BSDH CLINICAL AUDIT PRIZE

 

Improving Dental Care for Cardiac Transplant Patients

Emma O'Donnell


Authors

O’Donnell, E1 and Patterson, H2

  1. Clinical Lecturer and Honorary Specialty Registrar in Special Care Dentistry, University of Glasgow; 
  2. Consultant in Special Care Dentistry, NHS Greater Glasgow and Clyde

Background
The Scottish National Advanced Heart Failure Service manages cardiac transplantation within Scotland. Patients for cardiac transplant require dental assessment prior to acceptance onto the waiting list. Achieving and maintaining oral health is essential in preventing dental disease jeopardising the patient’s place on the waiting list. Once transplanted, these immunosuppressed patients are at risk of complications of dental disease and increased risk of cancers. 

Aims
Ensure that patients:

  • Are dentally assessed prior to listing 
  • Receive annual review while on waiting list
  • Are seen annually following transplant

Create clear protocol for the dental care of cardiac transplant patients.

Process
Baseline data was collected January 2021 investigating if those on the waiting-list had been dentally assessed with follow up review; and if those transplanted had been reviewed. Monthly data collection is planned.

Results
Since formal referral process for pre-cardiac transplant assessment to SCD was established in 2010, 98 of 121 patients successfully received dental assessment prior to treatment with 62 having review. Of those on the waiting list, 19 of 19 have been assessed. 

Discussion
Dental disease may hinder recovery or compromise a place on the waiting list. Patients may be on a routine waiting list for years. Annual review within the SCD department would be advantageous if planned to coincide with the pre- and post-transplant medical reviews.

Action plan

  • To be included in waiting-list updates.
  • Retrospectively review patients who have been transplanted to ensure dental follow up.
  • Investigate protocols used in other regional centres and evidence available to construct protocol for cardiac transplant patients’ dental care. 

 

Fluoride Provision for Special Care Patients: An Audit

Nicola Cloney


Authors

Cloney, N., Tkacz, K., Anderson, C. 

Sheffield Community and Special Care Dental Services

Background
‘Delivering Better Oral Health (DBOH): An evidence-based toolkit’ provides dental practitioners with evidence-based prevention advice. Preventative care for Special Care patients is essential, especially when operative treatment is challenging. 

Aim
To assess and improve compliance with DBOH guidance regarding fluoride provision in Special Care patients.  

Standards
100% of patients:

  • Current medical history and dental chart
  • Oral hygiene routine, dietary habits and caries risk documented

100% of patients at high risk of caries:

  • Application of fluoride varnish
  • High-strength fluoride toothpaste prescribed or dispensed 
  • Repeat prescription of fluoride toothpaste requested from GP 
  • A daily fluoride rinse prescribed/advised (if active caries)

Process
Cycle 1: Retrospective analysis of patient records (n=100) between October 2018 and October 2019. Comparison to standards and action plan development. 
Cycle 2: Retrospective analysis of patient records (n=75) between August and October 2020. 

Results
Cycle 1: Poor clinician compliance with set standards, with no categories achieving 100% compliance. Particularly low compliance with recording diet history and caries risk.

Cycle 2: 100% compliance with recording a current medical history and dental chart. Improvements noted in all other categories, but standard of 100% not met consistently. 

Discussion
Many patients may be unable to comply with suggested recommendations, such as mouthwash, due to physical/cognitive impairments, however contra-indications should be documented. High-fluoride toothpaste as a repeat prescription allows long-term cost-effective caries prevention and reduces the need for patients to contact dental services for prescriptions between recalls.  

Action plan

  • Inclusion of caries risk assessment on examination pro-forma
  • Staff training regarding caries prevention   

 


 

Service Evaluation of Dental Pathway for Homeless Cohort During Initial Covid-19 Surge

Maryam Ismail


Authors

Ismail M1  Al-Fozan M2

1. Speciality Dentist in Special Care Dentistry,
ENT and Eastman Dental Hospital, University College London NHS Trust

2. Consultant in Special Care Dentistry
ENT and Eastman Dental Hospital, University College London NHS Trust

Background
During the initial COVID-19 outbreak, people experiencing homelessness were vulnerable. The Britannia hotel in Camden housed those who were rough sleeping in the borough. An MDT was formulated to support the sheltered residents. It included: mental health and substance misuse, dental and medical services. The dental team provided oral health support in two ways.  Dental packs where distributed to residents and a bespoke urgent dental care pathway set up at the ENT and Eastman Dental Hospital.

Aim
To evaluate the effectiveness of the dental pathway 

Process
Data was collected in three ways: 

  • Prospective database 
  • Feedback questionnaire completed at end of face-face appointment
  • Questionnaire distributed by support staff to all hotel residents

Results
The questionnaires highlighted the lack of access to dental care and lack of awareness of existing services.  The main dental complaints included: pain, infection, mobility, broken or missing teeth. 94% of patients had urgent appointments booked following triage. The majority accessing the pathway found accessing the service easy and would recommend it to others. 

Discussion
Most residents felt a need for dental care and did not have access to dental care. Mouth care packs where used, however information leaflets where disregarded. The support of MDT can increase accessibility to dental services. 

