Older people - Francis report, ageing dentition and capacity conundrums

Question 1

The francis report

Answer 1

• Revealed appalling care of older people
• Shocking reports of abuse and neglect
• Not a single episode
• Accepted behaviour
• Resistance to change

Oral health of the elderly

• The good
• The bad
• The ugly

Question 2

demographics of age

Answer 2

Scotland (2013)

• Total population ~ 5.3 million
  
  • 17%: < 16
  • 65%: 16-64
  • 18%: 65+

An ageing population

• By 2037 those aged 65 and older will make up 25% of our population, an increase of 59%

A population living longer

• The average age of death rose from 71 in 1982 to 75 in 2011
• Older age groups increasing while younger age groups are static/decreasing

Question 3

challenges in the ageinig dentition (5)

Answer 3

• Increased number of people with long term conditions
  
  • 66% of over 65s will have a chronic condition by 2035
• Increasing age with concurrent increase in co-morbidities
• Polypharmacy
  
  • Over 65s currently taking 10 medications or more = 16.4%
    
    • Xerostomia – common side effect of drugs and also effect of taking many drugs – so effect compounded and dry mouth become profound
• dementia
  
  • Set to rise from 71,000 to 127,000 within the next 20 years in Scotland
    
    • Only 46% of people with dementia in the UK currently have a diagnosis
    • Communication with patients
    • Capacity/consent
• More people are keeping teeth for longer
  
  • Proportion of Scots retaining some teeth in 2012

Over 75s 54%

65-74 73%

55-64 86%

Question 4

issue of people keeping teeth longer

Answer 4

Initially looks good – more people retaining their teeth for longer

• But research shows that 90% of elderly and in care have untreated dental decay – both coronal and root caries

Question 5

how has oral health changed in care homes over the decades

Answer 5

Many studies – every decade for 40 years

Yet no changes

Need to raise the importance of oral health for all categories of patients but especially for dependent patients

Question 6

Francis Report - why do we tolerate low levels

“Too Great a Degree of Tolerance of Poor Standards ”

Answer 6

Why do we continue to tolerate this?

Became expected norm

Likely enter care home/ward with poor OH – but once admitted should be dealt with – but it hasn’t been

Question 7

neglect here

Answer 7

Stroke pt

• Ulceration – can easily see cause*
• Completely dependent on carers to call in dental team*
• Extract or bevel edges to prevent further ulceration*

Question 8

neglect here

Answer 8

• Multiple stroke pt with chronic anaemia*
• Continued to be given iron tablet – but couldn’t swallow tablets*
• Lay at back of mouth and burned a hole through side of tongue, cheek and floor of mouth*
• Inexcusable – no one checked*
• Liquid iron would’ve been more tolerable*

Question 9

issue here

Answer 9

• Supported at home not in hospital*
• Unpleasant bacterial infection that is widespread extra-orally not dealt with*
• Grossly carious and blacked teeth*

Question 10

main dental issue as a result of stroke

Answer 10

lose abilty to look after own oral hygiene

become dependent

Question 11

4 oral diseases seen commonly in elderly

Answer 11

• Caries/root caries
• Periodontal disease
• Oral mucosal disorders
• Oral cancer

Question 12

oral cancer prevalence

Answer 12

• One fifth of oral cancer cases diagnosed in the UK occur in people aged 75 and over
• Often present late, at an advanced stage
  
  • need to be checked even if edentulous
• Regular dental examination important
• Help with oral hygiene provides opportunity for carers to observe changes from normal and arrange a dental appointment
  
  • anything Abnormal - get it checked

Question 13

what is avoidable harm

• Francis report*
• “…and they must be protected from avoidable harm”*

Answer 13

Aspiration pneumonia may be fatal

• Oral bacteria are the main source of infection for aspiration pneumonia
  
  • importance of cleaning mouth more than aesthetics - bacteria harbour
• Poor oral health results in an increased bacterial load and subsequently increased risk of aspiration pneumonia
  
  • Millions of MO even when clean
    • Makeup of bugs change as well - danger
• Improved oral health reduced aspiration pneumonia

Question 14

issue here

Answer 14

• Staphylococcus mucositis (Glasgow 1990s)*
• Complete lack of oral care
• Mouth breathing stroke pt*
• Nil by mouth
• No one cleaning mouth so detritus (dead mucosal cells, saliva secretions) thick/gloopy – can choke due to mucosal plaque tethering tongue to palate*

Question 15

is our dental care of elderly safe?

