Patients who need additional support
Management of patients who need additional support
Patients who may need additional support include those with additional care needs (i.e. adults aged 16-64 who require support with daily oral care as a result of a physical, cognitive, medical or mental health condition) and frail and/or dependent older people.
Patients with additional care needs can face many barriers to good oral health. They may be more susceptible to disease development or face challenges with access to treatment, the provision of treatment and long term maintenance. Management can also be challenging as a result of specific medical or behavioural issues, which may affect their ability to cope with dental treatment or which make dental treatment more difficult. In addition, these patients may depend on support from carers to maintain their oral health.
The main issues related to periodontal care in patients with additional care needs are maintenance of oral hygiene and access to PMPR. Open Wide is NHS Scotland’s oral health improvement programme for adults with additional care needs and provides further information to support oral hygiene for these individuals.
Ongoing and long-term maintenance care inevitably involves caring for patients as they age. Patients can develop new co-morbidities and may also lose some of the manual and cognitive skills needed to maintain their dentition. A healthy, comfortable, and aesthetic mouth and dentition is needed to support adequate nutrition, general health and well-being in older patients. The Public Health Scotland publication Caring for Smiles provides greater detail on how to support the oral hygiene of dependent older people.
The main issues related to periodontal care in older patients are maintenance of oral hygiene, access to PMPR and the management of tooth loss. The wider management of tooth loss is beyond the scope of this guidance. However dentures, bridges and implants can be successfully provided for older adults and improve not only their oral function but also their nutritional levels and sense of well-being.
Oral hygiene measures may deteriorate in older age because of loss of manual skill, a change in levels of cognition or dependence on a carer for oral care. Patients with additional care needs can also find it difficult to perform effective oral hygiene and may rely on others for help with self-care. Measures which address these factors include:
- adaptation of existing oral hygiene aids (e.g. alterations to handles of toothbrushes to make them easier to hold);
- using different tools to clean teeth (e.g. electric toothbrushes rather than manual);
- supporting carers to learn the skills necessary to clean someone else’s teeth and mouth.
In addition, the use of high fluoride toothpaste can be considered to help prevent the development of caries. Toothpastes which are free of foaming agents and flavours may be useful for those with sensitive oral mucosa or who dislike strong flavours and those with swallowing difficulties or who are at risk of aspiration.
Detailed advice regarding care of older people, particularly those living in care homes, is available at Caring for Smiles.
Advice regarding care of adults with additional care needs is available at Open Wide.
For patients where oral hygiene is difficult, significant calculus deposits may build up and will need to be removed. PMPR can be challenging to deliver in some cases due to difficulties in accessing the dental surgery, patients being unable to sit or lie back in a dental chair for treatment, limited mouth opening or limited ability to cope with treatment. While recognising these limitations, it is important to attempt to provide treatment where possible that aims to remove calculus and plaque biofilm to support dental health.
Adaptations which may be helpful include providing domiciliary care, treating patients sitting up in the dental chair, using hand instruments rather than powered scalers and allowing time for the patient to rest intermittently during care. In some situations, it may be necessary to consider referral to assess whether sedation or general anaesthetic is indicated to allow delivery of more complex care or where the patient is not able to cooperate.
For patients who need additional support:
Provide long term maintenance care that focuses on maintaining a healthy, intact periodontium to support oral comfort, function, health and aesthetics.
- Note that adaptations may be required to oral hygiene practices to enable the patient or carer to maintain oral hygiene at as high a standard as possible (e.g. alterations to brush handles, powered toothbrushes).
If the patient’s oral care is provided by a carer, encourage and support them to learn the skills required to clean the patient’s teeth (see Caring for Smiles and Open Wide).
Carry out supra- and subgingival PMPR, where required and possible, using an appropriate method.
- Note that adaptations in delivery may be required (e.g. using hand instruments rather than powered scalers; providing treatment while the patient is sitting up).