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SMCDS DHF SENIOR ACCESS TASK FORCE PROJECT
In cooperation with the
CDA Foundation Geriatric Oral Health Access Program
Funded by a San Francisco Foundation Grant
FINAL ANALYSIS
Suzanne M. Valente, DDS
Project Director, Chair - SMCDS Elder Care
July 15, 2009
Table of Contents
Project Hypothesis................................................................................................................................................3
Public Policy Implications .....................................................................................................................................3
Implementation of the Project ...............................................................................................................................4
Comparison Between MDS 2.0 Data and GOHAP Evaluations ...........................................................................4
Follow-Up Care...................................................................................................................................................10
Evaluation of Treatment Outcomes ....................................................................................................................14
Observations Regarding Prosthetic Treatment...................................................................................................14
Recommendations for Prosthetic Care...............................................................................................................15
Lessons Learned ................................................................................................................................................15
Appendix A. Medical Clearance Form ..............................................................................................................17
Appendix B. MDS 2.0 ........................................................................................................................................18
Appendix C. Dentition Status.............................................................................................................................19
Appendix D. Prescriptions/Referrals..................................................................................................................20
Appendix E. Oral Health ....................................................................................................................................21
Appendix F. GOHAP Case Studies for Patients Receiving Denture Tx ...........................................................22
2
Project Hypothesis
It was our hypothesis, at the inception of this project, that the oral evaluation of the new residents of a nursing
facility (as part of the mandated timely completion of the MDS 2.0 document) often failed to accurately identify
the resident’s oral condition and oral care needs. If true, we could better set a foundation for good oral care for
these residents by having the oral evaluation completed by a dental health professional. Factors contributing
to our hypothesis were the following:
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Nursing staff are not trained to effectively evaluate oral conditions while dental professionals are trained
to recognize oral conditions itemized in the Oral Status and Disease Prevention section of MDS 2.0.
The inability of facility staff to accurately recognize oral conditions results in a failure to refer patients to
dentists or RDHAPs (Registered Dental Hygienists in Alternative Practice) in a timely manner.
The problems outlined above are compounded by the fact that the “dental provider of record” for these facilities
is not independently providing initial oral exams for these residents in a timely manner. It seems that the idea
of a mandate for a dental professional (DDS, DMD, or RDHAP) to evaluate an incoming resident and complete
the Oral Status and Disease Prevention section of the MDS 2.0 in a prescribed time frame would effectively
correct the aforementioned problems as well as offer the additional benefits listed below:
•
•
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A dental professional could also be required to provide an oral cancer exam as part of this initial
evaluation
A dental professional could be required to provide each patient a customized daily oral health regimen
for the facility staff to implement as part of this initial evaluation
Proper referrals for follow-up treatment, including hygiene, would be assured
Lastly, we believed additional training provided to the facility staff would ensure better provision of daily oral
care and a better ability of facility staff to recognize when patients develop an oral problem requiring the
attention of a dentist during their residence at the facility.
Public Policy Implications
Our project improved the quality of life and care for these residents. Additionally, implementing the changes
we propose would benefit caregivers in the following ways:
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Take the burden off nursing staff who are not equipped to fill out the Oral Status and Disease
Prevention section of the MDS.
Provide oral cancer exams which physicians generally do not feel comfortable providing (cite).
We would require that physicians fill out a medical clearance form for dental care at the time
they are evaluating patients and filling out the MDS 2.0, and interim MDS reports (see Appendix
A). This would be a time saver for the physicians, as well as protect the facility, dental care
provider and physician from liability that might result from dental care dangerous to a patient
because it did not make adjustments for specific medical considerations. (This was a serious
problem we encountered in this project, and presents a legitimate threat to a resident’s health.)
Expense management: Initial identification of patient’s daily oral care needs can allow the
facility and patient to take advantage of the documented cost reductions associated with
appropriate preventive care.
Expense management: Initial identification of patient’s oral conditions can allow care of unmet
need to take place at the earliest opportunity which would be less expensive than care which
responds to conditions only noticed later when the condition has progressed to a severe state.
Reduced cost of overall health care: the evidence documenting the relationship between oral
disease and other conditions such as diabetes and pneumonia is mounting. (cites) An
improvement in oral health can help with those conditions as well as help stabilize patients’
weight and improve their health by facilitating their nutritional intake.
