Training Dentists to Manage Patients who have Complex Medical Needs

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Training Dentists to Manage Patients who have
Complex Medical Needs
Lesley Longman
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Presentation will Discuss

• Patients
• what medical needs?
• Roles of the different dental providers
• Training
• Dentists (dental team)
• Resources funding, manpower, pt outcomes x

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Personal Overview
JOB!
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What are we preparing our young professionals
for ?

• Current NHS service delivery
• Is the salaried service still a safety net?
• Are specialist services delivering specialist
  care?

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Domiciliary Care

• Domain of Salaried services?
• Residential homes and nursing homes GDPs?

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Dental Workforce

• Dentists
• GDP
• DwSI
• Salaried services
• Specialist services (hospitals, dental schools,
  salaried services)
• Trainees
• Dental Nurses, Hygienists, Therapists,
  Receptionists, Dental Technicians

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What medical conditions are we talking about?

• Referral to Secondary Care by GDP
• Please treat this 65 year old patient who has
  a complex medical history
• Aspirin, ACE - inhibitor
• Wheel chair user

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Referral by CDO

• Please see this patient because they have
  mobility problems and they need an ambulance to
  take them to an appointment. We do not have
  access to an ambulance service

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Email by GDP?

• Advice on a 24y ? in end-stage renal failure 2ry
  to
• Wegeners granulomatosis, renal dialysis,
  multiple drugs including steroids
• I have written to his GMP about any complications
  with LA
• Would it be reasonable for me to treat him or do
  I need to refer.

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Who should be referred to Specialists?
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Patients who have complex medical needs

• Significant cognitive impairment
• 
  ............co-morbidities?
• LDs, brain injury, dementia, profound LDs and
  physical disabilities

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Equality?

• Most people with Learning Disabilities (LD) have
  poorer health than the rest of the population
• More likely to die at a younger age
• Access to the NHS is often poor and characterised
  by problems ..at worst, reports have identified
  abuse, undiagnosed illness and, in some cases
  avoidable death.
• (Valuing people now DOH, 2009)

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Health Needs of People with Learning Disabilities

• Greater health needs
• Above average death rate amongst younger people
• Older people more prone to age related disorders
• Increased risk of early death
• Leading cause of death is respiratory disease
• 2ND most common cause of death is CHD
• Equal Treatment Closing the Gap.
• Disability Rights Commission 04

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Prevalence Comparison.
British Psychological Society, Royal College of
Psychiatrists, 2009
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Learning Disabilities

• Risk of dying before the age of 50 is 58 times
  higher than the general population
• (Hollins, 1998)

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• People are uncertain how to find a dentist and
  the information they require is often not
  available in the right places, is not
  co-ordinated or is not kept up to date
• 
  Steele 2009

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Dementia Patient with Significant Medical
Conditions

• Referred with retained roots and caries
• Query regarding oral pain
• Risk assessment exercise

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Supervised neglect ?
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Complex Medical Needs

• Cognitive impairment with co-morbidities
• Patients who require medical prep/liaison
  hereditary angioedema, haemophiliacs,
  anaesthetist need to be present
• ASA III/IV

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ASA CLASSIFICATION

• I Fit well
• II Mild systemic disease
• III Severe systemic disease - limits activity -
  not incapacitating
• IV Severe life threatening systemic
• disease - incapacitating
• V Moribund

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Karen

• 55y female, dental anxiety
• Poorly controlled epilepsy, hypertension,
• CVA x 2, COPD, angina
• 1/3 seizures end in statushosp admission
• Appalling heavily restored dentition
• Did not want to lose her teeth

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JF

• 49y male, N Wales
• History of pain swelling 10y
• Needle phobic, last visit 15y ago
• Profound gag reflex
• required perio Tx, 2 extractns, 4
  restorations

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JF dental phobic

• Hypertension (BP 210/114)
• Pulmonary embolism - 8y ago
• Thyroidectomy - 10y ago
• Atrial fibrillation
• Warfarin
• 13 medicines Digoxin, lisinopril, celiprolol,
  simvastatin

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Bariatric Dentistry

• Morbidly obese patients
• Chair movement
• Airway protection
• Co-morbidities
• Ambulant v wheelchair users v trolley bed

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Education issues around oral health for all
stakeholders

• Carers
• GMPs
• Medical Specialists, Consultants in Public Health
• Support agencies

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Dental Team Student Training is Pivotal
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Student Training

• Unacceptable that dental trainees are not
  given optimal exposure to the oral needs of the
  most vulnerable members of society

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Student Training

• Special Care Dentists
• barriers to care
• case studies
• Outreach
• Vertically integrated approach
• Communication skills
• Prevention is pivotal
• The disadvantages of operative dentistry

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Cosmetic and Complex Treatments
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Steele 2009

• Oral health should be for life
• Keep a very clear focus on the future to minimise
  the risk
• All conservative/operative dentistry eventually
  requires repair/intervention

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Develop skills/qualities

• Disability Awareness
• Identify negotiate barriers
• Flexibility
• Innovation

If all you have in your tool box is a hammer,
all the world looks like a nail.
Abraham Maslow
Transferable Skills!!!
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Disability....

