Elderly Risk for Rapid Oral Health Deterioration: The ROHD Concept

Elderly Risk for Rapid Oral Health Deterioration: The ROHD Concept

Oral Health America Webinar Series O c t o b e r 11 , 2 0 1 8

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2018

CE Credit Available

2018

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Leonardo Marchini, DDS, MSD, PhD Geriatric Dentist and Prosthodontics Assistant Professor, Department of Preventive & Community Dentistry

2018

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Elderly Risk for Rapid Oral Health Deterioration: The ROHD Concept Leonardo Marchini, DDS, MSD, PhD 11

Why is it important to assess ROHD among elderly patients?

Most people are keeping their teeth for life. However, when they get older the combination of general health conditions and lack of adequate social support and/or a catastrophic event can lead them to ROHD. Many times, a dentist can perceive this risk during regular recalls (or lack thereof) and act preventively, avoiding severe irreversible consequences of ROHD. 12

ROHD risk factors (based on evidence) 1. General health conditions;

2. Social support; 3. Oral conditions.

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1. General health conditions -Cognitive deficit Alzheimer’s, other dementias

-Functional deficits Stroke, osteoarthritis, Parkinson’s, etc.

-Sensory loss Speech, sight, hearing, taste -Medication

Oral and systemic side effects, drug interactions 14

1. General health conditions -Manageable chronic diseases Hypertension, diabetes, osteoporosis, etc.

-Degree of dependence/autonomy Institutionalization, home care, dependence on caregivers, etc.

-Terminal diseases/palliative care -Life expectancy

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2. Social support

Expectations Family

Elderly patient

-Institutional support -Family/social support

Friends

-Financial issues

Institution

Finances

Health insurance, social security, etc.

-Expectations 16

3. Oral conditions -Oral hygiene -Periodontal condition

-Number of teeth/restorations -Prosthetic status Fixed, removable, implants -Oral lesions Inflammation, oral cancer

-Stop seeing the dentist 17

2 1 Dependent

3 1

4

Risk factors ✓General health conditions ✓Social support ✓Oral conditions

2 3

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How to analyze the risk?

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✓ Do we have (all) the data? ✓ What data are important? ✓ What will happen if we do nothing? ✓ What is the patient’s risk for oral condition deterioration?

✓ What are the treatment alternatives?

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Do we have (all) the data?

1. Practitioner decides on type of information to be used in ROHD risk assessment (completed before patient encounter) 2. Gather data/information with evidence of risk factors

that contribute to ROHD (risk factors based on evidence)

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What data are important?

Trick question!

Identify what of the data/information gathered is likely to be of significance for ROHD

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What will happen if we do nothing?

What is the foreseeable disease progression if no intervention takes place?

Is no intervention in line with the patient’s best interest?

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What is the patient risk for oral condition deterioration?

Risk factors for ROHD have not presented Patient is at risk for ROHD, not currently experiencing ROHD

Patient is currently experiencing ROHD

ROHD has happened – What risk factors led to ROHD?

2

1

3 4 24

What treatment alternatives can be done?

1. Identify possible interventions 2. Evaluate possible outcomes with and without different types of intervention (conservative/ preventive or extensive/invasive) 3. For each intervention, identify/offer evidence and rationale; recommend specific interventions 4. Develop a communications plan for the patient and/or caregivers 25

Assessing patients’ risk for ROHD ✓ ✓

What are the data?

What data is the most important/influential in regards to the treatment plan?

✓

What will happen if we do nothing?

✓

What is the patient’s risk for oral condition deterioration?

✓

What are the treatment alternatives?

1. Risk factors for ROHD have not presented.

2. Risk factors are presenting for ROHD

3. Beginning ROHD with immediate risk for further ROHD 4. ROHD has happened – What risk factors led to ROHD?

2

1

3 4 26

Self assess Do I have any bias during my ROHD risk analysis?

Did I miss any important data?

Was my communication plan effective?

What is the chance of preventing ROHD in this case?

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Case 1 Patient demographic and social information

✓ 92 year old female

✓ Has moderate to severe dementia ✓ Presents in wheel chair, speech is mostly incomprehensible and patient

has limited understanding of what is being said to her.

Dr. Montano, Class of 2017 29

Case 1 Health history

✓ Stable congestive heart failure ✓ History of Osteoporosis with Thoracic compressive stress fractures ✓ Chronic respiratory failure with hypoxia

✓ Hypernatremia (excess sodium in blood) ✓ History of hip fracture with reduction April 2010 ✓ Cataract surgery ✓ Penicillin allergy

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Case 1 Medications Drug

Indication

Oral side effects

Docusate

Constipation

No oral side effects

Fentanyl

Pain

Xerostomia

Furosemide

Congestive heart failure

Xerostomia

Gabapentin

Epilepsy, Seizures, Neuralgia Off-label: Insomnia

No oral side effects

Levothyroxine

Hypothyroidism

No oral side effects

Lorazepam

Insomnia

Xerostomia

Morphine

Pain

No oral side effects

Ropinirole HCL

Restless legs syndrome; extrapyramidal symptoms

No oral side effects

Acetaminophen

Pain

No oral side effects

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Case 1 Oral health findings

?

