Oral health care planning for people with degenerative conditions. Debbie Lewis Specialist in Special Care Dentistry Dorset Healthcare NHS Foundation Trust
The objectives of my session are! To consider the oral health issues affecting people with Parkinson's Disease, Dementia, MS and Huntington's Disease.! To discuss the impact of degenerative conditions on oral health.! To illustrate patient centred oral care planning.! To look at multidisciplinary team working.! To recommend a communication passport for people with degenerative conditions
Oral health care planning for people with degenerative conditions Due to progressive condition- Emphasis on rigorous preventive regimes Comprehensive restorative treatment Maintenance of the natural dentition Avoid the problematic management of dentures in later stages.
Oral Care Plan The lynch pin is to develop a written oral care plan, with involvement of the individual, family/and/or carer, which facilitates communication between the patient, carers and the dental team and helps to ensure that all involved in the individual s care are aware of her/his needs.
Oral Care Plan! Maintain comfort, dignity and self-esteem! To encourage independence and self-caremonitor ability! General health, medical condition and prognosis, medication and therapeutics! Previous standard of oral hygiene and oral care skills maintaining routines as long as possible
PARKINSON S DISEASE! Symptom / Impairment! Impact on oral health! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Hypersalivation and posture Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Hypersalivation and posture Medication- Levodopa Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Dysphagia Decreased quantity and quality of saliva Weak oral musculature Hypersalivation and posture Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Increased risk of aspiration infections Associated with poor oral hygiene Ability to tolerate treatment. Weak oral musculature Hypersalivation and posture Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Increased risk of aspiration infections Associated with poor oral hygiene/ability to tolerate treatment Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Hypersalivation and posture Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Increased risk of aspiration infections Associated with poor oral hygiene/ability to tolerate treatment Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Difficulty with dentures, Difficulty eating and drinking. Nakayama et al. J Epidemiol 2004 Drooling and posture Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Hypersalivation and posture Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Increased risk of aspiration infections Associated with poor oral hygiene/ability to tolerate treatment Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Difficulty with dentures, Difficulty eating and drinking Drooling and access to the mouth- head collar Medication- Levodopa
PARKINSON S DISEASE! Symptom / Impairment! Muscle rigidity Random movements Tremor Impaired Manual Dexterity Mobility Dysphagia Decreased quantity and quality of saliva Weak oral musculature Hypersalivation and posture Medication- Levodopa Impact on oral health! Ability to self care Ability to tolerate oral care/dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Increased risk of aspiration infections Associated with poor oral hygiene/ability to tolerate treatment Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Difficulty with dentures, Difficulty eating and drinking Drooling and access to the mouth- head collar Salivary disturbance and taste dysfunction
DEMENTIA! Symptom / Impairment! Cognitive skills Impact on oral health! Memory loss Dependence Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Impact on oral health! Ability for selfcare Denture wearing skills Capacity Memory loss Dependence Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Impact on oral health! Ability for selfcare Denture wearing skills Capacity Memory loss Support with oral care Lost dentures Dependence Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Impact on oral health! Ability for selfcare Denture wearing skills Capacity Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Wiseman 2005 Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Non- compliance Eating difficulties Impact on oral health! Ability for selfcare Denture wearing skills Capacity Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Refuse oral care- periodontal disease/caries Refuse dental treatment- Sed/GA Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Non- compliance Impact on oral health! Ability for selfcare Denture wearing skills Capacity Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Refuse oral care- periodontal disease Refuse dental treatment - Sed/GA Eating difficulties High sugar diet- caries Communication Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Non- compliance Eating difficulties Communication Impact on oral health! Ability for selfcare Denture wearing skills Capacity Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Refuse oral care- periodontal disease Refuse dental treatment - Sed/GA High sugar diet- caries Ability to express pain or discomfort-refusal to eat/ pulling at face/not wearing denture/restlessness/ disturbed sleep/moaning/shouting/crying Personality change may be due to dementia or oral problem
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem Impact on oral health! Ability for selfcare Denture wearing skills Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Refuse oral care- periodontal disease Refuse dental treatment High sugar diet- caries Ability to express pain or discomfort Pain- need diagnosis