• Berwick Report*
• “Patient safety should be the everpresent concern of every person working in or affecting NHS-funded care.”*

Answer 15

no

why is it tolerated?

commonly

• Francis Report*
• “ … and they must be protected from avoidable harm and any deprivation of their basic rights ”*

Question 16

4 points from UN convention of human rights

Answer 16

• Article 5
  
  • No one shall be subjected to degrading treatment
• Article 21
  
  • Everyone has the right of equal access to public service in his country.
• Article 25
  
  • Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care
• Article 27
  
  • Everyone has the right freely to participate in the cultural life of the community

Question 17

example of degrading treatment in francies report

Answer 17

“A lady of 95 years who was registered as blind and diabetic and suffering from pneumonia was left to sit in a corridor in A & E at Stafford Hospital for three hours. The care, when it was eventually provided, was good.

• Nobody talking to her, nobody looking after her
• Care when eventually given was good – just too busy

The next day the patient was transferred to Ward 10 where she was left in soiled bed clothes** and no one answered when she rang her call bell for help. **When the patient’s false teeth were lost she was assured that the dental department would provide a new set**, yet weeks later she was told such a service was not available. **The food provided to the patient was not suitable for a lady with no teeth** and despite being blind, **staff offered her no assistance with feeding**. For the patient’s entire stay, which was several weeks, **she was not washed or cleaned.

• Lied to
• Neglected for several weeks

Question 18

examples of failure of care in Glasgow

Answer 18

Mrs McGaw became very unwell whilst in a care home – care home weren’t aware she even had denture

• Transferred to a hospital maxillofacial unit by GMP - oral cause suspected
  
  • Died of ischaemic heart disease but her oral condition raised serious concerns
• Denture might have been left in her mouth for a period in excess of two weeks (thought to be 2 years)

Care home did not meet the oral health needs of those who needed help

Serious failings were identified and have since been addressed

• A body of opinions from the medical witnesses believe it quite likely that the denture contributed to Mrs McGaw’s death
• stroke pts unable to remove denture themselves – loss control of limb – but also cannot speak to communicate denture – mouth needs to be checked*

Question 19

difficulties of access to dental care for elderly (4)

Answer 19

• Mobility and access to dental premises
  
  • Disability and discrimination act
• Communication
• Dental anxiety
• Cost

Question 20

issue with hospital transport and dental care

Answer 20

• However, pts needing hospital transport can only be taken to hospital sites not high street dentists*
• Tried to get this changed for years
• Booked by pt – need good communication*
• May not be able to bring family member/carer as not enough space in ambulance*

Question 21

importance of oral health for general health

Answer 21

• Pain free and comfortable
• Risk of life-threatening spread of oral infection
• Infection can smell and taste unpleasant, inhibiting social interaction and thus self-wellbeing
• Nutrition

Question 22

older peoples prespective of oral health in QoL

Answer 22

• Older people perceive oral health as important to their own quality of life
  
  • Eating
  • Comfort
  • Appearance
  • Smiling/laughing/kissing
  • Personality
• Easy fix for quality of life – cleaning mouth*
• But no action to do this

Question 23

issue that occur to eating and oral health issues

Answer 23

Loss of teeth leads to:

• Impaired masticatory function
• Avoidance of foods that are hard to chew
• Not meeting nutritional needs
• Increased intake of processed, high cholesterol and lipid based foodstuffs

Too dry or sore

• Food intake restricted = restricted nutrition
  
  • General health compromise, oral health – teeth and supporting structures

Eating should be enjoyable – often one of the few pleasures left

Question 24

how is oral health important so indviduals can take part in social interactions

Answer 24

• Family visits
• Talking to friends
• Participating in social events
• Eating together
• Physical closeness is really important for emotional wellbeing*
• Unable if oral hygiene so poor and repugnant*