• Is not a professionally diagnosed deviation from
  biomedical norms but a complex collection of
  conditions, activities and relationships, many of
  which are created by the social environment
• Faulkes
  Hennequin 2006 JDOH

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Develop skills/qualities

• Disability Awareness
• Identify negotiate barriers
• Flexibility
• Innovation
• Cross-specialty and inter-agency working
• Safeguarding vulnerable adults
• Clinical holding
• Risk Management

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Risk Management
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SCiPE Task Force
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Post-registration courses

• Dentists
• Specialist training
• Section 63, BSDH
• Certificate, Diploma and Masters courses in SCD
  hands on!
• Dental Nurses NEBDN examination in SCD
• Therapists
• Technicians

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Referral Pathways.....problematic

• Commissioning
• Clinical expertise
• Local v Deanery v Regional
• GDPs v Salaried v Secondary care

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Network of Services

• Reliable communication and transfer of
  information between all stakeholders
• GMPs, Consultants, care agencies
• Readily available support from Specialists
• Seamless shared care
• Acknowledgement that this takes time

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Referral Pathways Clinic for immunocompromised
pts

• New patients

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Referral pathways

• Sedation for anxious/phobic patients

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2000 Acceptance criteria for sedation at LUDH

• Complex medical conditions ?
• Anxious/phobic patients ASA I,II
• Exodontia, MOS ?
• Disruptive gag reflex ?
• Restorative periodontal care under sedation ?
• Advanced restorative ?

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Acceptance criteria for sedation at LUDH2011

• Extractions - u/grad training ?limited No ?
• disruptive gag reflex, restorative ?
• Trauma/arthritis TMJ with limited opening ?

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SCD Sedation

• limited cooperation
• learning disabilities
• dementia
• movement disorders
• cerebral palsy
• Parkinsons disease
• multiple sclerosis
• Huntingtons chorea
• medical conditions exacerbated by stress.

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Diabetics

• high index of suspicion with ID diabetics
• Care with newly diagnosed
• quality of after care
• stability of the condition
• Janice 45y history of depression

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Anaesthetic Assistant

• Anaesthetic Assistant

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Difficult
Not got it right yet

• But worth continued effort

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(No Transcript)
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Sheila 43 year old-MS food via PEG
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Self harm
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Mrs J -

• 43y female
• polycystic kidney disease
• unstable angina (10 attacks/day)
• hypertension high cholesterol
• 10cm ovarian cyst
• obese,
• smokes 20 day
• 13 medicines

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Dental Need

• 75 of patients with Alzheimers disease need
  dental attention

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Complex Medical Needs

• Cognitive impairment with co-morbidities
• LDs, Brain injury, Dementia
• Patients who require medical support/liaison
  haemophiliacs
• ASA III/IV insert ASA slide
• In-patients at acute Trusts?

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Considerations

• Newly diagnosed
• Family, carers, conversations excluding the pt
• Timing of appointments
• Good v bad days
• Capacity
• Salivary gland hypofunction
• liaison

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Tips

• If someone is agitated, the environment might be
  too busy or noisy. 
• Relaxation techniques such as massage,
  aromatherapy and music can be effective and
  enjoyable
• Anticipate the possible future decline in dental
  status

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Treatment modifications

• Pain and anxiety control
• Communication

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Communication

• Those around the person should continue talking
  to them as though they understand. This helps to
  preserve their dignity.

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Miscellaneous group - SCD

• recreational drug users

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• Impaired mobility
• Poor cooperation
• Short appointments
• More frequent recalls

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SCD and sedation

• limited cooperation
• learning disabilities
• dementia
• movement disorders
• cerebral palsy
• Parkinsons disease
• multiple sclerosis
• Huntingtons chorea
• medical conditions exacerbated by stress.

