‘rescuer’ comes in to take over.
- Bringing in someone else with a fresh approach may encourage the individual to cooperate
how to deal with a toothbrush biter
Allow the person to continue biting on one toothbrush
Use another toothbrush to provide oral care
how to deal with a tongue thruster
- If the person’s tongue moves around a lot, or their lips are pressed tightly together, this may push the toothbrush out of their mouth or away from their front teeth.
- Use a gauze square wrapped around your forefinger to gently retract or hold back the tongue or lip.
- This will need patience and perseverance.
how to deal with a tongue thruster
- If the person’s tongue moves around a lot, or their lips are pressed tightly together, this may push the toothbrush out of their mouth or away from their front teeth.
- Use a gauze square wrapped around your forefinger to gently retract or hold back the tongue or lip.
- This will need patience and perseverance.
how to introduces a toothbrush to someone who is resistant
Small head
Soft toothbrush
dry toothbrush
flavouless non foaming F toothpaste
Toothbrush with meaning
E.g. I’ll use a red toothbrush in the top right area, then move to the yellow toothbrush for top left etc
pt seems resistant to oral care - what to do
ask why
pt seems resistant to oral care - what to do
ask why
pt has bleeding gums
Reassurance
Must provide oral hygiene advice – brush through bleeding
If still not resolving then seek an opinion
sensory aids for oral care
Oral Care is a Sensory Experience :
* Power Suit
* Use of sensory aid prior to brushing to destress and afterwards e.g. Stress ball
* Desensitisation - build up
* Counting
* Find a brush which is something they are interested in - football team, game etc
* Warm water
* Stories or Books
denture hygiene advice
Dentures must be removed form the mouth
* Reduces the risk of oral mucosal disease
Rinse dentures after every meal.
Clean dentures morning and night using a toothbrush and denture cream, or plain soap and water.
* Do this over a filled basin or a soft surface to reduce the risk of breaking the dentures if you drop them.
Soak dentures in disinfecting solution for at least 20 minutes once a day.
Soak dentures overnight in plain water
denture hygiene advice
Dentures must be removed form the mouth
* Reduces the risk of oral mucosal disease
Rinse dentures after every meal.
Clean dentures morning and night using a toothbrush and denture cream, or plain soap and water.
* Do this over a filled basin or a soft surface to reduce the risk of breaking the dentures if you drop them.
Soak dentures in disinfecting solution for at least 20 minutes once a day.
Soak dentures overnight in plain water
how to make oral care a positive habit
the habit loop
Habits need a cue /trigger
* Time of day
* Environment
* Object
* Preceding behaviour
* Person
Repetition
* To become habit, it can take 18 days (2.5 weeks) - 254 days (over 8 months) to embed a new habit.
* Mean number of days for change = 66 days.
Rewards
ways to facilitate behaviour change
7
- Supportive environments
- Stable environments
- Leverage the status quo – intervene in major change
- Piggyback – can it be added onto an already positive experience
- Make it easy – don’t move mountains
- Unique personalised cues
- Practice and repeat
what happens when indivdual in residential care
oral health assessment within 48hrs (risk assess and ID oral health risks and needs)
oral care plan - completed by carer when task complete, checked weekly by senior staff, reviews every 4 weeks
what is Disiability Distress Assessment Tool (DisDAT)
Distress is a useful clinical construct in providing care
DisDAT reflected patients’ distress communication identified by a range of carers
Provided carers with evidence for their intuitive observations of distress.
Method through which to understand the individual’s language of distress
Useful tool to identify an individual’s usual content cues, thus enabling distress cues to be identified more clearly
It is the first step in the journey ………..
- Observe the person
- A number of people
- Over a period of time
- Associated clinical decision checklist
3 thinsg to consider when planning operative dental tx for special care pt
Cooperation and anxiety
* Can they accept care
* Modality of tx
Safety and risk assessment
* Medical status
* Physical status/ disability
* Emotional status
Social status
* Dependence
* Support
* Maintenance of dental tx
determining risk of medical disease
involves
Evaluation of all risk factors
Medical risk
* Nature of disease
* Severity
* Control/stability
* Prognosis
* Effect tx plan and modality of any tx
Dental risk
* Anxiety
* Invasiveness
* Adjuvants utilised
* Sedation options (ASA class)
behaviour management techniques
7 exammples
- Acclimatisation
- Tell, show, do
- Relaxation
- Structured time – can work well with A.S.D. but have to understand constructs
- Multiple short appointments in staged approach
- Consider behavioural change and wider context when making treatment planning decisions
* Build of rapport and trust can be key
examples of how to stage short appts to get throught tx plan
Visit 1 Sit on the chair
Visit 2 Tooth brushing ( can allow you to have a look)
Visit 3 Exam
Visit 4 Radiographs
Visit 5 Small filling
Visit 6 Larger filling
Visit 7 Extraction
sedation in SCD
Sedation is a valuable tool in the management of people with physical and learning disability
* But risk assessments for each type must be undertaken on individual basis
Avoids the risks associated with general anaesthetic
Different set of skills required in assessment when compared to purely dentally anxious individual
Patient ability to tell you how they feel may not always be present so other assessment tools are required
* May not be able to communicate verbally with you initially
However, is not risk free particularly with the use of benzodiazepines: (can be unpredictable)