3
Implementation of the Project
The total number of residents consenting to participate in the project was 37. At project end, one year later, 26
participants remained. The attrition was due to the death of 10 of the participants, and one participant who
withdrew after receiving new dentures. Despite the small number of participants, we feel the results of our
year-long study in this particular patient population strongly confirmed our hypothesis.
One of the goals of this project was to integrate RDHAPs into the dental treatment team within this nursing
facility. RDHAPS are a new category of licensed dental healthcare provider. The RDHAP licensure allows the
RDHAP to provide hygiene treatment without direct supervision from a dentist within a nursing facility. There is
a shortage of dental professionals to provide care in nursing facilities. For example, at the time a contract was
being negotiated with Brookside facility for participation in this project there was a single dentist providing care
for Brookside and 29 other facilities in San Mateo County. No RDHAP was routinely treating residents at
Brookside before our project began. Within the project, RDHAPs were utilized to evaluate residents as if they
were just entering the facility. The RDHAPs provided oral cancer exams for participating residents, prescribed
a daily oral care plan for each resident, trained staff to provide that daily oral care, provided hygiene treatment
and ultrasonically cleaned dentures for the participating residents. Should our recommendations for initial
evaluation of nursing home residents be implemented, the RDHAPs would be a critical participant to fulfill the
increased need for dental providers in the nursing facility setting.
The restorative, prosthetic and oral surgery procedures were provided by an outside entity which the project
did not exert ultimate control over.
There were lessons learned from this project with respect to this particular population that compel us to register
some surprising recommendations for treatment planning. First, we did not anticipate the mortality rate to be
so high in these types of facilities. The time many of these patients have is limited and the delays experienced
in treatment provision must be reduced. Additionally, it is apparent once you work with this population that
treatment planning must take into consideration the patients’ ability to tolerate procedures and adapt to
change, especially new prosthetics. Improving quality of life is not always about providing ideal care in
this population.
We obtained valuable insight as to how the provision of daily oral care and periodic hygiene visits can improve
the quality of life for this patient population. We received positive verbal feedback from some of the patients,
and we were tracking the patients’ cooperation with the RDHAPs at the time of the evaluations. 53% of the
participants had a constant level of cooperation throughout the project. 30.5% of the participants improved
their cooperation as the project progressed, and only 16.5% of the participants had a declining level of
cooperation as the project proceeded. Considering most of these participants suffer from some form of
dementia, this was a far better outcome than we expected.
Comparison Between MDS 2.0 Data and GOHAP Evaluations
In general, the data collected by GOHAP in the participant evaluations allows us to make a direct comparison
between the data recorded on the MDS 2.0 data sheets (see Appendix B) and the data from this project (see
Appendices C,D and E). An explanation as to how this comparison has been made follows.
There are six items available to be checked in the MDS 2.0 data set. They are:
1) Debris at bedtime
2) Full or partial dentures
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3)
4)
5)
6)
Teeth Missing-No Replacement or Patient does not Wear
Broken. Loose or Carious Teeth
Gingival Inflammation, Swelling, Bleeding, Ulceration and/or abcess
Daily Care by Resident or Staff
The first item was not covered by the GOHAP evaluations. However, it was not checked as applicable for any
patient by the nurses in the MDS 2.0 data set. It seems neither the facility nor the RDHAPs performed their
evaluations of the patients at bedtime, so we do not report any discrepancies for the first item.
Item #2: In the GOHAP database, the Dentition Status screen (Appendix C), Prosthetics subheading contains
information as to whether the patient has a FUD, FLD, UPD or LPD. This provides a definitive answer as to
whether item #2 should be checked for each patient, and a direct comparison to the nurses’ records on the
MDS 2.0 dataset.
Item #3: In the GOHAP database, the Dentition Status screen (Appendix C), Prosthetics subheading records
missing teeth and also indicates whether or not the patient has a replacement prosthesis or not. Generally, the
RDHAPs also made notes on the evaluation sheets when they discovered patients had prostheses they were
not wearing. The actual evaluation sheets are scanned into the GOHAP database for reference.
Item #4: Carious teeth would be noted in the GOHAP database in the Follow-Up care section on the
Prescriptions/Referrals screen (Appendix D) with a referral for restorative Tx. Broken teeth can be designated
in the same area by a referral for restorative Tx. When the teeth were broken so badly as to be unrestorable,
the remaining root tips generally were noted independently on the evaluation sheets by the RDHAPs, and
there would be a referral for oral surgery. Loose teeth would be noted in the GOHAP database on the Oral
Health screen (Appendix E) within the designation of Tooth Mobility.