Dementia! Symptom / Impairment! Cognitive skills Memory loss Dependence Non- compliance Eating difficulties Communication Personality change may be due to dementia or oral problem Dementia Guidelines Impact on oral health! Ability for selfcare Denture wearing skills Support with oral care Lost dentures Access to dental services and ability to tolerate treatment Refuse oral care- periodontal disease Refuse dental treatment Sed/GA High sugar diet- caries Ability to express pain or discomfort Pain- need diagnosis
Marking Lost Dentures Storage Copy dentures Oral Assessment
Multiple Sclerosis! Symptom / Impairment! Impact on oral health! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balancebladder control problems Progressive disability Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Quality of life Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Quality of life Quality of life Eating and drinking Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Quality of life Quality of life Eating and drinking Ability self care Decreased quantity and quality of saliva Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Ability to tolerate treatment Ability to tolerate treatment. Eating and drinking Ability self care Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Swallowing problems Cognitive skills
Multiple Sclerosis! Symptom / Impairment! Tremor Spasms/Rigidity Impaired Manual Dexterity Fatigue Parasthesia Mobility balance Progressive disability Bladder control problems Memory Motivation.personalityDepression Facial Pain/ Trigeminal neuralgia Burning mouth Problem with vision blurred/double Decreased quantity and quality of saliva Swallowing problems Impact on oral health! Ability to self care Ability to tolerate oral care/ dental treatment Need Sedation/GA Access to dental services and ability to tolerate treatment Access to dental services and ability to tolerate treatment Ability self care Ability to tolerate treatment Ability to tolerate treatment. Eating and drinking Ability self care Xerostomia which increases the risk of dental caries, periodontal disease, oral infections, and denture problems, burning mouth Difficulty eating and drinking Tolerating dental treatment Cognitive skills Ability for selfcare, Capacity Denture wearing skills
Huntington s Disease! Symptom / Impairment! Impact on oral health! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problemschorea movements Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment High sugar consumption, Smoking, alcohol Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment High sugar consumption, Smoking, alcohol Ability self care. Access to dental services Ability to tolerate treatment Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment High sugar consumption, Smoking, alcohol Ability self care. Access to dental services Ability to tolerate treatment Difficulty eating and drinking- PEG Maintaining constant body wt/incr appetite/cram food/ choking Tolerating oral care/ dental treatment Medication Communication impaired speech and slurring
Huntington s Disease! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Chorea movements Medication Impact on oral health! Ability self care Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment High sugar consumption, Smoking, alcohol Ability self care. Access to dental services Ability to tolerate treatment Difficulty eating and drinking Maintaining constant body wt/incr appetite/cram food/ choking Tolerating dental treatment Xerostomia Communication impaired speech and slurring
Huntington s Disease! Show Poster! Symptom / Impairment! Loss of muscular coordination Short term memory lapses Loss of concentration and organisational skills May develop a lack of interest in hygiene and self-care. Cognitive skills Mobility Fatigue Bladder control problems Addictive tendancies Personality changes/mood swings/depression Degeneration of muscles involved in swallowing/ Swallowing problems Medication Communication impaired speech and slurring Impact on oral health! Ability to oral care/ tolerate treatment Ability to oral care/ tolerate treatment Denture wearing skills Access to dental services and ability to tolerate treatment High sugar consumption, Smoking, alcohol Ability self care. Access to dental services Ability to tolerate treatment Difficulty eating and drinking Maintaining constant body wt/incr appetite/cram food/ choking Tolerating dental treatment Xerostomia Ability to express need Access to dental services.
Patient centred oral care plan The flexible patientcentred approach is especially appropriate when planning care for individuals who have degenerative disease How much treatment can they cope with physically and psychologicallyretain well-being. Good days/bad days/time of day Realistic Which of their oral problems are they most concerned about getting treated? Enables an individual to have inclusion and involvement in the decisions made about their oral care needs and how they are met.
Patient centred oral care plan Treatment and aftercare may need to be modified to accommodate the patient s condition and living situation How well can their oral health be maintained? Who is able to give help with daily oral healthcare? Restore key teeth Skills and facilities required to manage delivery of care eg Diaco/hoist/ Sed/GA
Patient centred oral care plan High quality but low maintenance treatment should be the aim. There is no point in completing an ambitious course of restorative care if there is no adequate level of daily oral healthcare to maintain it.
Functionally dependent older people have higher rates of tooth loss, greater prevalence of denture related problems, greater prevalence and severity of caries, higher prevalence of periodontal disease and less likely to have seen a dentist for 5 years Henry 1995
Special Oral Care Aspirating toothbrush, Kimberley Clark
Shared care People with disabilities vary in their views on the type of service they want. Whilst some prefer to use mainstream services, others want more specialised services.