Action plan

  • The service should be flexible and pro-active, taking into account the complex lives and comorbidities of this cohort
  • Link service users to existing primary care dental services
  • Information leaflets to be reviewed and adapted

 

BSDH CLINICAL PRIZE

 

Evaluating Provision of Dental Treatment using Radiotherapy Mapping Templates for Patients Receiving Intensity Modulated Radiotherapy for Head and Neck Cancer

Laura McKay


Authors

McKay, L.1, Brooker, R C.2, Smith R J.1, Kwasnicki, A.1

  1. Special Care Dentistry Department, Liverpool University Dental Hospital, Royal Liverpool and Broadgreen Hospitals NHS Trust 
  2. The Department of Molecular and Clinical Cancer Medicine, The Northwest Cancer Research Centre, University of Liverpool, The Clatterbridge Cancer Centre NHS

Background
Head and Neck Cancer (HANC) is treated with radiotherapy, which has long lasting morbidities - osteoradionecrosis (ORN), trismus, mucositis and xerostomia. Intensity Modulated Radiotherapy (IMRT) uses non-uniform beams targeting the tumour, avoiding normal tissues, lowering the risk of complications. 
Pre-radiotherapy assessments are completed to assess dental health and provide treatment to reduce the risk of pain/infection and long-term ORN.

Templates were devised mapping the dosimetry per sextant for each tumour, which were categorised into low (<40Gy), medium (40<60Gy) and high risk (>60Gy) for ORN.

Aim
To assess if using dosimetry per sextant templates changes dental management.

Process
HANC patients were categorised by tumour site. The mean dosimetry per sextant was identified using staging scans and IMRT planning, then categorised by risk.

Results 
Overall the maxilla receives a low-medium dose (increased in oral cavity compared to nasopharngeal tumours). The ipsilateral posterior mandible receives high dose and the contralateral a medium dose. With oral cavity tumours the entire mandible receives high doses.

Discussion
IMRT delivers significantly lower doses to dental structures. Limiting the dose to glands, teeth and tooth-bearing structures lowers the risk of ORN, xerostomia and the severity of mucositis, which improves post-radiotherapy quality of life. Using templates to simplify why treatment is recommended we can ensure informed, valid consent is gained.

Action Plan
Use dosimetry per sextant templates when treatment planning in addition to clinical judgement, allowing patients to make informed treatment decisions. Improve communication with the oncology team so patients are aware of the necessity for dental treatment.


 

Multidisciplinary Management of a Dental Patient with Type 2 Neurofibromatosis (NF2)

Japarsh Gill


Authors

Gill, J., Bustin, J.

Department of Special Care Dentistry, Sheffield NHS Foundation Trust. 

Background
NF2 is a rare autosomal dominant genetic disorder causing mutation of the NF2 tumour suppressor gene. Reduced gene function causes tumour production in the central nervous system. Characteristically, bilateral vestibular schwannomas (VS) develop alongside sensory and physical disabilities.
Medical management includes monoclonal antibody therapy with Bevacizumab (Avastin).

Presenting problem
36-year-old male patient presented with history of pain and dental anxiety.  NF2 resulted in bilateral VS (acquired deafness) and cervical cord ependymoma (movement difficulties). He did not use BSL and communicated with support.

He was receiving Bevacizumab therapy on a monthly basis for four years, which was enabling disease stability and improved mobility.

Clinical management
Dental diagnoses:

  • Generalised plaque induced gingivitis
  • Multiple unrestorable caries 
  • Chronic periapical periodontitis
  • Restorable caries  
  • Instanding UR2

There was a high risk of medication related osteonecrosis of the jaw due to Bevacizumab; eight week treatment break was advised before dental treatment.
A full prevention plan was implemented and treatment was completed under general anaesthetic.

Discussion
A multi-disciplinary approach was vital; liaising with patients’ neurosurgeon, oncologist and anaesthetist was essential to consider treatment modalities, timing of treatment and implications on patients’ health. Communication barriers were overcome with reasonable adjustments.

Options discussed of either dentistry over multiple appointments (requiring frequent treatment breaks) or comprehensive treatment in one visit.  On balance, a general anaesthetic was agreed, as this would cause less disruption to disease stability. 

The patient was reviewed regularly after treatment; healing was uneventful and oral health is maintained.


 

The Dental Management of a Frail Patient with Complex Medical Needs

Elizabeth Cheales


Authors

Cheales E, Kerr B, Nizarali N.

Kings College London (KCL) and Guy and St Thomas’ NHS Foundation Trust

Background
A case report describing the dental management of a frail patient with complex medical conditions:

  • Congestive heart failure
  • Vascular dementia
  • Type II Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Chronic Kidney Disease – stage IV. 

The patient was classed as moderately frail (Clinical Frailty Scale, Rockwood, 2005).

Medications include:

  • Bisoprolol
  • Clopidogrel
  • Nicorandil 

Presenting problem
The patient was referred by his dentist for multiple extractions in the hospital setting due to his complex medical history and fluctuating capacity.

On examination there was evidence of dental infection, unstable periodontitis and lack of function, it was therefore essential to stabilise the patient's oral health. The treatment plan needed to take into account the future progression of dementia; planning for maintenance and the risk of deteriorating cooperation.

Clinical management 
On advice from the patient's cardiac team, a staged treatment approach was employed.

The patient’s early-stage dementia meant he presented with slower thinking and processing, by accommodating this he was able to consent for treatment.

Treatment:

  • Prevention
  • Periodontal treatment 
  • Extraction of remaining upper teeth
  • Restorations
  • Immediate upper denture

The patient also presented with a large ulcer present for over 3-weeks. The patient was referred to Oral Medicine
Diagnosis – Oral ulceration aggravated by Nicorandil medication.

Discussion
This course of treatment provided initial stabilisation of the patient’s oral health and engagement with oral hygiene practices. The treatment removed any source of infection, stabilised occlusion and required support from the oral medicine department.  Simple treatment was performed that could be maintained in the future when cooperation may be limited.