Item #5: In the GOHAP database, the Periodontal Case Type on the Oral Health screen (Appendix E)
provides specific information as to the gingival inflammation, swelling and bleeding noted for any patient.
Item #6: This item was consistently recommended by the nurses and the RDHAPs performing the patient
evaluations.
One patient was removed from the comparison because although he was enrolled in the GOHAP program, he
passed away before an initial evaluation could be performed. So, we have no data to compare to his MDS 2.0
data set.
Overall, if we compare the constellation of boxes checked for each individual patient, the nursing staff
got the same responses as the dental health care professionals just 19% of the time. The discrepancies
in each of the 5 categories we were able to compare are portrayed separately in the bar graph which follows.
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MDS Review
35
30
Patients
25
20
MDS 2.0
GOHAP
15
10
5
0
Full/Partial Dentures
Teeth Missing
Broken/Carious Teeth
Gingival Problems
Daily Care
As we hypothesized, the staff at the nursing facility had difficulty identifying the oral health issues in the MDS
2.0, and therefore cannot be expected to effectively refer patients for follow-up care. This would be mitigated
had the “dental provider of record” had a practice of routinely evaluating all new residents in a timely manner.
Our project evaluated the participants’ records to see just how long the residents were at the facility before
they were examined by the “dental provider of record”.
Days From Admission to Initial Oral Exam
1-30 Days
5%
No Initial Exam
5%
31-90 Days
22%
Over 365 Days
30%
91-365 Days
38%
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Certainly, the delay for most patients was far greater than we would have expected. Remarkably, had our
project not come to this facility, the numbers might have been much worse. It seems that the “dental provider
of record” performed a large number of initial exams on 8/10/2007 when she became aware the facility was
proceeding with the project. We point this out because it does obviate the need for “checks and balances” to
ensure optimal patient care, and the new RDHAP oral health professional can provide just that.
The first participants to be evaluated by the RDHAPs were evaluated in May of 2008. None of these
participants’ records showed any ongoing dental care, or any documentation that these patients had
outstanding dental care requirements. The evaluations revealed a different picture.
Edentulous Patients Requiring Dental Treatment at Initial Evaluation
Tx Required
25%
No Tx Required
75%
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Dentulous Patients Requiring Tx at Initial Evaluation
Hygiene, 100%
100%
80%
Prosthetic, 75%
Restorative, 62.50%
60%
40%
Oral Surgery, 25%
20%
0%
Tx Required
Most of the participants evaluated in May of 2008 did receive periodontal care in the first six months of the
project. Only one patient received care from the “dental provider of record” in that time frame.
Six months later in November of 2008, it was interesting that the “dental provider of record” hastened to
examine some prior and all new project participants just the day before the RDHAPs were scheduled to
perform the project evaluations. For this reason, the November 2008 evaluations reflect more patients with
identified dental needs and treatment in progress. However, the need for hygiene was reduced due to the care
provided in the previous six months. The cumulative graph for the identified needs for the entire project are
below:
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Edentulous Patients Requiring Dental Treatment at 6 Month Evaluation
Tx Required
47%
No Tx Required
53%
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Dentulous Patients Requiring Tx at 6 Month Evaluation
100%
Prosthetic, 84%
80%
Hygiene, 79%
60%
Restorative, 42%
Oral Surgery, 42%
40%
20%
0%
Tx Required
Follow-Up Care
Once the dental needs were identified for the participating population, the task was to provide care for as many
of these patients as possible. In this population, there are obstacles to treatment that would not be normally
encountered in the private practice population. Some patients were too sick to obtain medical clearance for
dental treatment.
As you can also see in the graph below, there were certain patients who were not treated because they or their
guardians declined treatment. We endeavored in this project to provide funds for those patients who did not
have insurance so that care would not be declined for financial reasons.
The patients who declined treatment did so for various reasons, not always known to the project. In some
instances, the mental status of the patient certainly factored in. Similarly, those patients who were declared
“uncooperative” were categorized as such because RDHAPs and the “dental provider of record” uniformly
found themselves unable to proceed with treatment, despite best efforts.
Some patients died before treatment could be rendered, and we certainly found that the mortality rate in this
population was much higher than we anticipated, as it appeared the healthiest residents were generally the
residents who personally, or through their guardians, agreed to participate.
