Mary

by Cindy Kleiman, CDA, RDH, BS

Can it really be 25 years ago that I treated my first traumatic brain injury (TBI) patient? I remember his name and his face so well. I remember how nervous and scared I was to see him. The nurses brought Richard into the dental department at the rehabilitation hospital, and I assisted the dentist in treating him on his bed.

Here it is years later, and I am waiting for a couple to bring in their daughter, Mary, for me to see. Mary became a TBI patient in a car accident several months ago. Again, I feel a little nervous about seeing her, as these brain injuries are the most challenging patients I've treated over the years. Treating a TBI patient is difficult physically, and even more so emotionally. Yet these patients have brought me the greatest reward and satisfaction of my career.

I never had an interest in treating TBI patients, but 25 years ago I accepted a job doing just that. I was also asked to treat those who had a stroke or spinal cord injury. I was truly blessed to have two wonderful dentists who mentored me and had the patience for me to absorb the skills it takes to treat someone like Richard or Mary, who will be arriving shortly.

Of the two million cases of TBI per year, motor vehicle accidents comprise by far the largest number. TBI results from the rapid deceleration of the brain. Injuries include shearing (tearing) of the nerve fibers, contusion (bruising) of the brain tissue from crashing against the skull, brain stem injuries, and edema. I'm in an unusual situation, as I only treat these patients post-injury; I never knew them as they were. This is much easier than it is for those hygienists who knew them pre-injury. Knowing what they lost is the hard part. TBI often destroys the human being they once were and, in turn, breaks your heart.

As the 24-year-old Mary arrives in my office, I only know her as the shell of a woman she is today. Even with months of care in both a regular and a rehabilitation hospital, Mary is still in the prolonged period of unconsciousness called a coma. Medical dictionaries describe unconsciousness as a lack of reaction to stimuli. Unlike sleep, someone in a coma cannot be aroused. In her comatose state, Mary may exhibit movement, make sounds, and experience some agitation.

The progress of coma is measured by the patient's increasing awareness of external stimuli. There are many levels of coma that the patient will pass through as functionality increases. Mary, like all others, was given the Glasgow Coma scale test. It is a standardized system used to assess the degree of brain impairment and to identify the seriousness of injury and its correlation to outcome. In time, you hope the patient heals to a higher and higher level until they are no longer in a coma.

Many people think that seeing someone in a coma must be like in the movies — in bed and unable to move. Mary is not like that. She is brought to see me in a high-back wheelchair with her head supported by a headrest. She is catheterized, with her urine running down a long tube into a bag attached to her leg. She has another tube called a gastrostomy. This provides a way for Mary to be fed directly into her stomach. Mary's parents deliver liquid nourishment directly through this tube. Mary also has dysphagia, a condition that I learned about while treating my very first TBI patient, Richard.

Dysphagia is a swallowing disorder. It is characterized by difficulty in oral preparation for the swallow, or in moving material from the mouth to the stomach. This also includes problems in positioning food in the mouth.

Dysphagia has many implications for my treatment of Mary, because if she has swallowing problems and can't eat orally, she is also at very high risk for aspirating prophy paste, water, or bits of calculus. When fluid or debris enters the lungs through the trachea, it can cause a lung infection or pneumonia. Thus, ultrasonic cleaning or use of an air/water syringe is never an option for patient care.

I quickly bring Mary and her parents into my operatory so we can begin reviewing her medical history. I want to spare her parents from seeing the looks their daughter will receive in a reception area. I'm sure they have seen the looks before. The others in the reception room don't mean to be rude, I'm sure. I want to minimize the discomfort for everyone.

As with most TBI patients, Mary is on an anticonvulsive. Luckily, it is not Dilantin. Antispasmodic medications, as well as many other drugs, are commonly used for patients in comas. Due to the increased use of medications, oral complications such as xerostomia need to be evaluated. Once we're situated in the treatment room, the parents share with me that Mary was driving her car without wearing a seat belt and crashed through the windshield. The sadness on their faces is the same sadness I've seen for many years. It still makes me feel deeply sympathetic.

Her parents are very concerned about Mary's oral hygiene, as it failed to get much attention in the hospital or rehab center. The lack of good oral hygiene care in medical facilities is something to which I've never become accustomed. I will continue to educate the nursing field on this deficiency in the total care of their patients. Teaching nurses is a positive response to my agitation. They don't know what hygienists know. They're amazed by what I convey to them about oral care of their patients.

I begin to explain to Mary's parents the oral complications of someone in a coma. As Mary had excellent oral hygiene prior to her accident and minimal caries history, I assure them that the risk of increased decay is minimal. In the absence of oral food intake, caries is one problem with which caregivers are not burdened. It has been noted in articles that reduced oral feeding minimizes the amount of fermentable carbohydrates in the mouth. Therefore, it would be expected that the caries rate would be decreased. It has also been noted that the amount of food that typically enters the mouths of tube-fed (TF) patients is inadequate to support an acidogenic plaque. If, in the future, Mary is able to eat orally, caries could again become a concern.

The main issue I need to deal with is the large amount of calculus build-up, including on the occlusal surfaces. Few articles have been written on treatment of this type of patient, but those that have been written all mention an excessive amount of calculus, even when studies included increased oral hygiene. This increase of calculus occurs even with the decrease of plaque scores. I have seen this for many years and have hypothesized that it may be due to the lack of swallowing, mastication, and talking. The mouth in these patients gets very little movement.

In addition, I've noticed that these mouths smell different than those of other patients. Just like the hygienist in a grocery store line can smell a patient with bad periodontal disease, I can smell if the patient is tube-fed before I see it written on a medical history. It smells different from other conditions. One must remember that Mary has not had a drink of water for months. It has been noted that decreased salivary flow predisposes the patient to an overgrowth of bacteria in the saliva. This decrease in saliva allows anaerobic pathogens to thrive in the oral cavity, which can put a patient at risk for aspiration pneumonia. Excellent and consistent oral hygiene can greatly decrease this risk.

