Treating Patients with Spinal Cord Injuries

Most oral health professionals lack adequate training in treating patients with spinal cord injuries (SCI), which may make them hesitant to reach out to this population.¹ Individuals with SCI face many barriers to accessing professional dental care, including the cost of treatment, transportation issues, and dental anxiety.² While adults with SCI may visit a dental office annually, they do not always receive professional preventive care.³ In order to ensure quality of care for all patients, dental hygienists should be knowledgeable about effectively managing patients with SCI.

According to the United States Centers for Disease Control and Prevention (CDC), approximately 200,000 individuals experience SCI, with 12,000 to 20,000 new occurrences expected annually.⁴ The National Spinal Cord Injury Statistical Center reports that the average age of injury is 42.6 years, with SCI occurring overwhelmingly in men (80.7%), and with a higher incidence among whites (67.0%).⁵ Motor vehicle accidents are responsible for 36.5% of SCIs, followed by falls (28.5%); acts of violence (14.3%); other/unknown (11.4%); and sports injuries (9.2%).⁵

Tetraplegia (also known as quadriplegia) is characterized by paralysis of all four limbs. It is caused by damage to the neck area, primarily from injuries above the C-4 vertebrae. This area of the spinal column controls the diaphragm, requiring many individuals to use a mechanical ventilator via a hole in the throat.⁶ Paraplegia, on the other hand, is the complete or incomplete paralysis of the legs and trunk but not the arms. This occurs from injuries sustained at the thoracic, lumbar, or sacral level of the spinal column. Depending on the location and severity of the injury, individuals may have partial movement of the lower extremities and may be able to walk with assisted devices.⁷

RELEVANCE TO ORAL HEALTH

Many individuals with SCI compensate for the loss of their upper extremities by using mouth-stick devices. These devices assist individuals in performing daily tasks, such as signing their name, dialing a phone, or typing on a computer. The use of the mouth in this manner makes good oral health even more critical.¹

Individuals with SCI often take medications that reduce muscle spasms and assist with bladder control that may also cause xerostomia.³ A reduction in saliva production can affect the ability to speak, interfere with the digestion process, and make mastication and swallowing uncomfortable and challenging. Complications with mastication and swallowing can result in the individual’s diet consisting only of soft foods.⁸ A reduction in saliva also may result in food debris staying on the teeth longer, in addition to the individual not receiving the antibacterial and antifungal effects of saliva.⁸ This type of oral environment can place patients with SCI at great risk for developing dental caries.³ Intervention strategies for xerostomia should include education on the importance of oral self-care, and the use of saliva substitutes; fluoride; xylitol-containing products; gum, mints, or lozenges to relieve dry mouth symptoms; and remineralization therapies.

Individuals with SCI are more susceptible to secondary medical conditions, and poor oral hygiene can lead to chronic inflammation—taxing an already compromised immune system.⁹ Depending on the degree of paralysis, individuals with SCI may find oral self-care difficult and rely on their caretakers to perform this daily task.

CLINICAL IMPLICATIONS

In accordance with the American Dental Hygienists’ Association Standards of Care, the dental hygiene process of care should be followed (assess, diagnose, plan, implement, and document) with patients who have SCI.¹⁰ As with all patients, a comprehensive medical history should be completed prior to the scheduled appointment. The health history should include the patient’s health beliefs, cultural beliefs, social status, psychological assessment, and contact information for other members of the patient’s health care team. In order to successfully manage patients in the dental or dental hygiene setting, the clinician must assess whether the individual can safely undergo care.¹¹ A comprehensive medical history and risk assessment assist the dental team in providing quality, personalized patient care.

Disabled respiratory systems and increased risk for asphyxiation due to weakened respiratory musculature can cause individuals with SCI to be anxious regarding dental treatment.² The dental team should incorporate appropriate strategies to assist patients by responding in a nonjudgmental manner and enabling them to exert some degree of control. This can be managed through the clinician utilizing the tell-show-do approach to care and providing periodic rest breaks.¹² Additionally, medications may be recommended for anxiety management, but the dental team should consult with the patient’s physician to decide which drug is most appropriate. By addressing the issue of anxiety up front, the clinician will be able to provide patient-centered care and establish a foundation for a trusting patient-provider relationship.

Patients with SCI are at increased risk of autonomic dysreflexia, a life-threatening condition.¹ While relatively rare, the condition occurs when the autonomic nervous system reacts to a stimulus, causing acute hypertension. Bladder issues, such as kidney stones or urinary tract infections, can initiate this response. Other conditions that can precipitate autonomic dysreflexia are pressure sores, ingrown toenails, complications from urinary catheterization, and pain. Signs and symptoms may include head­ache, hypertension, bradycardia, sinus congestion, chills, flushing perspiration, and anxiety.¹ The dental team must be able to recognize the signs of this condition so that immediate emergency medical attention can be provided.

PATIENT MANAGEMENT CONSIDERATIONS

Based on the information gathered from the patient health history, the clinician needs to consider a variety of strategies when caring for patients with SCI. A preappointment consultation with the patient and/or caregiver may be helpful. This appointment enables the clinician to complete a comprehensive risk assessment, so the patient can be safely treated in the private-practice setting.¹¹ This consultation will also assist the clinician in determining if a medical consult is necessary, as well as appointment considerations (best time of day for patient and length of time the patient can tolerate treatment).

