Assignment task:
A 60-year-old man with amyotrophic lateral sclerosis (ALS) is wheelchair bound and dependent on multiple caregivers who work daytime and evening shifts to provide for his daily personal needs, including grooming, bathing, feeding, healthcare and medication dosing, and bowel and urine management programs.
One of the daytime caregivers brings the patient to the dental appointment using a special van for wheelchairs. The patient is a new patient to the dental office.
Although he is nonverbal, he appears to understand what is being said. Radiographs are taken and a thorough examination reveals several dental issues:
1. Multiple large, unrestorable caries
2. Severe, diffuse gingival inflammation
3. Heavy plaque and/or biofilm coating the teeth
4. Halitosis
The patient does not indicate pain associated with any of these problems, but the dental professional notes that ALS may mask pain. The attending caregiver is not a relative but has forms that indicate he has been given permission to bring the patient in for the dental appointment but will need to get approval from the patient's legal guardian for any treatment.
Upon questioning the caregiver, he does not indicate any knowledge of the patient's oral condition nor complaints of pain. The dental professional feels compelled to discuss proposed treatment and issues with the guardian. The caregiver is able to call the legal guardian, who is the patient's wife, so that the dental provider can review treatment options, as well as concerns. Upon reviewing the concerns with the patient's wife, she indicates she has been busy since she now has to work full time. She also states that her husband does not seem to have any pain and that his teeth have never been a problem. She agrees that his teeth did not seem to be clean, but she relies on the caregivers for attending to his personal hygiene. She admits that dental care has not been the priority, given his medical condition and his other needs. She stated that he has
"State Insurance" and hopes that will help with his dental needs because he does not have dental insurance.
Discussion of Case 1: First, the dental provider needs to determine if this is a case of dental neglect or lack of education on the part of the wife and the care providers regarding understanding the relationship between oral health and general health and the consequences of the patient's ALS, which may mask pain. The dental provider can request contact information for the patient's physician and request a medical consultation about the consequences of the untreated dental diseases and any further health information that can be gleaned before beginning dental treatment. The dental provider will need to develop a comprehensive treatment plan with explicit instructions for a consistent and daily mouth care regimen for the caregivers to follow for both daytime and evening shifts Since the patient is dependent on others for his total personal care needs. It is Crucial to provide considerable oral health education on the relationship between oral health and general health with particular focus on the patient's advancing medical needs. Both the wife and the care providers are encouraged to incorporate daily oral healthcare into the patient's daily oral hygiene regime and follow a frequent dental maintenance schedule for professional care once his acute dental treatment needs are addressed. The dental provider also will need to engage the wife in providing oversight that daily oral healthcare is part of the caregiver services that either she provides or the other attendants incorporate into patient's daily healthcare regimen. Before making a determination of neglect, the dental provider will need to identify whether financial limitations and a lack of oral health literacy exist among the patient's wife and the care providers and whether the patient is brought back to the dental office for subsequent treatment and follow-through with the prescribed dental services and dental hygiene care plan for home and future professional oral healthcare.
1- Do you recognize any signs or symptoms of abuse and neglect?
2- Is the patient in a dangerous situation?
3- Is the incident reportable by mandate? why?
4- What actions should be initiated by an oral health care professional?
5- Given the legal jurisdiction of licensure, what agency is contacted to report a case of suspected abuse or neglect?
6- Is there a risk to the patient safety if you approach the caregiver or the person accompanying the patient to the appointment to seek additional information?