by Shirley Gutkowski, RDH, BSDH
The other day, I was thinking about Walter. He was a patient of mine for three years. Every three months, Walter came in joking about the torture chamber and left thanking me for providing such good treatment. He once even insisted on giving me a tip. He had recently won at the slots in Las Vegas and, feeling good, he slipped me a five. I bought bagels for the office with the money. It has been nearly a year since he has graced my day with his wit and charm.
In general practice, we get to see a variety of people. Patients of all ages — some very young, and some very old — are part of our routine. For the most part, the adult patients are independent. They drive themselves over to the office, accept treatment plans, and pay their own bills. That was Walter too, totally independent. He drove a big Cadillac to all of his appointments, cracked jokes, and paid in cash. Although last time, I think his daughter drove him in her car. She filled out a check and he signed it. I now know that Walter was in the pre-decline state, starting down the slope from independence to a state of dependence.
I came across his chart today during a chart-purging operation. My schedule fell apart when a family of three called to cancel their appointments. Looking at his chart today, I noticed that not only had he missed a whole year of preventive treatment, he was also supposed to have a tooth filled. Looking at the year-old X-ray, decay is evident under a crown on an upper left molar. He missed the appointment to fill it. A quick check of the computer schedule shows that Walter is coming to see the dentist next week; he isn't completely lost.
I wonder what happened to him and why he has been gone for the last year ...
Walter is arriving by van today. It seems that he is now living in one of the long-term care facilities in our city. The attendant helps him out of the van and stabilizes the walker until he's steady. He looks very much older than I remember him. The walker is bobbling but somehow it keeps him from falling. His left leg is dragging and the slipper he is wearing is hanging on by one hook of Velcro.
Once in the reception room, the attendant gives me the envelope containing Walter's medical history, including two pages of medications. It seems that Walter had a stroke and several TIAs since his last visit here. Mystery solved. As he wobbles back to the operatory, he makes a crack about the torture chamber. The tone is mechanical; the humor is gone from his voice, the twinkle in his eye replaced by the dull look of someone on many medications. Walter is complaining of tooth pain on the upper left.
New bitewing X-rays are the first order of business, and a periapical film of the upper left will help the doctor's diagnosis. The films reveal a number of new areas of decay when compared to the films from last year. The tooth that needed a filling a year ago now has decay into the pulp. It's likely this is the tooth bothering him, and an extraction will be necessary. No definitive treatment will take place today. We'll have to check on his medications. His medical team will likely want him to stop the blood thinners he's taking for a time before the tooth can be removed.
A visual inspection of Walter's mouth doesn't surprise us. All the teeth are coated with plaque and materia alba. We can detect some of last night's green vegetable in the embrasures. Walter can no longer take care of his own teeth, and no one else seems to be doing it either. I don't believe that his family knows about the condition of his oral health, or that he has outstanding treatment needs.
Oral care usually falls to the nursing assistants in the nursing homes. For a number of reasons, it slips to the bottom of the list of duties they perform. They have an arduous job. Not only do they take care of these elderly gents at a very personal level, they also must deal with death, depression, and the demands of residents with dementia on a daily basis. All the staff at the facilities run from calamity ... to catastrophe ... to tragedy all day. Even though we know that regularly cleaning his mouth well will decrease some of their burden, oral care for the residents cannot compete with the other tasks.
I doubt they understand oral care is wound care, not just a cosmetic exercise. They probably don't know of the link between gum disease and stroke either. Walter had periodontal disease; that's why he was in my chair so often.
The dental assistant removes the plaque with a toothbrush so the doctor can discern the amount of damage and formulate a treatment plan. The plan will be much different now that Walter is dependent. The dentist will choose extraction over root canal treatment in the short term and the associated tooth replacement options of a partial denture, and then full dentures as part of the long-term plan. Glass ionomer filling material with its high fluoride release, over amalgam or composite resin materials, is another treatment decision. The dentist is in minimalist mode, developing comprehensive treatment plans that will keep Walter out of pain and out of danger for more decay.
The change to decline
I remember that Walter and I worked so hard to keep his teeth. He was so proud that he had more teeth than all of his poker pals did, combined. As dental health care providers, we must consider what will happen to people with teeth as they enter into the stage of dependency. What are we to do with people with teeth? That's the difficult question staring us in the face. Someone other than the owner will be taking care of the dentistry we'll be providing. Depending on overworked CNAs to use a floss threader, for example, is asking a lot. Dental exams should be part of the entry sequence to a long-term care facility so problems, or "watches," can be addressed when the patient can still benefit from minimal restorative treatment.
