[Medically compromised patients in the dental office: demographics and progress in health care]. / Risikopatienten in der zahnärztlichen Praxis : Demografie und medizinischer Fortschritt.

Due to changing demographics in our society, there are an increasing number of patients with risk factors presenting for dental care. Unfortunately valid screening instruments to identify these patients are lacking. Especially in elderly patients, there is often an association between the high number of prescribed medications and oral symptoms. Using supportive therapy in oncology (e.g., radio(chemo)therapy) as an example, the role of modern dentistry and its interaction with general medicine is illustrated. Modern substances, e.g., antiangiogenetics, with still unknown side effects represent challenging new developments in the field of oral medicine. Even with some examples of positive representation of patients with risk factors in the health systems, e.g., § 28 SGB V, it is clear that the pressure on the costs in the health systems leads to an undertreatment of patients with risk factors. Only by adapting dental and postgraduate training with respect to these aspects, together with better financial reimbursement of the additional efforts, will this trend be overcome.

Missing links in oral health care for frail elderly people.

A national interdisciplinary strategy is needed to address the comprehensive oral health care needs of frail elderly people residing in long-term care facilities. Reasonable care within the social and personal context of frailty encompasses active prevention of disease augmented by necessary restorative treatment, provided with sensitivity to a person"s propensity to seek care. Typically, dental emergencies are managed quite well in longterm care facilities, either by treating the resident on site or by transporting the resident to a local clinician. In addition, facility administrators are usually well aware of their legal responsibilities to provide diagnostic services to residents before disease or dysfunction causes irreparable damage. Consequently, many facilities have arrangements with dental hygienists, dentists or denturists for periodic clinical assessment of all residents, or they seek help at the first sign of trouble. On the other hand, effective, widely accepted strategies for assisting frail residents with daily oral hygiene are lacking, and in many regions across the country it is overly difficult for frail residents with severe oral impairment or dysfunction to receive appropriate care and treatment. A cooperative effort from many disciplines will be needed to provide these missing links in Canadian health services and to realize the principle of providing maximum benefit to the least advantaged in society.

[Oral pathology in a denture practice]. / Orale pathologie in een tandprothetische praktijk.

An 86-year-old edentulous patient visits a denturist for the provision of a new set of dentures. In the region 36/37 of the lower denture base extension is a bony like structure apparent, that does really not bother the patient. The denturist refers the patient for further diagnosis. It appeared to be a benign condition (traumatic periosteal ossification) that did not require surgical intervention. The responsibilities and capabilities of the denturist with regard to the treatment of edentulous patients are discussed in light of the current Dutch legislation.

Ethical and legal issues in special patient care.

Dental professionals encounter a number of challenging ethical and legal dilemmas when caring for special patients. Questions may arise in securing consent for treatment; using restraints; overcoming economic, social, and physical barriers to care; and dealing with patient abuse. These concerns generally stem from underlying conflicts between any of the fundamental ethical principles of autonomy, nonmaleficence, beneficence, justice, veracity, and fidelity. When securing consent for treatment, practitioners must consider both legal competence and decision-making capacity. If decision-making is impaired, input should be solicited from others to arrive at treatment decisions in keeping with the patient's values concerning dental care. To guard against the inappropriate use of restraints, 10 guidelines are presented for consideration. Providers should strive not to allow economic considerations to influence their care unduly either by failing to offer a full range of options or by providing care that is below usual standards. Services must be made available to disabled individuals on the same basis that they are available to others without disability. This principle forms the basis of the Americans with Disabilities Act, which stipulates what accommodations must be made to ensure that physical and social barriers do not impede access to dental care. Finally, special patients, particularly the frail elderly, are at increased risk to become victims of abuse. Dental professionals should be familiar with the warning signs and symptoms of such abuse and their obligation to take actions to end it.

Consent for dental therapy in severely ill patients.

This article provides an overview of legal standards for informed consent, and discusses this in the context of dental care for elderly or severely ill patients. Legal analysis is made on variations in state common law and legislation, focusing on the difference between a practitioner-oriented approach versus a patient-oriented approach to informed consent. Analysis is also made regarding advance health care directives in cases of patient incapacity. The purposes of this article are to provide interested dental educators with an understanding of the important legal concepts in this area and the nuances of state law, and to discuss how these can be properly applied in facilities that treat severely ill or geriatric patients.

Informed consent and the elderly dental patient.

The fastest growing segment of the population is currently comprised of those people 65 and older. The competency of these elderly individuals is often called into question when decisions about medical care are to be made. This article explores the concepts of a valid informed consent and provides an overview of competency assessment for the practitioner as it pertains to the geriatric dental patient.

Effect of an oral health training program on knowledge and behavior of state agency long-term-care surveyors.