The accessibility of the dental facility must be evaluated. For instance, there should be enough space in the treatment room for a wheelchair, and the facility should meet the Americans with Disabilities Act guidelines.¹³ The revised Americans with Disabilities Act recommendations for wheelchair accessibility Guidance on the 2010 Americans with Disabilities Act Standards for Accessible Design provide a comprehensive outline of the current guidelines for public facilities.¹⁴ The dental team needs to have sufficient training in the management of the patient with SCI, including how to execute a proper wheelchair transfer, as well as the right equipment to facilitate a transfer.

Clinicians must have ample time allotted in their schedules to provide comprehensive care, which includes the time it takes to get the patient transferred from the wheelchair to the dental chair. Other dental team members should be available to provide assistance with duties, such as charting and suctioning.

Dental team members need to be knowledgeable about the identification and management of autonomic dysreflexia and management strategies for patients with dental anxiety.

INTERVENTION STRATEGIES

Some individuals with SCI may be able to perform oral self-care with the help of adaptive devices. Other patients may require assistance with oral self-care. If the patient requires assistance, the oral care interventions need to include the caregiver as part of the process. Dental hygiene interventions should address:

• Education about the disease process (eg, caries or periodontitis)
• Oral self-care recommendations (adaptive devices based on the patient’s level of dexterity)
• Nutritional counseling to address oral health issues
• Appropriate pain control measures (hypertension must be avoided, as it can result in life-threatening conditions, therefore, a minimum amount of epinephrine should be used in local anesthesia; opiates are contraindicated because they can cause depression of the central nervous system; barbiturates are not recommended, as they can cause severe hypotension; nitrous oxide may be safely administered)¹⁵
• Type of therapy recommended (eg, prophylaxis vs nonsurgical periodontal therapy; the water setting on ultrasonic units should be kept low for individuals who have challenges with dysphasia and/or upper respiratory issues)
• Adjunctive therapies, such as fluoride, therapeutic mouthrinses, and sealants, should be implemented¹⁶
• Management of xerostomia
• Smoking cessation (if applicable)
• Collaboration with other health care specialists (such as occupational therapist, nutritionist, and/or psychologist)
• Referral to appropriate specialist, if applicable
• Depending on oral status of the patient, more frequent continuing care visits may be recommended

CONCLUSION

Although individuals with SCI present with unique circumstances, proper education and training in special care populations is within the reach of dental hygienists. By utilizing the appropriate management and intervention strategies, oral health professionals can not only safely care for individuals with SCI, but provide them with the services they need to improve quality of life and maintain optimal health and well-being.

REFERENCES

1. Sullivan AL, Morgan C, Bailey J. Dental professionals’ knowledge about treatment of patients with spinal cord injury. Spec Care Dentist. 2009;29:117–122.
2. Yuen HK, Wolf BJ, Bandyopadhya D, Magruder KM, Anbesaw SW, Slinas CF. Factors that limit access to dental care for adults with spinal cord injury. Spec Care Dentist. 2010;30:151–156.
3. Yuen HK, Shotwell MS, Magruder KM, Slate EH, Salinas CF. Factors associated with oral problems among adults with spinal cord injury. J Spinal Cord Med. 2009;32:408–415.
4. United States Centers for Disease Control and Prevention. Spinal Cord Injury: Fact Sheet. Available at: cdc.gov/traumaticbraininjury/scifacts. html. Accessed October 16, 2014.
5. National Spinal Cord Injury Statistical Center. Spinal Cord Injury Facts and Figures at a Glance. Available at: nscisc.uab.edu Facts%202013.pdf. Accessed October 16, 2014.
6. Spinal Injury Network. What is quadriplegia? Available at: spinal-injury.net/quadriplegia.htm. Accessed October 16, 2014.
7. Spinal Injury Network. What is paraplegia? Available at: spinal-injury.net/paraplegia.htm. Accessed October 16, 2014.
8. McRae J. Dry mouth causes in spinal cord injury: causes and treatment. Dental Nursing. 2011;7(8):14–17.
9. University of Washington, Rehabilitation Center. Northwest Regional Spinal Cord Injury System. Maintaining Oral Health After Spinal Cord Injury. Available at: sci.washington.edu/info/newsletters/articles/10_spr_ oral_health.asp. Accessed October 16, 2014.
10. American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. Available at: adha.org/resourcesdocs/7261_Standards_ Clinical _Practice.pdf. Accessed October 16, 2014.
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12. Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Aust Dent J. 2013;58:390–407.
13. Internet Journal of Allied Health Sciences. Beyond Brushing Teeth: Pilot Study Reveals Community Based Opportunities To Promote Oral Care For Clients With Spinal Cord Injury. Available at: ijahsp.nova.edu/articles/Vol11Num3/Sullivan.htm. Accessed October 16, 2014.
14. Department of Justice. Guidance on the 2010 ADA Standards For Accessible Design. Available at: ada.gov/2010ADAstandards_index.htm. Accessed October 16, 2014.
15. Scully C, Dios PD, Kumar N. Spinal cord injury. In: Scully C, Dios PD, Kumar N, eds. Special Care In Dentistry: Handbook Of Oral Healthcare. Edinburgh, Germany: Elsevier; 2007:427–432.
16. Stiefel DJ. Dental care considerations for disabled adults. Spec Care Dentist. 2002;22(Suppl 3):26S–39S.

From Dimensions of Dental Hygiene. November 2014;12(11):30–32.