NMDA Journal Summer 2018

9 with their ADL’s. The severely demented are barely aware of their surroundings, and are reluctant to leave their comfort zone. They need help with all of their ADL’s and are usually incontinent and institutionalized. As dentists we notice that this population does not deal with dental issues well as they do not keep their mouths clean and have difficulty keeping appointments even if they have someone to schedule and bring them to appointments. Because of these issues, make sure that you have another person involved in their lives to talk to such as a family member, social worker, caregiver or POA (Power of Attorney). The best person for a change in homecare is the person responsible for their ADL’s. This is easy if it is a family member or live-in caregiver. It is hard if they are institutionalized because the care givers change each shift. Taking photographs of a dirty mouth and sending it with the patient and writing out homecare orders to both kinds of caregivers, and showing them how to provide homecare is imperative if you want to save teeth. IMPORTANT QUESTIONS TO ASK WHEN PROVIDING TREATMENT ARE: • Do they have a valid complaint you can treat? If they describe a delusional issue like their upper jaw is splitting in two, don’t go there. You can’t fix it. • How long is the patient going to live? Some people have terminal cancer, end stage dementia, ALS, or renal failure. Are you going to do a permanent crown, or a nice temporary crown cemented permanently, or smooth off a broken cusp and call it a day? • Can the mouth be cared for by the patient or the helper? I get this scenario frequently: The 94 year old patient does not clean her mouth. She is now immobile with a care giver living with her who does not clean her mouth. She has rampant decay, and in the past two years, I have done several crowns with root canal therapy and I could do many more procedures such as extractions and removable prosthetics. I know in my heart, she will lose the partial in days because she won’t wear it because change is hard and adaptability is near impossible. We have a talk and decide that esthetic issues like missing front teeth are not a concern because function is still possible. We agree that she is no longer a sex object. So for the future, deplaqueing quarterly, checking for pain, silver nitrate/fluoride application and smoothing rough/sharp areas from newly broken teeth becomes the treatment plan. • Can you perform the procedures? You can do anything if they are sedated and restrained. And sometimes you absolutely have to get out an infected painful tooth. But most of the time, these combative, mean, uncooperative, demented people do fine with the dental disease they have. After all, you are perceived as a stranger assaulting a confused, vulnerable, frail oldster. The nerves are so receded and small that they rarely cause problems even with areas of large decay until the tooth breaks off and even then, you can smooth down the rough area. Preserving painless root tips gives them a chewing base. One time I was called in to find a solution for a lady who had just bit out a junk of arm on a caregiver in a nursing home. We came up with two solutions: edentulate or have her wear a football helmet. The home and family chose the helmet. • Are they capable of tasking? Some people just can’t follow through. How many times are you going to make a denture or partial on the person who loses them biannually or even more often? If they are taking them out and losing them, they are not wearing them in the first place. A common story: I want you to make my mother new dentures. Okay, how did she lose them? She takes them out when she eats and they got thrown away. So why do you want her to have dentures? She needs them to eat. (I didn’t make her new dentures.) Make sure that potentially lost dentures and partials are labeled. A patient with a labeled denture went to the bank forgetting his ID to cash a check. When asked for an ID, he took out his denture. • How do you deal with the patient who asks for work and has no intention of following through because they really just want a place to visit? You have them come in for their quarterly deplaqueing etc. visit and say you will do the work when their homecare is better. (Never) These people are usually dead within a few years so these visits don’t go on forever. I love the people who come in and enjoy visiting with them. In summary, you have to make a paradigm shift when treating the demented, frail, and incapable. Come up with treatment plans in relation to how long does your work needs to last and if work is even relevant. In these cases, go with temporary crowns with permanent cement, reline instead of remaking partials and dentures, retrofit crowns and bridges, don’t extract painless broken teeth or root tips but do polish off rough and sharp areas, use silver nitrate or silver diamine with fluoride to reduce decay and gingivitis. I get a lot of push back on getting caregivers to provide homecare for this population. Often the caregivers don’t even take care of their own mouths. Here are some common comments and retorts: • It takes away his dignity when I brush his teeth. Do you wipe his bottom? • It makes me wanna throw-up when I look in his mouth. Then don’t look—do it by feel. • He won’t let me. Find strategies. The caregiver can hand the toothbrush to the oldster and tell them to brush their teeth while the caregiver is also holding the tooth brush gently to guide direction. If the oldster is combative, use the behind two person technique where the oldster is sitting in a kitchen chair or wheel chair. One person has his knees on the ground and crosses the oldster’s arms and holds their hands gently but firmly. The other person holds the oldsters head against their chest (this is important to have the head on the chest and not the face, because the oldster will head butt you) and with the other hand brushes their teeth telling continued on next page  nmdental.org