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
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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?
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 L eading cause of death is respiratory disease 2 ND 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 IFit & well II Mild systemic disease
IIISevere systemic disease - limits activity - not incapacitating
IVSevere life threatening systemic disease - incapacitating
VMoribund
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Karen 55y female, dental anxiety 55y female, dental anxiety
Poorly controlled epilepsy, hypertension, Poorly controlled
epilepsy, hypertension, CVA x 2, COPD, angina CVA x 2, COPD, angina
1/3 seizures end in statushosp admission 1/3 seizures end in
statushosp admission Appalling heavily restored dentition Appalling
heavily restored dentition Did not want to lose her teeth Did not
want to lose her teeth
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JF 49y male, N Wales 49y male, N Wales History of pain +
swelling 10y History of pain + swelling 10y Needle phobic, last
visit 15y ago Needle phobic, last visit 15y ago Profound gag reflex
Profound gag reflex required perio Tx, 2 extract ns, 4 restorations
required perio Tx, 2 extract ns, 4 restorations
Bariatric Dentistry Morbidly obese patients Morbidly obese
patients Chair movement Chair movement Airway protection Airway
protection Co-morbidities Co-morbidities Ambulant v wheelchair
users v trolley bed 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
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 Commissioning
Clinical expertise Clinical expertise Local v Deanery v Regional
Local v Deanery v Regional GDPs v Salaried v Secondary care 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 LUDH 2011 Extractions -
u/grad training limited N o disruptive gag reflex, restorative
Trauma/arthritis TMJ with limited opening
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SCD & Sedation limited cooperation limited cooperation
learning disabilities dementia movement disorders movement
disorders cerebral palsy Parkinsons disease multiple sclerosis
Huntingtons chorea medical conditions exacerbated by stress.
medical conditions exacerbated by stress.
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Diabetics high index of suspicion with ID diabetics high index
of suspicion with ID diabetics Care with newly diagnosed Care with
newly diagnosed quality of after care quality of after care
stability of the condition stability of the condition Janice 45y
history of depression Janice 45y history of depression
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Anaesthetic Assistant
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Difficult But worth continued effort Not got it right yet
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 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: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? n anxious/phobic n disruptive gag reflex n
Limited cooperation n 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 Admin IV
sedation - RCT - monitored - ECG UTA - in hospital UTA - in
hospital Reappointed for extraction & cons - aneurysm & MI
six weeks ago 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 Sexually assaulted aged 16
dental phobic referred from clinical psychologist wanted to remain
in control wanted to remain in control female to Tx planned escape
route door left open during Tx not to tx in supine position