Question 25

issues of caring for elderly in practice

Answer 25

* Caring for the elderly is not business friendly * Domiciliary dentistry * Arranging transport to dental clinic * Longer appointments * Failed appointments * Is our current workforce big enough to meet the need? * Patient centred care * **Care of this group cannot be allowed to be compromised by financial constraints**

Question 26

key way to target issues highlighted in Francis report

Answer 26

education and training for nurses and carers 'Caring for smiles' * A guide for oral health professionals to deliver training for staff in care homes * Enables carers to provide a high standard of oral care for dependent older people NES not have qualifications for Oral health for carers

Question 27

barriers to making postitive changes in elderly OHRQoL

Answer 27

* Oral health is a low priority in care plans – need to be equal * Carers have limited knowledge of oral health * Carers have difficulty in gaining access to residents’ teeth * High turnover of care staff * Poorly paid care staff * Do they feel valued?

Question 28

Berwick's key principles

Answer 28

* Place the quality of patient care, especially patient safety, above all other aims * Engage, empower, and hear patients and carers at all times * Foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work * Embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge

Question 29

research into elderly oral health care

Answer 29

* Community Oral Health Research Group * Oral Health of Older People research theme * Scottish Oral Health Research Collaboration

Question 30

the life course of a dentition

Answer 30

Start edentulous and progress through * Rarer to become edentulous at end now Restorations in between – varying degree

Question 31

things used to imporve oral health care for younger population

Answer 31

Laws, intervention, public health upstream approaches happening so that children and young people will have better outcomes

Question 32

loss of teeth through life reasons

Answer 32

Better now at controlling risk factors and reducing tooth loss Always going to be socioeconomic issues – but improving public health *ability to prevent alcohol/smoking induced issues, improving oral hygiene, educating on diet etc*

Question 33

issue with amalgam fillings old practice

Answer 33

amalgam and Extension for prevention mentality * dentist will extend cavity preparation to prevent recurring caries around restoration * meaning harder to repair as retention lost Today – evolving techniques and materials now have ability to bond onto the fractured tooth so can repair the teeth and extend life span * Also useful for non-carious tooth surface loss  historically extracted but can now do minimal intervention restorations

Question 34

issue of more people having teeth for longer and living longer

Answer 34

% of edentulous adults declined consistently over the last 30 years But dental decay prevalent in the older dentate population * Higher risk of Tx – physically frail, mentally confused, maybe house bound or instutionalised are we prepared By 2040 those of 64 will make up to 25% of population

Question 35

some common medical issues in elderly

Answer 35

* Increased number of people with long term conditions * An estimated 4 million older people in the UK (36% of people aged 65-74 and 47% of those aged 75+) have a limiting longstanding illness. * Increasing age with concurrent increase in co-morbidities (55-98%) * Cardiovascular Diseases and Stroke * Cancer * Diabetes * COPD * Polypharmacy * Over 65s currently taking 10 medications or more = 16.4% * *Xerostomia! – common side effect and effect of polypharmacy – compound effect (health and quality of life impact)* * Dementia * 2014 850,500 * 2025 1.14 million 2051 2 million * Only 46% of people with dementia in the UK currently have a diagnosis * 1 in 3 people over 65 will die with a form of dementia * Communication with patients * Capacity / Consent * Very few dentists in Scotland can sign an AWI certificate

Question 36

cost of dementia

Answer 36

economy Vs research investment * Every dementia patient costs the economy ￡27,647 billion per year: more than the UK median salary (￡24,700 billion). * patients with cancer cost ￡5,999, heart disease ￡3,455, stroke ￡4,770 per year.

Question 37

the impact of aging and systemic disease on dental care

Answer 37

* A population at an increased risk of oral disease * Polypharmacy * Impaired ability to co-operate * Access - moving and handling (hoisting, mobility aids etc) * Medical conditions complicate the provision of dental treatment * Medical conditions contraindicate the provision of dental treatment What to do? When? How to get help from?