We can see to it that people who are in a pre-decline state can have preventive treatments that can decrease the chance of decay creeping up on them as they become more dependent. In Walter's case, and so many other cases, a temporary filling placed in the hygiene operatory after the last prophylaxis could have saved him this particular toothache. Using clinical judgment to make use of the Atraumatic Restorative Treatment (ART) technique could have eliminated this complicated treatment plan. A bonded glass ionomer into that upper left tooth before he left on the day it was diagnosed would possibly have saved some of the discomfort he is in today. It may have also allowed him to keep that tooth instead of having it removed under such a complicated medical condition.
A pre-admission dental exam would have alerted the family that dental needs were still necessary. Another tooth could have taken up the charge and caused problems first, of course. Unless we have the crystal ball upgrade, there is no way to know which tooth will act up first.
Three critical items in the armamentarium for pre-decline elderly are fluoride varnish, xylitol, and glass ionomers. When used in the office, the glass ionomers can be excellent barriers to sensitivity, erosion and decay. The material won't last 20 years. Longevity has a different scale when working with the adult dependent population.
Fluoride varnish is an important adjunct. It is still noticeable months after initial placement if it is not removed purposefully with a brush or by the mechanics of eating. This coating acts with the calcium and phosphorus in saliva to make the teeth less susceptible to acids. It will supercharge accumulated plaque with fluoride to help tooth surface remineralize as fast as it de-mineralizes.
Glass ionomers have the added benefit of releasing fluoride for long periods without the chance of becoming dislodged by simple brushing. One brand is intended to be used in a thin layer of real protection on the particularly susceptible areas of the teeth of people who have difficulty removing plaque, namely children and dependent adults.
Four grams of xylitol throughout the day in the form of chewing gum or lozenges has enormous potential for decreasing decay. Recently, a Finnish study reported that among all the benefits of xylitol regarding dental disease, it also is helpful in decreasing bone loss in those afflicted with osteoporosis. The dosage is quite a bit higher than four grams for this benefit. All these things — xylitol, fluoride varnish, and glass ionomer surface protectants — should be in the protocol for patients in the dental hygiene schedule who are in pre-decline or dependent.
Walter could have benefited from all of these therapies during his quarterly visits. To date, there are not many protocols available to us to deal with the elderly in private practice. Something has to change. We have materials today that, if used judiciously, can prevent some of these problems with decay. Until the facilities make it a practice to include an oral exam, or at least contact the dentist of record as part of their intake process, dentistry and dental hygiene will have to increase their level of preventive actions in people such as Walter who suddenly arrive for their appointments in the care of another. There's no way to know if a person at any age will suffer a debilitating illness or event. Walter could just as easily have been in an automobile accident at the age of 32 and put into this state of disrepair.
Who's going to take care of the teeth we save, or restorations we place? That question alone is the one we should keep in the back of our minds when considering treatment plans of those who appear to be entering a state of dependence. The clues about Walter were everywhere. Suddenly, he had someone to drive him and fill out a check for him. The doctor and I should have had the insight to know something was up with his mind or his health — we should have treatment planned differently. Stepping out from between the lips and looking at Walter's life would have alerted us to the possibility of this situation.
The doctor and I have learned a lot today. We'll be more aware when our elderly patients come in. We'll be more ready to talk about power brushes, surface protectant glass ionomers, fluoride varnishes, and temporary fillings of glass ionomers at the time of diagnosis.
On Walter's papers, I will write a note to the nurse and the doctor to make sure that Walter has his teeth brushed. The dentist will prescribe Lozi-Flur once per day to help increase the fluoride — delivering the low-dose, long-duration fluoride supported by the literature. He also wrote in the notes that a xylitol gum should be chewed for five minutes, four times per day. The doctor and I know from previous experiences that nursing assistants will gladly give gum over brushing a resident's teeth, and we know that studies show that xylitol gum in these circumstances can be as effective in decreasing decay as increased brushing in these dependent groups.
Walter will make an appointment for the tooth extraction on his way out. The driver will take him back to his new home and the dentist will discuss the treatment plan with Walter's physician. I'm lucky to work with a dentist who is so diligent about his patients. It took me a long time to find someone who practiced dentistry in a way that allowed me to practice dental hygiene my way.
Shirley Gutkowski, RDH, BSDH, has been a practicing dental hygienist since 1986. She is a popular speaker and award-winning author. Gutkowski and Amy Nieves, RDH, are the co-authors of "The Purple Guide: Developing Your Dental Hygiene Career," a handbook for graduates from dental hygiene school (www.rdhpurpleguide.com). Gutkowski can be contacted at dentwrite@ aol.com.