Training Dentists to Manage Patients who have Complex Medical Needs Lesley Longman.

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

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

Personal Overview

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?

Domiciliary Care Domain of Salaried services? Residential homes and nursing homes GDPs?

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

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

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

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.

Who should be referred to Specialists?

Patients who have complex medical needs Significant cognitive impairment............co-morbidities? LDs, brain injury, dementia, profound LDs and physical disabilities

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)

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

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

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

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

Dementia Patient with Significant Medical Conditions Referred with retained roots and caries Query regarding oral pain Risk assessment exercise

Supervised neglect ?

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

ASA CLASSIFICATION IFit & well II Mild systemic disease IIISevere systemic disease - limits activity - not incapacitating IVSevere life threatening systemic disease - incapacitating VMoribund

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

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

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

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

Education issues around oral health for all stakeholders Carers GMPs Medical Specialists, Consultants in Public Health Support agencies

Dental Team: Student Training is Pivotal

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

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

Cosmetic and Complex Treatments

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

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!!!

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

Develop skills/qualities Disability Awareness Identify & negotiate barriers Flexibility Innovation Cross-specialty and inter-agency working Safeguarding vulnerable adults Clinical holding Risk Management

SCiPE Task Force

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

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

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

Referral Pathways: Clinic for immunocompromised pts New patients

Referral pathways Sedation for anxious/phobic patients

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

Acceptance criteria for sedation at LUDH 2011 Extractions - u/grad training limited N o disruptive gag reflex, restorative Trauma/arthritis TMJ with limited opening

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.

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

Anaesthetic Assistant

Difficult But worth continued effort Not got it right yet

Sheila: 43 year old:-MS food via PEG

Self harm

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

Dental Need 75% of patients with Alzheimers disease need dental attention

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?

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

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

Treatment modifications Pain and anxiety control Communication

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

Miscellaneous group - SCD recreational drug users recreational drug users

Impaired mobility Poor cooperation Short appointments More frequent recalls

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

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)

Education : Postgraduate Primary care is pivotal Responsible restorative care Informed consent, patient information Prevention Referral pathways

Medically compromised patient

Administration of midazolam via a PEG

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.

Who needs sedation? n anxious/phobic n disruptive gag reflex n Limited cooperation n movement disorders medical conditions exacerbated by stress

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

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.

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

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

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

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.

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.

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

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

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).

Access to care Physical Skill mix Management possibilites

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

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

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

Training Dentists to Manage Patients who have Complex Medical Needs Lesley Longman.

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Transcript of Training Dentists to Manage Patients who have Complex Medical Needs Lesley Longman.