Question 38

polypharmacy

Answer 38

*Xerostomia! – common side effect and effect of polypharmacy – compound effect (health and quality of life impact)*

Question 39

why is there a large unmet need for oral care in care homes

Answer 39

research – hard to obtain lack of funding for research and care *care home residents often excluded from research – dementia, capacity etc* * need to ID barriers to over them

Question 40

challenges dentistry faces

Answer 40

* Increasing population age, resulting in an great number of older people * Experiencing multiple co-morbidities and polypharmacy * Resident in care homes * Increasing numbers are dentate * Increasingly complex dental treatment history * Significantly high levels of disease and treatment need

Question 41

death of a dentition 5 causes

Answer 41

* Oral hygiene * Caries * Periodontal disease * Oral mucosal disease * lichen planus

Question 42

periodontal issue

Answer 42

*Pockets are harbour for bacteria and periodontal pathogens – link to systemic inflammatory disease*

Question 43

importance of soft tissue examinations

Answer 43

remove denture!! ## Footnote *If mouth not examined regularly easy to miss denture stomatitis, fungal infections, lichen planus, ulcers, oral cancer*

Question 44

root caries impact

Answer 44

*circumferential and cause tooth to snap off*

Question 45

prosthesis impact

Answer 45

plaque retentive factor

Question 46

lichen planus

Answer 46

* Comfort when eating * Difficulty in performing oral hygiene * may not be able to communicate this well * Risk of malignant transformation * Management of disease cannot just stop because they have dementia * Systemic disease and polypharmacy may contraindicate certain therapies Can the Oral Medicine Consultant perform domiciliary care? *Busy* *Often Dx younger but as become dependent on care – fall off radar and not follower up*

Question 47

head and neck cancer

Answer 47

**Early Assessment, Diagnosis and Management are essential** * Present with more advanced disease at * assessment * Delay in diagnosis * Symptoms unable to be communicated * Lack of attention paid * Misdiagnosis * Those who have undergone previous oncological care – inc recurrence risk, more speicifc health needs (poor mouth opening, salivary function etc) * Surgery * Radiotherapy

Question 48

3 things to always do for a good examination - soft tissue

Answer 48

* Regularly * Good light source * Dentures out the mouth – can see mass on lower left that would be a high risk site – easily missed on local in with dentures in

Question 49

aspiration pneumonia

Answer 49

*life threatening spread of infection due to unclean mouth* * Most common cause of death in patients with dysphagia associated with neurological impairment * Crusting around oral mucosa contains staph aureus – introducing bacteria * Incidence: 18% nursing home acquired vs 5% of community acquired * Preventable – good OH on regular basis often seen in * *Older adults who are dependent* * *Receive food via NG tube or* * *Mouth breathing* * *Nil of mouth* * *Oral health neglected – not cleaned*

Question 50

WHO 1946 - health

Answer 50

* “ That **good health** is a state of complete **physical, social and mental well-being,** and * *not merely the absence of disease or infirmity** * Health is a resource for everyday life, not the object of living, and is a positive concept **emphasizing social and personal resources** as well as physical capabilities” * Poor oral health affects general health and QoL* * Importance of oral health in systemic disease play*

Question 51

QoL aspects for older people

Answer 51

* Having good social relationships * Maintaining social activities and retaining a role in society * Having a positive psychological outlook * Having good health and mobility * To enjoy life and to retain one’s independence and control over life * *Nutrition – food intake restricted – general health and QoL – few joys left*

Question 52

preservation dentition impact on older people

Answer 52

* “Frail older people are positively influenced by natural teeth and this effect seems to increase with increasing frailty” * “Preservation of teeth contributes to a positive body image and self-worth”

Question 53

treatment planning in dementia early stage

Answer 53

* Should oral assessment be part of multi-disciplinary care of the person with dementia following diagnosis? * Planning for the future as we consider the progressive nature of dementia * Assessment * Identify and attempt to retain “Key Teeth” * Focus on high quality restorations * Are complex restorative treatments able to be cared for in the long term? * Establish a preventative regime * Replica impressions of dentures – likely lost in hospital and care homes. * Can help if need to make new ones as place to start as maybe harder if pt gets dementia, lacks capacity, getting used to new ones

Question 54

KEY teeth save in Tx planning

Answer 54

* Occluding pairs of teeth * Number of teeth * Attempt to retain anterior teeth

Question 55

pros and cons of making edentulate

Answer 55

* *Is the ultimately preventative measure really better than cure?* * *​denture care may be more feasible for some than complex OH* *but* * Natural teeth have a significant impact on QoL * Chewing and eating * Nutrition * Independence / pride and achievement * Social aspects of life