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Health Needs of People with Learning Disabilities

• Higher risk of tumours of the oesophagus, stomach
  and gall bladder
• Higher mortality is related to associated
  conditions of the LD (i.e. Severe mobility
  impairments, seizures, vision/hearing impairments
  and being unable to feed oneself)

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Education Postgraduate

• Primary care is pivotal
• Responsible restorative care
• Informed consent, patient information
• Prevention
• Referral pathways

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Medically compromised patient
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Administration of midazolam via a PEG
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Learning Disabilites and Dementia

• prevalence of dementia in people with other forms
  of LD is also higher than in the general
  population. Some studies (Cooper 1997, Lund 1985,
  Moss and Patel 1993) suggest that the following
  percentages of people with learning disabilities
  not due to Down's syndrome have dementia
• 50 years and over 13 per cent
• 65 years and over 22 per cent.
• This is about four times higher than in the
  general population. At present, we do not know
  why this is the case, and further research is
  needed. People with learning disabilities are
  vulnerable to the same risk factors as anyone
  else. Genetic factors may be involved, or a
  particular type of brain damage associated with a
  learning disability may be implicated.

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Who needs sedation?

• anxious/phobic
• disruptive gag reflex
• Limited cooperation
• movement disorders
• medical conditions exacerbated by stress
  

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• The remit of the Salaried Dental Services is not
  always well understood, with the potential for
  inappropriate referrals and patients bounced
  between providers, sometimes also including
  hospital services. It is important that special
  care services are used appropriately. Valuing
  Peoples Oral Health6 provides advice in this
  area and commissioners should use this to help
  align services to need. Local services for
  patients could also be helped by local patient
  pathways and clinical networks involving
  specialists in special care dentistry, supported
  by commissioning plans and providing local
  information to patients and their carers. p58

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• Down's syndrome and Alzheimer's disease
• About 20 per cent of people with a learning
  disability have Down's syndrome, and people with
  Down's syndrome are at particular risk of
  developing dementia. Figures from one study
  (Prasher 1995) suggest that the following
  percentages of people with Down's syndrome have
  dementia
• 30-39 years 2 per cent
• 40-49 years 9.4 per cent
• 50-59 years 36.1 per cent
• 60-69 years 54.5 per cent.

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Dementia

• 820, 000 people in UK and rising
• Neurodegenerative progressive disease that
  affects the ability to perform life's daily
  activities
• Co morbidities depression, tradive dyskinesia,
  Xerostomia
• Carer issues

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• Prevention and high quality provision
• Steele 2009
• We recommend that strong clinical guidelines are
  developed to support dentists and patients
  through specific pathways of treatment.
• Steele 2009

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• It is older people who probably express greatest
  concern. The review mailbox received many
  submissions from older patients worried about the
  costs of maintenance and many older people who we
  listened to also feel their teeth require more
  care and attention. They are keen to keep their
  teeth but are worried about the cost.
• Steele review 2009

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Responsibilities of the dentist

• using a combination of evidence and experience to
  provide care that is in the best interests of the
  patient
• ?? dealing with long-term solutions to problems
  created by disease, not just performing quick
  fixes
• ?? offering good and honest communication
• ?? displaying behaviours that unambiguously put
  the patient first
• ?? helping patients with their own self-care
  responsibilities.

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• Any dental service should then be able to provide
  quick and definitive pain relief to anyone who
  needs it. This should not be a large or expensive
  part of a service, but it must be there.

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• Preventing the damage caused by disease at an
  individual level is a high priority for
  investment. Every cavity or periodontal pocket
  represents irreversible damage, with lifetime
  consequences and costs.
• p43

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• Advanced aspects of restorative care are provided
  only when there is a stable oral environment,
  where disease risks are managed and when the
  patient is established in a continuing care
  relationship.
• p45

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• There are multiple opportunities to embed oral
  health in public health national campaigns
  around preventive behaviours to support patients
  in taking greater responsibility for their own
  health monitoring and promoting good oral health
  behaviours alongside alcohol reduction and
  smoking cessation programmes recognising the
  common risks shared with major oral diseases
  (decay, gum disease and oral cancer) and
  defining actions to create a healthier
  environment (e.g. working with the food industry
  to reduce levels of sugar).

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• Access to care
• Physical
• Skill mix
• Management possibilites

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Steele 2009

• Advanced aspects of restorative care are
  provided only when there is a stable oral
  environment, where disease risks are managed and
  when the patient is established in a continuing
  care relationship. p45

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Mrs JR

• Admin IV sedation - RCT - monitored - ECG
• UTA - in hospital
• Reappointed for extraction cons -
  aneurysm MI six weeks ago

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Suzanne D - 23y

• Sexually assaulted aged 16 dental
  phobic referred from clinical psychologist
• wanted to remain in control
• female to Tx
• planned escape route
• door left open during Tx not to tx in supine
  position