Shared care Shared care between general dental practice and a special care service General dental practice offers advantages that Include: Continuity of care Opportunity to access mainstream service Wider choice of service providers-incl. hygienists/therapists Attend the dentist with the rest of the family
Shared care More convenient location than a specialist centre is likely to have If some items of management or treatment are complex, then the support of a special care service may be necessary Facilities for sedation and general anaesthesia, or access to these services are essential, for some people with degenerative conditions Access to Domiciliary care is also essential
Key Skills Flexibility Teamwork Communication Assertiveness and Anticipation Manual handling and Map reading Planning and time management Improvisation Networking and liaison Gerodontology Guidelines for the Delivery of a Domiciliary Oral Healthcare Service 2009 www.bsdh.org. uk
Equality- Access to care Dedicated Parking Signage Handrail and ramp Waiting area seating/ communication aids Low reception desk Accessible toilets Hoists/ wheelchair tippers
Multidisciplinary Team for People with Degenerative Conditions. Pharmacist Speech & language Therapy Voluntary orgs Community nursing team Day centre and care home staff Patient Hospital Specialist Relatives and carers Community mental health teams General medical practitioners Palliative care teams Dental team and specialist Occupatonal therapist Specialist Nurse Social services
Voluntary orgs
Standards for Care Homes Oral health assessment Independence- striking balance to maintain adequate oral health Standards for routine oral and denture hygiene linked to the National Minimum Care Standards- Standard 13 (HIQA,2007) Structured,modular training for carers to assist/and/or provide daily care with a standardised resource Oral Care Plans/Oral Health Charter Written oral care plans can facilitate communication between dental team, patient and carers
MULTIDISCIPLINARY
Aims of the Clinic There is strong evidence that providing patients and carers with information about their condition has a positive effect on physical, psychological and social outcomes National service framework Long term Conditions!. Knowledge/understanding! Anxiety! Decision making/patient involvement! Patient professional partnership! Communication with the family (May 2003)
MULTIDISCIPLINARY The medical consultant sees people by appointment and other services work more informally. Other professionals include a dietician, speech and language therapist, specialist nurse, occupational therapist, psychologist, genetic counsellor and an oral health promoter who is available for advice and to help facilitate access to oral health care.
With the input from patients of the service and their families/carers, the oral health promoter and her team have developed an information leaflet specifically for people with Huntingtdon s disease and their carers MULTIDISCIPLINARY
MULTIDISCIPLINARY Many of these patients have received preventive oral health advice with the aim of establishing good habits early on in the disease process. They have also been supported with accessing oral healthcare and have been able to close the loop by providing feedback to the oral health team at follow up clinics.
People with dementia Provides a snapshot of the person behind the dementia Habits Hobbies Likes and dislikes Communication This is me
This is me This leaflet will help you support me in an unfamiliar place My name Please place a photograph of yourself in the space provided. My name: full name and the name I prefer to be known by I currently live Carer/the person who knows me best I would like you to know My home and family, things that are important to me My life so far
My hobbies and interests Things which may worry or upset me photo This is me is about the person at the time the document is completed and will need to be updated as necessary.
This is me should be completed by the person or persons who know the patient best and wherever possible with the person themselves. Please refer to the back page for guidance notes to help you complete This is me. I like to relax by My hearing and eyesight My communication My mobility My sleep My personal care My eating and drinking My medication
The trials of being a human diary When am I seeing Dr Zan? I ve booked you in on Monday Thought Dr Floss was coming then No, I ll remind you again on Sunday So, when is Dr Floss coming? That s the following week \you can forget about Dr Floss for now I find myself declaring- tongue in cheek What time is it with Doctor Zhan We re going at half past 4 That is a bit late. Yes, but mum I have got a day s work to cram in before So we re not seeing Doctor Zan next week? Yes we are- what I just said And I must tell Dr Floss about my throat? No, she s the one comes about your head What am I seeing Dr Zan for? You said your throat is troubling you Oh is it? I don t remember that And you can get your jab against the flu So where do we go for Dr Floss? We don t; she comes out to visit us And you re taking me to Dr Zan s? (Bite my tongue not to retort: I think I ll let you get the bus. ) So when do I see Doctor Zan? Next Monday afternoon Seems such a long time to have to wait Monday will come around so soon Will we be back in time for Dr Floss? Don t worry- that s a different day So I don t have to remember then? No, I ll remind you anyway What was that you said before I have to remember about on Sunday? Nothing mum, it s me has to recall to remind you about Monday (sigh)
Thank you debbie.lewis19@btinternet.com Any Questions?