Question 56

treatment planning in dementia mild stage

Answer 56

* Maintenance and prevention are essential *clean and healthy* * Ability to co-operate may deteriorate limiting the ability to provide care intervention * Consideration must be given to medical status and its implications upon provision of care *domiciliary care?* * Access becomes increasingly more challenging * Cost * Transport

Question 57

ART caries management

Answer 57

Atraumatic Restorative Technique * *good for elderly* * *No fee in Scottish Dental Remuneration (like regular oral hygiene visits – gold standard prevention)* *Stepwise approach* * *Excavate caries as far as possible without breaching the pulp – removing infected soft dentine but leave affected dentine as layer on top of pulp. Seal in with GI* * *Cut off food supply for bacteria and caries- Stabilise things* * *More cleansable* * *Only spoon excavator and GI – so little equipment if domiciliary visit*

Question 58

ART Vs Conventional resin in older free living adults

Answer 58

R.C.T. providing a 2 year survival ART = 85.4% *quite successful* Conventional = 90.9%. 75% of participants were judged to have poor oral hygiene. * *No need to know longer as average length of stay in care home is 2 years* * *Alt is Hall technique in adults*

Question 59

risk factors for restoration failures in elderly

Answer 59

* Lower number of tooth brushings/day * Absence of prosthesis * Posterior location of the tooth * Higher baseline plaque index

Question 60

treatment planning in dementia late stage

Answer 60

* Focus on comfort * Moist, clean and healthy mouth which is free of pain and infection * Non-invasive * Emergency management – limited options

Question 61

fine line balancing between

Answer 61

treat to what extent

Question 62

64 Year old Male Referred via multiple sites – finally 4th referral to Special Care at RAH **Medical History:** CVA 2003 Vascular dementia 2013 High blood pressureDiabetes Walks with a stick and arm support required. **Medications:** Amlodipine; aspirin; metformin; metoprolol; paroxetine; ramipril; ranitidine; simvastatin; temazepam **Social History** Wife is main carer and POA – she reports various access difficulties to services over last 2 years with little treatment offered. Required ambulance transport to attend **On examination:** Oral condition poor with multiple retained roots Sinus leaking pus above buried root of 24 Lower anterior teeth in reasonable condition .

Answer 62

medications * *Want is to go to impact dentistry?* * *What oral side effects?* ***Need more info, capacity etc*** * How can we have prevented this?* * *Need to consider long term for pt – make their life easier in the future but take into account pt best interests*

Question 63

90 year old Female * **2012** * First presentation for assessment of pain. * 48,47 extracted and new F/P constructed. * **2013** * 45 pain – filled then extracted a few months later due to pain. * Lower lip and gum sore – shiny and atrophic appearance – * GMP prescribed prednisolone mouthwash * Diagnosed erosive lichen planus with associated vulval/vaginal pain: referred Dermatology * **2014** * 33,34 extracted due to pain – poor healing and evidence of MRONJ * Seen at oral medicine clinic then as a domiciliary – ability to leave house reduced * Multiple treatments tried including tacrolimus – condition failed to resolve satisfactorily (for lichen planus – had sores, lesions) **Medical History:** Angina; arthritis; asthma; knee replacement; ischaemic heart disease; osteoporosis; chronic kidney disease; xerostomia; xerophthalmia **Medications:** Carbocisteine; carbomer eye gel; citalopram; fluticasone proprionate and salmeterol cfc free inhaler; folic acid; furosemide; GTN spray; hypromellose eye drops; isosorbide mononitrate; Oral Balance® gel; paracetamol; risedronate sodium; salbutamol; tiotropium;

Answer 63

* Exposed bone for over 8 weeks that wasn’t healing and medications - MRONJ?* * treatment considerations* * *likely had constant pain for years due to lichen planus* * *Is she is the best place? QoL?* *Tx complicated but need to take into account QoL*