This study examines the effect of a training program on long-term-care (LTC) surveyors' knowledge of factors affecting oral health and their behavior in citing oral health deficiencies of LTC residents. Twenty surveyors were recruited for the experimental group, along with a non-equivalent comparison group of 31 surveyors. The experimental group participated in a three-hour interactive, case-based training program. The experimental group had a significant increase in total knowledge (p < 0.002) post-test scores with a moderate effect size, eta 2 = 0.115. The training program resulted in a statistically significant increase (p < 0.0001) in oral health citation behavior for the experimental group for six months following training. This study provides evidence that an interactive case-based training program can affect participants' knowledge regarding oral health of LTC residents and participants' oral health citation behavior. As the elderly population experiences an increased life expectancy with increased need for assistance with Activities of Daily Living (ADL), similar training programs will become an important factor in assessing the quality of care provided to LTC residents.

A focus on the institutionalized aged and special care patient for today's practice.

Dentists must understand the growing institutionalized-aged and special-needs population, the places wherein they reside, and the unique challenges of access that confront both the patient and dentist. This article discusses governmental regulation and legislation of long-term-care facilities and outlines professional duties and requirements of dentists who care for residents of such facilities. It will also cover the treatment needs of this population and the venues available to the hospital-trained dentist.

Treatment planning for the problem patient: restorative, ethical, legal and psychological perspectives. Case 4: Mr Lester.

'Mr Lester' is the final case study in a series of four articles that aims to look at some of the problems patients may present with when they visit their dentist. Each article starts with a brief scenario about the hypothetical patient and his/her clinical problems. As well as the clinical problem, each case also raises ethical, legal or psychological problems. All of these issues are discussed and possible management strategies and treatment options investigated.

Rights access and justice in oral health care: justice toward underserved patient populations--the elderly.

Recent data indicate that health utilization, calculated on the basis of visits to physicians, specialists, surgery rates, and hospitalization stays, increases with age. Yet, visits to the dentist decrease with age. Although dentistry has made dramatic improvements in the provision of oral health care over the past half-century, access-limited populations including older adults are burdened with the poorest levels of oral health. Many factors contribute to the oral health problems faced by elders. Also, because of its marginalization from general health and public health care delivery systems, oral health does not garner meaningful consideration as a social good. Needs associated with oral health cannot be met without a rethinking of concepts that define oral health and recognition of its impact on general health and quality of life. Determining the extent to which elders endure an undeserved or unreasonable burden of illness and disability is an important first step toward understanding the meaning of "justice" in the context of caring for elders. A clearer understanding of justice allows the oral health community to begin to recognize appropriate levels of responsibility to address the issue of just and respectful caring for this vulnerable population.

Problems in the care management of the aging patient: legal, financial and practical implications.

The graying of America poses many challenges to the dental professional. As the population ages, most dental practices are experiencing growth in percentage of older people served. The dental practitioner must be on the alert to special problems associated with the treatment of the older patient. Failure to identify these common concerns may result in patient non-compliance, failure to achieve treatment goals and heightened risk of malpractice. In addition, dental professionals who are aware of the multiplicity of factors that impact the aging process can better promote their own successful aging. This article focuses on identifying some of the key "hidden" issues typically facing older patients which can adversely impact dental treatment; and, practical techniques for managing these problem areas. Also covered are common financial and social concerns associated with aging and suggestions for how dental professionals can avoid complications from compounding in their own lives.

Defining oral neglect in institutionalized elderly: a consensus definition for the protection of vulnerable elderly people.

BACKGROUND: The authors administered surveys to develop an operational definition of oral neglect in institutionalized elderly (ONiIE) in the United States. METHODS: The authors administered a Delphi technique survey involving three rounds to a panel of 19 geriatric dental experts in 1995 to arrive at a definition of ONiIE. The authors validated the 1995 ONiIE definition by administering a Delphi technique survey involving four rounds to a subset of eight experts from the 1995 panel. RESULTS: The panelists in the 2009 survey validated the 28 oral diseases or conditions that were part of the 1995 ONiIE definition and added one new oral condition-bleeding. They also reached consensus agreement for each of the 29 listed oral diseases and conditions regarding both the diagnostic stage at which those diseases and conditions should be included in a definition (mild, moderate, or severe) and the specified time period required to constitute neglect (that is, total "time to qualify as neglect" was eight days for acute conditions and 35 days for chronic conditions). CONCLUSIONS: An expert-driven consensus ONiIE definition was established. It consists of 29 oral diseases and conditions, each of which has been associated with a diagnostic stage and a specified time period required to constitute neglect. CLINICAL IMPLICATIONS: Since federal legislation that funds payments to nursing homes for the care and housing of their residents requires that there shall be no oral neglect, this validated consensus ONiIE definition provides a utilitarian means to enforce that legislative expectation.