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Treatment Perspective
30
25
Patients
20
No Tx
Uncooperative
No Medical Clearance
Declined Tx
Deceased
Received Tx
15
10
5
0
Periodontal
Prosthetics
Restorative
Oral Surgery
In this graph we also show the participants who received treatment as well as the participants who, for no
verifiable reason, did not receive care they needed from the “dental provider of record”. All patients requiring
periodontal treatment received care from the RDHAPs in the project.
In light of the mortality rate of this population, it seems prudent to evaluate the timeframe during which dental
care was provided. See the graph below which segregates the timeframe of care by procedure:
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Timeframe of Tx
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14
Number of Patients
12
10
No Tx
9-12 Months
6-9 Months
3-6 Months
Less Than 3 Months
8
6
4
2
0
Periodontal
Prosthetics
Restorative
Oral Surgery
Certainly different procedures have predictably different times for provision of treatment. Periodontal treatment
(in this setting periodontal treatment refers solely to hygiene procedures) as well as restorative treatment and
oral surgery require only medical clearance and perhaps a week of lead time to complete the process.
Prosthetics understandably has a much longer time frame because of the treatment itself, and the requirement
for pre-authorization by Denti-Cal and private insurance.
It seems appropriate to point out that patients in this resident population were not considered candidates for
periodontal surgery by the project. From a practical standpoint, the intense level of follow-up home care
essential for surgical success is improbable due to physical and mental limitations of the patients and the time
constraints of caregivers. Further, the health of most residents is too compromised for this type of treatment.
These considerations make the probable financial barriers irrelevant.
The graphs below segregate the timeframe of treatment by provider—RDHAPs who provide periodontal
treatment, and the “dental provider of record” who provides prosthetic treatment, oral surgery and restorative
treatment. Specifically, we are looking at the amount of work identified and completed after the initial
evaluation and during the timeframe of the project.
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Tx by RDHAPs
6-9 Months
Less Than 3 Months
3-6 Months
Tx by Dentists
Less Than 3 Months
3-6 Months
No Tx
6-9 Months
9-12 Months
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Evaluation of Treatment Outcomes
The periodontal care made participants more comfortable, their breath better and, for some, improved their oral
and overall health. We had hoped to be able to quantify these findings, but we find it difficult to do so.
Because these participants had different medical doctors of record, the use of A1c tests was not universal or
consistent for each diabetic patient. Therefore, it would be impossible to accurately state the improvement in
their prophylactic and daily oral care assisted in controlling their diabetes; although the scientific studies
support that conclusion. (Add cites).
We have discovered it is not realistic in this population to assess whether our improved oral care for these
patients effectively halted the progress of periodontal disease or even reversed it. Without accurate data that
assessed the patient’s status at admission, it is impossible to determine when the periodontal damage
occurred and how rapidly. Many patients entering these facilities have been at home attempting to care for
themselves, and their inability to do so is why they were admitted into a skilled nursing facility in the first place.
These patients likely had serious periodontal disease at admission. Serious periodontal disease cannot be
reversed; at best it can only be stalled with meticulous home care. Meticulous home care in a skilled nursing
facility, with patients generally affected by some form of dementia and xerostomia from numerous medications
is an impossible dream.
However, our proposed program of effective screening of new admissions by a dental health professional
could provide each new resident the opportunity to have a daily oral care plan tailored to their needs.
Additionally, referral for periodic periodontal treatment, if appropriate, would be initiated immediately, not
months or years later when the “dental provider of record” gets around to an initial exam.
In the case of prosthetic treatment (which is by far the predominant care provided by the “dental provider of
record”), we have compiled Case Studies for the residents who received prosthetic care. These allow us to
examine this aspect of patient dental care in greater depth. See Appendix F.
Observations Regarding Prosthetic Treatment
These case studies obviate the need for a different approach to care for edentulous patients in these types of
facilities. The relevant observations would be:
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Patient mortality is high and the time delay for a dentist to examine the patient and Denti-Cal to
approve new dentures leaves patients without any relief for extended periods of time.
Patients are often impaired both physically and mentally in such a manner that they are unable to
adapt to new dentures.
Patients often have physical oral characteristics that are very unfavorable to fabricating new
dentures that will be both comfortable and functional for the patients.
From a patient cooperation and tolerance perspective (as well as financial constraints on the
dentist) generally a new denture is fabricated after just one or two appointments. This does not
allow for the customization that would ensure a denture that fits and functions well.