Question 64

equilbrium of oral biofilm disease

Answer 64

Oral biofilm-based diseases are controllable If we get the balance right… * Reasonable oral health, without pain or infection * Oral comfort to allow for social interaction * Limit operative dental care * Avoid the challenges associated with sedation * Avoid the significant morbidity and risks associated with General Anaesthesia * Move away from pharmacological approaches to care to embrace philosophies centred around the individual

Question 65

5 team members of holistic care approach for elderly

Answer 65

* Carers * Family and relatives * Dentists and Dental Care Professionals * Medical Professionals * Public Health

Question 66

communication techniques for dementia

Answer 66

* Approach from the front * Break it down tasks into steps – * short words, simple sentences * Non-verbal * smile, gentle touch * Get the environment right * quiet, avoid sensory overload communication techniques * Rescuing * Distraction * Bridging – *move conversation on from something that is upsetting them* * Hand- over- hand * Chaining – *you start they end vice versa*

Question 67

Capacity issue

Answer 67

The Adults with Incapacity Act is there to protect vulnerable people Further training, enhancing knowledge and skills is now available to enable dentists to assess capacity and provide AWI forms where appropriate * Essential in order to reduce inequality and provide access to care If we are unable to provide an AIC ourselves developing strong relationships with medical colleagues is essential

Question 68

possibilities for future endeavours in elderly dental care

Answer 68

* Greater integration of services and inter-disciplinary healthcare to deliver care * Achieving a great understanding of the burden of oral disease and how best to manage it * A FiCTION equivalent for older people to understand and provide an evidence base? * Prevention at a Public Health Level * Appropriate amendments to the Statement of Dental Remuneration

Question 69

Caring for smiles basics

Answer 69

* National programme to promote good oral health for residents in care homes * Training carers * Empowering carers and breaking down barriers * Valuing dependent people and the people involved in their care

Question 70

mouth care without a battle

Answer 70

resource * Positively affected the provision of oral care by carers * Empowerment to provide mouth care * Improved familiarity with mouth care procedures * Provision of mouth care for those who presented with challenging behaviours * Improved staff self-efficacy and promoted a culture of mouth care provision

Question 71

care home - limited knowledge to oral health barriers

Answer 71

* Significant challenges in obtaining vital data for this vulnerable group * Often excluded from research based on capacity * Funding resources * Numerous barriers presently *in situ* associated with the data collection field * Understanding the differences between care home resident vs. free living with dementia

Question 72

Socransky complex causes of aspiration pneumonia

Answer 72

Question 73

5 key prinicples of AWI act

Answer 73

1. Benefit 2. Minimum necessary intervention 3. Take account of the wishes of the adult 4. Consultation with relevant others 5. Encourage the adult to exercise ‘residual capacity’

Question 74

AWI - means incapable of (5)

Answer 74

* Acting * Making decisions * Communicating decisions * Understanding decisions * Retaining the memory of decisions

Question 75

* 25 year old male attends your practice from an acute psychiatric ward. * He has a large asymptomatic hole in his front tooth and the medical staff thought it would be best to have it checked. * The patient has been admitted to the psychiatric ward suffering with an acute drug induced psychosis. * The medical staff are confident that this psychosis will be relatively short and would expect the patient to return to better health in the near future. Clinical Findings * Tooth 21 has a large carious cavity involving the mesial and palatal surfaces. * A periapical radiograph taken shows a radiolucency associated with the apex of tooth 21. Treatment options: 1. Do nothing 2. Begin endodontic treatment 3. Extraction Assessing capacity * The clinician to patient interaction * Does this person have capacity to make a decision? * What treatment would you provide in this situation?

Answer 75

consideration **Benefit** * Infection is present but it is asymptomatic * Reversible psychiatric condition, expected to recover in short period of time * Likelihood to interact with dental services subsequently? Minimum necessary Intervention * The extraction of a front tooth can never be reversed * 1st stage of endodontics allows for the initial management of infection and the placement of a dressing over the tooth to prevent progression of caries * On recovery from the condition there is then the option to decide with the patient on the definitive treatment for the tooth Take account the wishes of the adult * The ability to determine this in the situation is challenging * Must still be able to respect the wishes of the individual * Just because the person has a psychiatric diagnosis does not mean they are unable to make a decision in relation to the care of their mouth Consultation with relevant others * Medical team * Will provide further information of psychiatric diagnosis * Can provide an AWI on your behalf if required * Family or relevant others who may be able to give insight into person’s wishes Encourage the adult to exercise ‘residual capacity’ * The reversibility of the condition resulting in the incapacity is important * On recovery from this acute episode the person will be in a position to make an informed decision * This is not necessarily an acute emergency but still requires appropriate management

