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Treating a patient with dementia

I have a patient that is in her mid 50s in desperate need for SRP’s. She has advance stages of dementia. Her homecare is very poor due to her caregivers in ability to get the patient to cooperate with brushing/flossing. She has heavy plaque and sub calculus. I will be treating her LR quad this coming week but am concerned with administering local anesthetic due to her not understanding post op instructions with not biting her tongue etc. She needs the tx but is difficult to work with during tx because she does not understand why she is at the dentist. What are any suggestions with local anesthetic and how to help the patient understand what tx I will be performing. Thanks in advance for any suggestions.



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11 Answers

Deciding on treatment for patients with dementia and other end of life diseases can be difficult. I believe it is about balancing their need for the treatment and their quality of life. If treating them will traumatize them and cause more harm, then palliative treatment might be best. My dad had dementia and many things could “set him off” and cause a major disruption in his daily life. We, his loved ones and caregivers, decided that unless he was in pain, we would do just the most minimal treatment.
For your patient, talk with her loved ones, offer other treatment options. Maybe a prophy with very thorough OHI for her caregivers. Check mobilities to ensure that there aren’t any teeth that are hindering her eating. If her caregivers are able to keep her teeth relatively plaque and food debris free, and she is able to eat without pain, this may be what is best for her.
I work with patients with Alzheimer’s and other related dementia’s and have found that it is always best to look at their situation before considering what treatment is necessitated.
I hope this helps. 🙂

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Almost always, caregivers have Power of Attorneys that allow you to discuss the patients care with them.
I am going to stress, until you have seen the effects of trauma on a patient with dementia, it is difficult to understand how it can impact their life. We have this idea that since people have dementia, they will not recall the trauma…not true, it can be very disruptive and harmful.
When we talk about doing invasive treatments, SRP, it can be very traumatic to someone with dementia. To be frank, their life expectancy is greatly shortened, their home care is poor or non-existent, the important thing is, they are comfortable and are able to eat. Ask yourself how someone in this phase of life will benefit from 4 quads of SRP with anesthetic. If the answers to this do no outweigh the negative effects on the patient, I personally wouldn’t do it.

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One more thing, and I apologize for being so insistent and rather bossy about all of this but, I have a lot of personal experience with this so am able to see it from both the side of the dental professional and the loved one.
Most short acting anesthetics do not have a vaso-constrictor. This means the percentage of actual anesthetic is higher and the amount we can safely use is cut almost in half. It can be harmful on the heart, liver and kidneys, especially on our patients with compromised health.

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If hygiene is extremely poor I think advanced treatments are contraindicated…without homecare and follow-thru your desired results are bleak. ..perhaps prophy’s every 3 months is a better option for someone non-compliant without understanding

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This is such a difficult situation for both patient and clinician. Depending on pocket depths you are dealing with, you could try a shorter acting anesthetic or try tac-gel to get you through tougher areas. You definitely need to allow extra time or you could try shorter appts and do sextants instead of quads. Good luck!

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Wow this one is really tricky. I would discuss all post operative instructions and treatment with a care giver or the person that brings her to the office. Im not sure if thats okay by hippa standards but in this situation the patient needs another care provider to assist her due to her dementia. I personally feel that we should do everything needed for our patients health and possible getting approval for treatment from whomever has the legal authority would be a good place to start discussing srp. I also agree with Lrskda that a shorter anesthetic would be most ideal as well.

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I have a patient with advanced Alzheimer’s and the spouse brushes and flosses the patients teeth three to four times daily. This patient is on 3 month cc intervals. The past few months there has been great decline and the patient does not remember how to open and will bite the spouses fingers very hard. We have to use bite blocks and move the blocks around so that we can try to clean the teeth. I do know the patient has a sedative cream applied to her neck and chest an hour before the dental appt. it used to help, but at this stage the spouse is lucky to just be able to rinse the patients mouth. The spouse doesn’t give up. I don’t think you should put your patient through the stress of S/RP. Maybe use Oraqix and bite blocks and do the best you can to keep her pain free and able to eat.

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A patient with advanced dementia should not be put through the trauma of S/RP!! The risks outway the benefits in this situation. You must only do what the patient can tolerate and no more. A patient suffering from this awful disease and their caregivers have much more important things to worry about. S/RP would not do much good if the patient can’t follow it up with good homecare anyway.

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I personally would only prophy her, she cannot get the homecare she needs now and SRP could upset her/ set her off or at least make it difficult to eat for a few days.. look at eh long term..what benefit is there in doing SRP if homecare is not followed through by her caretakers. Save her the experience.

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I agree with the other answers. If she is not in pain maybe palliative care is best. I wouldn’t want to risk traumatizing het since she doesn’t understand why she is even there. Chances are due to the poor home care SRP may not do alot for her anyway. Maybe try one quad with oraquix or similar product if your office has it and see how she does with it. If she does well then schedule the other quads and go over home care with the caregiver and hope for the best. And put her on a frequent recare (I have some patients that come every 2 months). If she doesn’t tolerate it well then stop and maybe reschedule for another day and just do what she can tolerate. Sounds like a difficult case. Good luck!

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I saw my first 90 year old dementia patient at school just the other day. They had bad perio and no home care. The patient was comfortable with the setting and was use to dental appointments through out his life. The patient need two quads of NSPT but I gave minimal treatment as not to traumatize them. I use to work as a CNA with dementia patients and have to say that was the hardest job I ever did. To treat or not to treat is a hard decision to make. You want to provide the best service for your patients that you possible can which includes their mental well being.

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