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

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.

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