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How do you manage a severely disabled and G tube-fed patient?

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This question was submitted by a general dentist:

Is there a resource with current information on appropriate oral care for severely disabled and G tube-fed population? There are many position papers and guidelines indicating that this population needs care. However, I found only limited information on the actual clinical treatment provided to them and on what the treatment goals should be. These patients often present with gross calculus, limited cooperative ability for professional cleaning, and present with the risk of an aspiration pneumonia.

Any attempt to clean the teeth in the office is limited at best, then the question is: what is the value to the patient, if calculus is not completely removed? Also, would the use of a cavitron not aerosolize the bacteria that may be responsible for pneumonia and increase the risk of pneumonia?

At what point should one consider G.A for these patients in the absence of any sign of acute infection or pain? The risks of utilizing general anesthesia for these patients is often quite high, not to mention the cost of this morality.

A video of this work being performed in office and with general anesthesia would be a very helpful resource.  

 

Dr. Michael Sigal, from the Faculty of Dentistry at the University of Toronto, provided this initial rapid response: 

There are no evidence-based published guidelines or videos on this that I am aware of.

The Objective is to remove all the calculus/plaque and debris to reduce the oral inflammatory load that can lead to both local problems, such as gingivitis, periodontitis and systemic problems i.e. aspirated calculus with stagnant long standing > 1 week plaque has more gram negatives which can lead to more pneumonia, fresh plaque daily, if aspirated does not seem to be a problem i.e. does not lead to pneumonia.

Current research at the Mount Sinai Hospital and papers recently submitted for publication to the peer-reviewed journal of Special Care in Dentistry indicate that after a thorough cleaning that oral inflammation was reduced for at least 3 – 6 months as re-measured at recall. This means that we have solid evidence that our preventive care is reducing oral inflammation.

We do such cleanings on uncooperative individuals who are dysphagic with G tubes etc. in our ambulatory clinic with protective stabilization, multiple suctions, at least 3 operators and Ultrasonic scaler in an upright or semi- upright position. I have found over the years that cleaning in the ambulatory clinic and paying attention to the breathing and swallowing patterns of the patient was safer and less traumatic than a GA. I have had more complications under GA, such as delayed recovery, post-op in recovery aspiration leading to admission with pneumonia, cardiac arrest, etc… We have not had any cases of pneumonia post ultrasonic cleaning in our clinic with multiple suctions going; however, we have had this after GA.

This is the training our Mount Sinai Hospital dental residents and University of Toronto Pediatric Dentistry Specialty graduate students receive in their programs.

Our standard for extensive calculus builders is the 3 month recall cleaning, plus the use of a tartar fighting toothpaste on a daily basis. If they only have perio/OH issues we may do an examination under general anesthesia to obtain radiographs and re-establish and define their oral health baseline once every 5 years and we have found that in most individuals their oral health is stable as measured by the progression of periodontal disease, new caries or loss of teeth.

 

Do you have any particular question on this topic? Do you have any comments or suggestions? Email us at oasisdiscussions@cda-adc.ca

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5 Comments

  1. Reza Nouri November 19, 2013

    this is a very useful post. I’m very happy to see that Dr. Sigal’s work on this area is providing some evidence for preference of in-office treatment as opposed to frequent unnecessary treatment under GA with its associated morbidity as stated by Dr. Sigal and other experts in the field. G-tube fed patients have an extremely low risk of caries despite the significant amount of calculus build up that reappears within a few months of scaling. I hope that in most hospitals the practice of routine GA for the provision of scaling for G-tube fed patients will be substituted with the same regimen mentioned by Dr. Sigal.
    sincerely,
    Reza Nouri, Vancouver-BC

    Reply
    1. Paul Smith November 21, 2013

      Happened to treat one of these patients today in the O/R under GA. Ran the suggestion that in office treatment in the modality suggested would be appropriate by my anaesthetist. He could not reconcile the attendant airway management risk with the other potential risks associated with a GA. Frankly neither can I.

  2. Anonymous November 19, 2013

    This modality may be appropriate in a training venue with adequate staffing and students present. In our situation we treat these patients on an annual basis under GA and to date we have had none of the afforementioned issues. We do the best we can with the limited hospital resources and personnel available. Airway management is the imperative with these patients.

    Reply
  3. Peter Brymer November 19, 2013

    Hi, This protocol sounds very good. I would like to know 1- how many patients per year would you see in this condition. 2- how many visits would it take for a new patient with moderate /heavy calculus. 3– how long would it take the patient to get the initial visit 4– who would pay for the treatments. There are many G tube patients in our LTC homes.
    Thanks

    Reply
  4. Adrian Luckhurst November 19, 2013

    I have treated a variety of patients over the past 40 years both in hospital and in private practice with the inability to swallow ,either caused by accident or congenital abnormality.Sometimes these patients have previously been routinely administered a G.A,without pursuing whether the patient can accept dentistry in a routine manner. This may be time consuming but the result of gaining the patients confidence even if mentally challenged is very rewarding.
    One will find high calculus accumulation even onto the occlusal surfaces, decay is not a problem as no food enters the oral cavity.Unless a recent event had resulted in the condition and previous decay was present.
    In these cases a Ga may be required to control areas of disease .The patient can usually be handled in the office or facility with 3month hygiene, initially try hand scaling ,then try with the cavitron , all the time consistent suctioning is required with plenty of rests for the patient and encourouragement.
    It is imperative that the staff in the facility know how to brush the patients teeth and an in-service demonstration can be invaluable ,which may need to be repeated in the event of staff turnover.Dentifrices that reduce calculus should be recommended.
    Dr. Adrian Luckhurst

    Reply

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