Communication regarding new denture discomfort is erratic at best. Often patients will hide the new
dentures that hurt rather than wear them, or just insist on going back to the old dentures, if they
exist.
The delays in getting the dentist out to the facility to adjust new dentures are a hardship upon the
patient.
The failure rate of new full dentures in this project was 100%, excepting one patient who we were
unable to obtain follow-up data for because she died shortly after delivery of her new dentures.
A single patient received a lab reline of her dentures, and that outcome was unsatisfactory as well.
The patient receiving a new partial denture hid the appliance and was clearly unsatisfied with it.
However, it is possible with adjustment the patient could be comfortable with his new appliance.
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•
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The lack of communication between the patient, facility staff and dentist was contributory in this
apparent failure of care.
There was one reported success in prosthetic care. This was the repair of a partial denture.
The physical changes these patients go through (weight fluctuations or hormonal issues which can
affect bone mass) can render adequate dentures ill-fitting in short periods of time. Case in point;
Irene Featherstone. There needs to be a stopgap measure to ensure patient comfort and ability to
eat.
Recommendations for Prosthetic Care
1) The soft denture reline or “tissue conditioning” procedure (D5850 and D5851) would have been a better
clinical choice for these patients, excepting the patient who had a new partial denture fabricated, and
the patient who had a partial denture repaired. Had tissue conditioning been provided for these
patients, the fit and function of their old dentures would have been immediately enhanced.
2) A tissue conditioning procedure can help the provider determine whether the patient would have a good
result with a denture remake, especially if the provider intends to open the bite or make other
substantive changes with the new dentures.
3) Tissue conditioning is a procedure that can be performed bedside by a dentist, with minimal
involvement of the patient and in a short period of time. The expense to do so is minimal.
4) Tissue conditioning is reimbursed by Denti-Cal and requires no prior approval; and in these facilities
should be the treatment of choice for full denture patients with ill-fitting or poorly functioning dentures.
5) Tissue conditioning provides the opportunity for a patient’s tissue to reach optimal health, and the
patients love the comfort this procedure provides. The only downside to this procedure is the lack of
longevity. Denti-Cal does allow multiple iterations of this treatment within specified time frames.
Lessons Learned
Quality of oral care in nursing facilities is not adequate, however we can solve most shortcomings and improve
these residents’ quality of life with relatively few modifications in the current infrastructure. In short, we need to
do three things:
•
Mandate a dental professional (DDS, DMD, or RDHAP) evaluate each incoming resident and complete
the Oral Status and Disease Prevention section of the MDS 2.0 in a prescribed time frame.
•
Mandate that within this intake evaluation by a dental professional (DDS, DMD, or RDHAP) each
incoming resident receive an oral cancer exam, referrals for immediate oral care needs and a written,
customized daily oral health care plan.
•
The physician’s intake physical exam paperwork for patients in these facilities must include a medical
clearance form for dental care. The form we developed for this purpose in the project is a part of
Appendix A. Our experience in this project has shown we need additional safeguards to ensure that no
patient is ever provided oral care/treatment without appropriate medical clearance.
From a practical standpoint, the following points must be emphasized:
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•
The implementation of the newly created licensure category RDHAP will assist in providing adequate
dental personnel to fulfill patient evaluation and care needs. RDHAPs can also be utilized to train
facility staff to efficiently implement oral care regimens for the residents.
•
RDHAPs will also provide a “check and balance” in following the oral care and treatment of the patients.
Having a second dental health professional involved will bring in a second set of eyes to ensure that
patient needs are not overlooked.
•
The changes we propose in the system will relieve the facility staff and physicians from the burden of
recognizing and caring for oral conditions they are not specifically trained to address.
•
Implementation of our recommendations is cost-effective because in the short term the expense is
minimal. In the long term our recommendations for preventive oral care would certainly save on overall
heath care costs. It is a long established principle that early diagnosis of disease provides the patient a
far better outcome at a significantly lower cost to the system.
•
Treatment planning must take into consideration the patients’ ability to tolerate procedures and adapt to
change, especially new prosthetics. Improving quality of life is not always about providing ideal
care, but we can provide higher quality oral care every single day.
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Appendix A.