* Over sedation
* Respiratory depression
* Abnormal reactions
4 types of sedation
oral
intra nasal
inhalation
IV (dentist led or anaesthetist led)
oral sedation
Patient is still required to take medication
Can be disguised in a drink
Can be unpredictable (bolus dose, pharmacodynamic / pharmacokinetics can vary hugely with this population group)
intranasal sedation
Increasingly used
overcomes patient having to take medication orally
Relatively quick onset in comparison to oral
inhalation sedation
Can be contraindicated as patient requires the understanding to be able to breath in and out through the nose piece
Least risk associated with this modality (30% NO, 70% O2 still more than atmospheric; environmental cost/sustainability side of nitrous oxide)
Significant behaviour management required
intranasal (dentist or anaesthetist led)
In most cases utilises midazolam
Drug can be titrated safely to maximum effect
Risk of respiratory depression
Significant benefits with muscle relaxation / involuntary movement
* Huntington’s Disease, Cerebral Palsy
when is inhalation sedation useful
6 scenarios
- Anxious pt
- Medical risk modified by stress
- Level of co-operation is important
- Assessment on same day
- Margin of risk if very minimal
- Even in the most medically compromised this technique is an option
pros of IV sedation
2
Cost-effectiveness - debate
Broader range of treatment options (compared to GA – tends to be more radical)
titrated drug to maximise effect
muscle relaxation - good for Huntington’s, cerebral palsy
cons of IV sedation
5
Co-operation for assessment and ASA status (I or II dental, III hospital)
Co-operation for cannulation
Paradoxical reactions
Requires 24 hour post op responsible person for 1 on 1 care
May require multiple appointments
May give NO place cannula, then stop NO and start titration IV drug
risk associated with GA
Death - 1 in 100,000 - 1 in 200,000
Risk increases with age, complexity of surgery, emergency surgery or very unwell before procedure
Brain damage, Nausea and vomiting, Lethargy, delayed recovery etc.
Increasing complexity associated with increasing co-morbidity – increased risk
Medical status – All human systems must be evaluated to determine level of risk
Social status – treated as an inpatient or an outpatient? Is it safe for them to go home?
risks to warn pt/carer of for GA SCpt
Feeling sick and vomiting – this usually occurs immediately, although some people may continue to feel sick for up to a day
Shivering and feeling cold – this may last a few minutes or hours
Confusion and memory loss – this is more common in elderly people or those with existing memory problems; it’s usually temporary, but occasionally can be longer lasting
Bladder problems – you may have difficulty passing urine
Dizziness – you will be given fluids to treat this
Bruising and soreness – this may develop in the area where you were injected or had a drip fitted; it usually heals without treatment
Sore throat
*Allergic reaction to the anaesthetic (anaphylaxis) uncommon
Waking up during your operation*
3 situations when GA best options
a. Significant volume of treatment
b. Patient is uncooperative
c. If significant medical complexity is evident patient can be managed in a controlled and safe environment with medical support
tx plan tends to be what when go for GA tx
More severe treatment plans:
* No crown and bridge unless extra-coronal can be placed without GA
* No endodontics (can be exceptions, strategic teeth in presence of good OH) - Infected teeth and teeth with pulpal involvement are removed
* Teeth of poor prognosis may be removed
* Opposing non-functional teeth may be removed – prevent overeruption and causing issues later
Render the oral health stable and predictable with little risk of symptomatic dental disease in the 2 – 3 years following that episode of treatment, thus minimising the need for repeat exposure to GA
what happends when pt seen for GA
Patients receive dental assessment
Patient is called to pre-op medical assessment
If suitable, will then attend hospital for General Anaesthetic
* Checked in
* Sees anaesthetics team
* Dentist confirms plan and ensures all paperwork in place
* Pre-med given if required
* Anaesthetics team provide care - Nasal tube for comprehensive care!
Dental team
* Examination (EUA)
* Radiographs
* Treatment planning – quick, think now and long term
* Scale and Polish
* Restorations
* Extractions ( non-surgical and surgical)
* +/- others e.g. Bloods, hair cuts, toe nails cut, ear wax removal etc.
when to refer
3 situations
- Pain and swelling and swelling where no alternatives exist but must be managed acutely
- Obvious dental disease when no alternative treatment modality is possible to facilitate dental care
- A number of years since a reasonable examination in the presence of poor oral hygiene and suspicions of disease
The individual with good oral hygiene and no obvious dental disease does not require a regular GA for examination !!!!
Local criteria available
basic prinicples of dental emergencies for uncoop pt
buy time
revesible pulpitis and uncoop pt
how to manage
Can you gain enough access for ART ? (atraumatic restorative technique)
Or temporisation (GI)
irrevsible pulpitis and uncoop pt
how to manage
Can you gain enough access to place a sedative dressing? (ledermix)
Antibiotics are not effective in the management of pulpal inflammation
periapical infection and uncoop pt
how to manage
Antibiotics and plan for the future – sedation or G.A.
benefit of SC pt being seen in primary care
6
- Learning disability is more common in families of a lower socioeconomic status
- Proximity – financial, work, transport for person +/- carer
- Relationships may already be established
- Family members may attend practice
- Longitudinal care - Prevention and Follow up
- Equal opportunity to services