As I begin to examine Mary's mouth, the treatment room is full. Both parents as well as a dental assistant are with Mary and me. I never work alone in this situation. No one knows Mary as well as her parents, and I need their help in understanding the meaning of sounds she may make. I keep Mary in her chair, positioning it in relation to the dental chair as to allow my best access. I pull the operatory light over to illuminate the work area as best I can. I work in a standing position. I want to be sure that I have Mary's head in the most comfortable position for her, as well as the best position to prevent aspiration. This means moving her as little as possible. I am the one doing the most adjustment of position.

Mary's oral condition is very common to this type of patient. Once I look past the calculus bridge, I immediately observe her heavily coated tongue, which I assume is from lack of eating, speaking, or other oral activity. Teaching the family to use a tongue cleaner will solve this problem. In fact, this task is easy in the TBI population, as they do not have a gag reflex.

I am pleased to see how good the gingival tissue looks and can tell that her parents and attendant are truly trying to provide the best care for her. Being on Tegratol rather than Dilantin is a help as well, as the tissue doesn't become overgrown with Tegratol as it does with Dilantin. Calculus is another story. It covers the lingual, buccal, and occlusal surfaces. My challenge awaits me.

Prior to scaling, I instruct her parents how they can personally perform the best possible care for their daughter. Even though she has excessive calculus, I do not recommend a tartar control toothpaste due to the foaming ingredient, sodium laurel sulfate. More foam makes it harder to prevent aspiration. I think a safer choice is using a non-foaming toothpaste, such as the Biotene brand. I find it much easier to ensure all of the paste is out of the mouth when I am not dealing with the foaming action. In addition, I feel the product is safer to use should some be swallowed. Biotene's enzymes should help to correct some of the bacterial imbalances in a tube-fed mouth. In addition, it is designed for the patient with xerostomia. Regardless of the patient's salivary flow, I use it in these patients due to its non-foaming property.

I soon learn Mary doesn't like me in her mouth, so oral hygiene needs to be done quickly and easily. For brushing, I ask the parents to use a Remedent toothbrush (www.remedent.com). This product allows the caregiver to brush the buccal and lingual surfaces at the same time, with the occlusal surfaces being done afterwards with the opposite end of the brush. The bristles are soft and angled gingivally. Even with a very little patient opening, I can get all surfaces brushed with a minimum of time and without upsetting Mary.

I've learned that to get attendants or family motivated to provide good oral hygiene care, I must make it as easy as possible. A TBI, TF patient requires an enormous amount of care, so if the techniques are as easy and effective as possible, the follow-through will be much better. Flossing or other interdental cleaning must also be modified, with us trying out various products to see what would work best. We find that using the Glide Floss Pik works well, but I don't insist on it being used daily. Three to four times per week is an attainable goal. We talk about Mary's malodor and how to improve it. Again, due to its safety, I suggest using Biotene Mouthwash swabbed on with a slightly dampened toothette, the only time to employ this overused little gadget. Since Biotene is alcohol-free, it won't further dry the oral tissues, and even if a small amount does go down, Mary will be just fine. This product can be used on any compromised patient as often as one would like.

With Mary's new oral hygiene schedule reviewed, it is now time to go to work. We have a two-hour appointment scheduled, but I will only work as long as the parents feel Mary is handling the procedures well. They can tell better than I can. I explain that I will do the best job I can, but I cannot be perfect. After doing this for so many years, I am comfortable that doing the best job under the circumstances is good enough. Mary does not open for me, so we use a prop. Mary will not turn her head the way I need it to be, she is not seated in a dental chair, nor can I use an ultrasonic or the air/water syringe. It took me a long time to realize it is OK not to be perfect.

With the assistant helping me, I begin to scale off the calculus. I try to slice the deposits off. It's almost like taking a thin slice of Swiss cheese off of a chunk. I am lowering the risk of large deposits being aspirated. This is done with excellent suction and a mouth prop in place. I will only use a universal curette and a sickle. I've never seen an instrument designed for the occlusal surfaces, so I have found the sickle works the best. My positioning is horrible, as I have to bend in every direction that Mary cannot. I can only see one TBI patient a day to protect myself from bodily injury. My assistant and I work slowly and steadily, being very careful that all deposits and blood are evacuated away. I need to make the most of each moment while I am working. I am also aware that TBI can lead to oral hypersensitivity, so I work as gently as I possibly can.

With my patient tired, and my back and neck fading as well, we call it a day. No, Mary's teeth are not perfectly clean, but by the parents' reaction you would have thought they were. Mary will be back to see me in six to eight weeks. That is important to control the large quantities of calculus she will accumulate. Treating Mary in the operating room would be much more productive and easier, but most families prefer not to have their loved ones in an OR that often.

I feel that by working with both an assistant and a motivated family, I've reached my goal. I've successfully reduced some of the pathogenic bacterial load and eliminated some calculus. Just as importantly, I've given the family some tools to work with. I've communicated everything I was doing directly to Mary and only spoke kindly to her as we were working. Anything that I did not want her to hear, I discussed outside of the operatory.

The degree to which this type of patient hears and understands is unknown, so I always speak to her as if she understands everything. Most importantly, I always remember that she is not just a tube-fed, TBI patient. She is these parents' little girl, and many hopes and prayers are on her. The family has gone — I gave of my energy, my concern and my time. I've done this now for 25 years, and just as my very first patient, Richard, left me drained, so am I again today. However, I am now older and my back hurts more and my neck aches longer, but I would never have it any other way.