Medical Clearance Form
Within the project itself, Dr. Valente reviewed patient records for each of the participants and submitted these
forms to the patients’ physicians of record for completion. The review of the patient records is a very timeconsuming process in this circumstance. This is precisely why the “dentist of record” for this project did not
always obtain medical clearance from the physician prior to medical treatment. After the project was complete,
the RDHAPs who continued patient care at Brookside complained about the difficulty in updating clearance for
care. If a new physician will be following the patient after admission, this form should be forwarded to the
referring physician for completion as a part of the admission process. If the same physician will continue care,
they should fill this form out at admission, checking off the relevant health conditions themselves.
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Appendix B. MDS 2.0
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Appendix C. Dentition Status
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Appendix D. Prescriptions/Referrals
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Appendix E. Oral Health
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Appendix F. GOHAP Case Studies for Patients Receiving Denture Tx
Patient #l
Admitted to Brookside on 6/18/2004
Initial oral exam by Dentist on 8/10/2007
GOHAP referral for prosthetics upon first RDHAP evaluation 5/08
Dentist’s notes on 11/14/2008: denture old, teeth worn, vertical dimension overclosed by 2mm, patient shows
good motivation for treatment.
2/7/09: FUD and FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation—After 3 adjustments, pt. is currently wearing old FUD and FLD, pt.
has denture sores and new dentures do not fit well.
Additional data: Patient has lost 44 pounds since admission in 2004, 10 pounds in the last year.
Patient #2
Admitted to Brookside on 5/1/2007
Initial oral exam by Dentist on 8/10/2007
Dentist’s notes on 11/14/2008: patient confused (but motivated for Tx?), dentures loose, vertical dimension is
OK.
GOHAP did NOT refer for prosthetics upon first RDHAP evaluation 11/15/08. It was noted that bone in
posterior is poor.
3/31/09: FUD and FLD lab reline delivered to patient
OUTCOME: At 5/09 GOHAP evaluation—Patient is unsatisfied with fit of dentures, has denture sores on lower
left, and the lower prosthesis is still ill-fitting.
Additional data: Patient has lost 5 pounds since admission 2 years ago.
PATIENT NEVER RECEIVED MEDICAL CLEARANCE FOR TREATMENT
Patient #3
Admitted to Brookside on 8/9/2002
Initial oral exam by Dentist on 8/10/2007
GOHAP referral for prosthetics upon first RDHAP evaluation 5/08
Dentist’s notes on 11/13/08: partial dentures contraindicated due to periodontal condition
GOHAP did NOT refer for prosthetics upon second RDHAP evaluation 11/15/08.
2/16/09: UPD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation —RDHAPs report patient is not wearing UPD, it has been hidden.
When retrieved and placed in patient’s mouth he complains #4 clasp is too tight—needs adjustment.
Additional data: Patient has lost 27 pounds since admission in 2002, 10 pounds in the last year.
Patient #4
Admitted to Brookside on 11/29/2005
Initial oral exam by Dentist on 8/10/2007
GOHAP referral for prosthetics upon first RDHAP evaluation 5/08 as FLD is painful
Dentist’s notes on 8/7/08: Patient does not want new dentures, but DDS is recommending new FUD/FLD
12/5/08: FUD/FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation —Patient complains there is pain when wearing new dentures, they
do not fit, only wears dentures to eat.
Additional data: Patient has gained 24 pounds since admission in 2005.
Patient #5
Admitted to Brookside on 7/15/2005
Initial oral exam by Dentist on 8/10/2007
GOHAP referral for prosthetics upon first RDHAP evaluation 5/08
Dentist’s notes on 8/7/08: FUD/FLD is adequate—no Tx recommended
Dentist’s notes on 11/14/08: FUD/FLD ill-fitting and worn, recommend new FUD/FLD
2/7/09: FUD/FLD delivered to patient
OUTCOME: Patient died before 5/09 evaluation by project—no report on whether FUD/FLD were functional
for patient.
Additional data: patient lost 17 pounds since admission in 2005.
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Patient #6
Admitted to Brookside on 2/28/2008
Initial oral exam by Dentist on 10/3/2008
Dentist’s notes on 11/14/08: patient overclosed by 2mm, dentures old, recommend new FUD/FLD
GOHAP did NOT refer for prosthetics upon first RDHAP evaluation 11/15/08.
1/12/09: FUD/FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation--After 2 adjustments FLD still fits poorly, patient has denture sores LL.
Additional data: Patient’s weight has remained stable since admission.