Question 76

* 58 year old male * Diagnosis of rapidly progressing early onset dementia * Has recently moved into a care home * Wife is welfare power of attorney * Supported in self-care Clinical Findings * Relatively co-operative for assessment * Retained roots 15,11,23,34 and 47 * Previous left-sided facial swelling (treated with antibiotics by GMP) * Stable periodontal condition * Removable partial maxillary denture Assessing capacity * The clinician to patient interaction * Does this person have capacity to make a decision? * What treatment would you provide in this situation?

Answer 76

**Benefit** * Retained roots with chronic infection * Dementia likely to deteriorate to a point where all co-operation for treatment is lost * There is benefit to keeping some teeth for retention of a denture, function, aesthetics and quality of life **Minimum necessary intervention** * How well is the person able to tolerate dental treatment * Do you actively treat or do you palliate? * Minimum necessary intervention does not mean do nothing **Take account the wishes of the adult** * What were this person’s feelings about their teeth * Consultation with people who knew him may give more information * What are his opinions just now? **Consultation with relevant others** * The patient’s wife has Power of Attorney * She must be consulted prior to any treatment being performed **Encourage the adult to exercise ‘residual capacity’** * Although this person has dementia it does not mean he is incapable of making a decision * Should be included in this process * Re-assessment of capacity at each visit to determine level of capacity

Question 77

if providing treatment as a GDP and no capacity present

Answer 77

* Discuss treatment and consult with power of attorney, welfare guardian or nearest relative * If agreeing to treatment you must request a capacity assessment and provision of a Section 47, Adults with Incapacity Certificate from the General Medical Practitioner * They should confirm status of POA and observe legal documents confirming status * It is possible to provide a treatment plan to the GMP on the form allowing them to sign the course of the treatment

Question 78

progressive conditions and AWI

Answer 78

* AWI can last up to 3 years * For lifelong and progressive conditions where no capacity is likely to be regained, it is sensible to have an AWI certificate running for dental examination for this time period * For individual courses of treatment a separate certificate should be completed limited to the time period for the estimated completion of treatment

Question 79

assessing capacity of * 29 year old male * Moderate Learning disability * Attends with a carer * Carer reports patient being off food recently * Won’t let anyone help with brushing his teeth Clinical findings * Buccal swelling associated with 23 * Multiple retained roots * Multiple carious teeth

Answer 79

* The clinician to patient interaction * Does this person have capacity to make a decision? * What treatment would you provide in this situation? * The clinician to carer interaction * What information you need to require and how to obtain to

Question 80

considerations * 29 year old male * Moderate Learning disability * Attends with a carer * Carer reports patient being off food recently * Won’t let anyone help with brushing his teeth Clinical findings * Buccal swelling associated with 23 * Multiple retained roots * Multiple carious teeth

Answer 80

**Benefit** * Infection is present * Number of carious teeth which require intervention to prevent further infection **Management of the emergency situation** * Poor co-operation to attempt removal of roots as source of infection * Unable to consult with legal guardian * Indication for the use of antibiotics but definitive treatment planning is required **Minimum necessary intervention** * Significant treatment need and volume of treatment required * Poor co-operation at initial visit * Minimum necessary intervention may well be the provision of care under general anaesthetic **Take account the wishes of the adult** * What is the patient able to communicate about their wishes? * Previous experience of treatment may give some clues **Consultation with relevant others** * Important to contact the legal guardian prior to the provision of non-emergency treatment * It is important to clarify the legal position of the person and documentation must be seen **Encourage the adult to exercise ‘residual capacity’** * There is a responsibility to allow the individual to use what capacity they do have to express their views * This may require the use of communication adjuncts

Question 81

special care dentistry services and AWI

Answer 81

* Received the additional training required to provide AWI certificates Experience and expertise in the assessment and management of people who lack capacity * **Referral options**