?

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Radiographs from 2015

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Case 1 Which other health team members should be involved?

Health care team member Primary Care Provider What is the severity for each health conditions and what are the priorities for care (which one can kill them first?)

Pharmacy What patient problems are drug related ?

Nursing What is patient capacity to subscribe to treatment recommendations?

Other dentist or DH Nutritionist What nutritional factors are contributing to disease/condition?

Physical therapist/Occupational therapist What are the long-term outcomes for therapy programs?

Social worker What are barriers/solutions to follow through based on the home situation ? Who is the PoA? Family caregiver Who are the people responsible for the patient’s activities of daily living on a day to day basis?

Translator/interpreter

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Case 1 Do we have all the data? ✓ Patient has been seen by the GMU rotation students since April of 2011 ✓ Patient was on hospice care at last visit in October of 2015. Treatment planned at that time was not completed as patient was not expected to live more than 6 months ✓ #14 DB was treated with Glass ionomer cement, all other lesions were planned to be treated with silver diamine fluoride. ✓ Patient was seen February 2017. No longer on hospice care. ✓ ✓ ✓ ✓

How have oral hygiene routines been done?

Is the Pt able to express pain/discomfort?

Family expectations?

Insurance?

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Oral pain is usually reported by the patient. However, older patients with dementia and other conditions affecting their cognition are often unable to communicate their symptoms.

Non-verbal signs of oral pain that should be considered include the following:

✓ Neglecting to eat

✓ Disinterested in food

✓ Avoiding oral hygiene

✓ Chewing of the lip, tongue or hands

✓ Noisy breathing

✓ Pulling at the face or mouth

✓ Negative vocalization

✓ Not wearing dentures

✓ Tense body language

✓ Grinding of teeth or dentures

✓ Protection of sore areas

✓ Aggression

✓ Distressed facial expressions

✓ Alteration in activity level

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Case 1 What data is more relevant for ROHD and treatment planning?

✓ Patient has moderate to severe dementia and inability to maintain own oral hygiene; Nurses do not brush patient’s teeth ✓ Patient’s POA (son) lives in Davenport, doesn’t visit his mother regularly; so he’s not around to help mother brush her teeth.

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Case 1 What will happen if we do nothing?

✓ Patient could potentially get an acute infection from the retained root tips.

✓ Teeth with existing caries could fracture, leaving patient with fewer teeth to chew, decreasing quality of life if loss impairs ability to eat.

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Aspiration pneumonia

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Beikler & Flemmig, 2011 Periodontology 2000, 55: 87-103 42

Case 1 What is the patient’s risk for rapid oral health deterioration?

1. Risk factors for ROHD have not presented.

2. Risk factors XYZ are presenting for ROHD 3. Beginning ROHD with immediate risk for further ROHD 4. ROHD has happened – What risk factors led to ROHD?

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Case 1

What treatment alternatives can be done?

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Case 1 What treatment alternatives can be done?

Option 1 Extract all retained root tips.

Excavate carious lesions; restore with appropriate glass ionomer.

Prophy, topical fluoride, exit exam.

Maintenance: Prevident, Caregivers OHI, Fluoride varnish, recalls.

Option 2 Leave/monitor retained root tips, silver diamine fluoride placement on retained root tips to prevent caries Excavate carious lesions; restore with appropriate glass ionomer Prophy, topical fluoride, exit exam.

Maintenance: Prevident, Caregivers OHI, Fluoride varnish, recalls.

Option 3 No treatment 45

Case 1

What treatment would you pick? Why?

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Case 1 Treatment of choice Option 1

Extract all retained root tips.

Excavate carious lesions; restore with appropriate glass ionomer.

Adult Prophy, topical fluoride, exit exam

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Case 1 How would you communicate the treatment and maintenance to the

caregivers?

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Case 1 Communication plan for patient or caregiver regarding the proposed treatment and maintenance care

✓ Explaining Tx and gaining consent from PoA

✓ Post-surgery instructions for NH staff ✓ Post-operative instructions for NH staff

✓ Maintenance plan for NH staff – How to gain their support?

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Case 1 Self-assessment

✓ Communication ✓ Prevention ✓ Invasive x Conservative

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Acknowledgements ✓ Dean Johnsen for ROHD conceptualization

✓ Dr. Cowen for continuing support on its implementation

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Thank you for your attention! leonardo-marchini@uiowa.edu 53

Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes.

• Write your questions in your control panel on the upper right hand of your screen.

• Submit questions at any time.

2018

CE Credit Available

2018

Contact Information

• •

Dr. Leonardo Marchini • leonardo-marchini@uiowa.edu David Martin • David.Martin@oha-chi.org

2018

THANK YOU! Let’s improve the oral and overall health of all Americans together.

2018