Patient #7
Admitted to Brookside on 11/21/2006
Initial oral exam by Dentist on 10/3/2008
Dentist’s notes on 11/14/08: dentures old, recommend new FUD/FLD
GOHAP’s RDHAP examiners were told by patient she was getting new dentures at evaluation 11/15/08.
1/26/09: FUD/FLD delivered to patient
OUTCOME: Patient left the project and did not undergo 5/09 evaluation. However, Director of Nurses advises
in May 2009 patient is still suffering with new dentures. Record shows 5 denture adjustments in February and
March.
Additional data: PATIENT HAD NOT RECEIVED MEDICAL CLEARANCE FOR TREATMENT AT THE TIME
DENTURES WERE FABRICATED.
Patient is experiencing ongoing weight loss (29 pounds in the last 6 months).
Patient #8
Admitted to Brookside on 6/15/2007
Initial oral exam by Dentist on 8/10/2007
Dentist’s notes on 11/14/08: recommend new FUD/FLD
11/15/08 GOHAP evaluation included oral surgery referral to remove root tips and subsequent prosthetics
referral for new FUD/FLD.
4/20/09: FUD/FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation--Patient cannot wear new dentures as they are ill-fitting. RDHAP
notes no extractions of root tips performed which contributes to poor fit.
Additional data: Patient gained 3 pounds since admission in 2007.
Patient #9
Admitted to Brookside on 6/15/2007
Initial oral exam by Dentist on 8/10/2007
Dentist’s notes on 11/14/08: recommend new FUD/FLD to maintain TMJ health
11/15/08 GOHAP evaluation—patient did not have dentures available for evaluation, aware new dentures to be
fabricated.
2/24/09: FUD/FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation—Patient is not wearing new dentures, both are ill-fitting.
Additional data: Patient has gained 20 pounds since admission in 2007.
Patient #10
Admitted to Brookside on 9/5/2007
Initial oral exam by Dentist on 6/2/2008
GOHAP referral for prosthetics upon first RDHAP evaluation 5/08
Dentist’s notes on 6/16/08: Patient refuses prosthetic treatment.
Dentist’s notes on 11/14/08: Patient agrees to LPD repair
GOHAP evaluation by project RDHAPs on 11/15/08—note LPD repair in progress
1/14/09: repaired LPD delivered to patient.
OUTCOME: At 5/09 GOHAP evaluation--Patient seems satisfied, no denture sores under repaired LPD
Additional data: Patient gained 13 pounds in first 9 months after admission, but has lost those 13 and an
additional 21 pounds in the last year.
Patient #11
Admitted to Brookside on 11/19/2007
Initial oral exam by Dentist on 8/7/2008
GOHAP did NOT refer for prosthetics upon first RDHAP evaluation 5/08
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Dentist’s notes on 8/7/08: Patient’s dentures adequate, but patient wants new dentures (based upon cost) so
DDS is recommending new FUD/FLD
Dentist’s notes on 11/14/08: FUD/FLD ill-fitting and worn, recommend new FUD/FLD
GOHAP did NOT refer for prosthetics upon second RDHAP evaluation 11/15/08
New dentures rejected by Denti-Cal, lab reline accepted
2/6/09: lab relined dentures delivered to patient
OUTCOME: At 5/09 GOHAP evaluation—After 4 adjustments, LFD is still loose, ill-fitting. Patient is not
satisfied with relined dentures, DDS is recommending new dentures again.
Additional data: Negligible weight loss.
Patient #12
Admitted to Brookside on 11/4/2008
Initial oral exam by Dentist on 11/14/2008
Dentist’s notes on 11/14/08: denture old, vertical dimension is closed by 2mm, good motivation for treatment
but poor lower ridge.
GOHAP referral for prosthetics upon first RDHAP evaluation 11/15/08--lower prosthesis loose
12/17/08: new FUD/FLD delivered to patient
OUTCOME: At 5/09 GOHAP evaluation—After one adjustment, the patient has denture sores under lower
denture, the lower denture is ill-fitting and causes pain when patient chews.
Additional data: No weight loss.
NOTES ON AN ADDITIONAL CASE:
Patient #13 was referred by GOHAP for prosthetic treatment upon evaluation in May of 2008. Patient #13 was
treatment planned for a new FUD/FLD by DCOP in November of 2008. However, the Denti-Cal request was
denied because a new FUD/FLD had been fabricated for the patient in September of 2007. The patient had
experienced only a slight weight gain in the time since receiving the new dentures in 2007.
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