Friday, November 28, 2014

Finding dental care for people confined to home

Have you ever had a patient at home who was in need of dental care? Perhaps they were receiving hospice services or maybe they were just discharged from the hospital not on hospice, but still too frail to get to the dentist. Of course the focus is often on the medical issues, yet the most significant issue was broken rotted teeth, which made oral intake nearly impossible without pain. Clearly, the answer here is not opioids for pain control, but rather to take care of the root problem: access to dental care.

Clearly dentists and their staff are not part of a hospice or palliative care IDT, but when you need them, boy do you need them. If the short case I outlined is not clear enough for you, I would really encourage you to read “Love” by Jean-Noel Vergnes, DDS, PhD recently published in the Annals of Internal Medicine (paywall). Written by a dentist in France caring for his wife who had a stroke and was desperately in need of dental care he himself could not provide, it illustrates the anguish of not being able to provide care you know someone needs.
“And little by little, it got difficult to clean her teeth with a toothbrush, too; she made little animal noises all the time, as if we were hurting her. So, it’s true that I didn’t take that much care of her mouth.”
Yet in the end there is a deep satisfaction when a dentist is found who will come to the home and provide the much needed care for his wife.
“Knowing that such a possibility existed made me change my mind. Actually, I’d always had this little voice in my head telling me that I wasn’t doing what was best for her, that I might be convincing myself that it was useless just because I didn’t have the strength to get on with it.”
Reading this story makes me reflect on the access to home visit dentists in my metro service area. When we need a dentist, the team works frantically to find someone willing to come out. So what are the barriers for a dentist? Is it malpractice insurance out of the office? Lack of access to the ever more complicated tools while in someone’s home? Lack of adequate reimbursement? Lack of time? I know many dentists do charitable activities in urban and foreign locations (usually for children), so I know the barrier is not likely to be a cold, uncaring heart. How can we as palliative care providers strengthen this relationship with dentists so the care is not needlessly delayed? The answers are likely complex and different in every community, and I know the answer is not the DentiDrill Home Dentistry Kit. Yet, I’m hopeful by asking this question of our great communities we might find a better answer together. Then maybe more people can have memories like this:
“She gave me a wonderful, broad smile. She was beautiful, so very beautiful. Ah, how can I put it? I knew that smile would be her last. I smiled back at her, savoring the moment . . . a moment that I couldn’t even try to describe. And that smile was, indeed, her last. I’ll remember it every day that I have left to live.”
by: Christian Sinclair, MD, FAAHPM  - When he is not writing payback posts for GeriPal, you can find him over on Pallimed. (Post 1 of 4 in the World Series of Blogs payback)


Margaret Fleming said...

Is the real problem that this person could not, for some reason, go to the dentist before the stroke? Is this a financial problem? I've read about teeth getting broken in surgery. But rotted teeth take time. Is this a transportation problem for this patient and others? Would be interested to read more about the problem for others.

kathy kastner @kathykastner said...

So glad you've written about oral care.When Scott Simon (@nprscottsimon) was tweeting about his mother's final days, one of the most poignant for me was 'groaning in pleasure when here teeth were flossed'. Our mouths are so often overlooked in the focus on medical, and yet oral health can make a difference in 'successful' outcomes' treatment as I learned from 'the impacted nurse' mag

Ruth Hill said...

Just plain ole oral care is hard to get these days for hospice patients. Many of our patients have dried exudate on their tongue which impedes breathing.I am constantly instructing home health aides on mouth care, but some hospice agencies are reluctant to purchase the Toothette mouth moisturizer that is available. A few cents of prevention is worth a pound of cure.

Christian Sinclair said...

Thanks for the comments everyone.

Margaret, in the story his wife had a stroke three years prior and had been in a facility but he could not stand the guilt after he left her. She would resist any oral care as well, and one day when her dentures came out a real tooth came out as well. They got medical transport to get to the dentist but they heard it would take multiple appointments and that was too much on her. I would encourage anyone with library access to ACP to try and get it, there are many other good points in there. Alas it is behind a paywall. I'll ask them on Twitter.

Christian Sinclair said...

Kathy, thanks for sharing the story about Scott Simon. So much to learn from that experience. I followed along when it happened but missed that part.

Agree that preventative oral care is critical in patients near the end of life, especially when they are no longer able to do that for themselves. Frustrating to hear that supplies are a cost concern but with operating margins for hospices getting squeezed ever tighter, stories like that may become more common.


Really important topic to point out. thanks for sharing

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Mike Walbom said...

Thank you for sharing this experience. I am a dental student conducting research about this very topic! I am very excited to see so many comments on this subject. There is definitely a lack of care for home bound patients especially those is hospice care. I would appreciate any input, advice, information or experiences you have about dental care for home bound patients. My wife's grandfather recently passed away and I had the privilege of cleaning his teeth for the last time days before he passed. His oral care was severely neglected while in hospice care and I figured if it's happening here it has to be happening all over. My goal is to validate the need and seek solutions to help this growing population with their oral care.