Dental care for the patient with a spinal cord injury
J . Richard Durnan, DDS Robert Thaler, DDS, Bronx, New York
Various devices such as a wheelchair lift and mo bile dental equipment facilitate the treatment of paraplegic or quadriplegic persons in private of fices. Some special considerations are necessary during a dental procedure to allay the patient's anxieties, such as fear of asphyxiation. Most im portantly, the dentist must instruct the patient in proper oral hygiene since the masticatory func tion of the teeth is necessary for the general health of these persons. Preventive dentistry is especial ly important for the quadriplegic who may use his teeth to perform certain activities.
Traumatic injury to the spinal cord can be suf fered by persons in automobile accidents, sports, violence, or mishaps at home or work. Polio myelitis, tumors, and degenerative diseases also may injure the spinal cord. Whatever the cause, the injured person suffers irreparable damage. A t best, he looks ahead to a lifetime o f moving about in a wheelchair, perhaps dependent on others for his basic needs. 1318 ■ JADA, Vol. 86, June 1973
Present-day medical care provides the injured person with the prospect o f an ever-increasing life span and has as its goal his ability to manage the activities o f daily living (A D L). Treatment at a spinal cord injury center, such as the one at the Bronx Veterans Administration H ospi tal, is carried on in an atmosphere o f reality: the goal o f the patient’s management of daily ac tivities is sought with understanding and help, not with sympathy and pity.
Paraplegia and qua d rip le g ia Persons with spinal cord injuries are referred to as paraplegic individuals if the lower extremi ties are involved, or quadriplegic individuals if both upper and lower extremities suffer loss of sensation and motor function. There are many gradations o f impairment within these two broad categories; both involve loss of bladder and bowel control. Some paraplegics require only minimum as sistance and manage to carry on their A D L us ing a wheelchair, crutches, and leg braces. These individuals are regarded as being almost as un encumbered as uninjured persons. In some in stances, the individual’s range of mobility may be further extended by the use o f hand controls in an automobile. Toward the other extreme are
Fig 1 ■ Electric-powered wheelchairs controlled by patient’s chin movements.
those patients who, although not confined to bed, are capable of only limited head movement. However, even these quadriplegics attain a cer tain degree of mobility through the use of de vices such as the electric-powered wheelchair controlled by the patient’s chin, his breath, or his eye movement (Fig 1).
dental chair is moved and the litter is positioned adjacent to the fixed dental unit. Of course, mo bile equipment would provide greatly increased flexibility. U se of good suction equipment and the rubber dam decreases the possibility of the patient’s ingesting or aspirating small objects. Impressions can usually be made with little dif ficulty, even though the patient may be in a su pine position.
Hospital dental care In the hospital, patients with spinal cord injur ies may be seen by the dentist at many stages of their progress after the injury. In the early stages, physical as well as psychological con siderations may preclude all but the most nec essary emergency treatment. Palliative care such as the placement o f sedative restorations can be accomplished at the patient’s bedside with a limited armamentarium. A s conditions become more favorable, comprehensive dental care can be rendered. U se of equipment de signed for bedside use will facilitate treatment of the patient who may not be transported easily to the hospital dental clinic. If possible, how ever, it is more convenient for the dental team to operate in the dental clinic. Patients on lit ters may be treated in the dental clinic if the
Treatm ent of the patient in a w heelchair The patient in a wheelchair may be treated in either a hospital dental clinic or in a private prac titioner’s office. The patient who is to transfer from the wheelchair to the dental chair requires no special treatment. If the person must remain in his wheelchair, however, a device should be available that can position the wheelchair prop erly. Such a wheelchair lift has been developed and is in use at the West Roxbury Veterans A d ministration Hospital (Fig 2). Other modifica tions of the customary dental-chair base are commercially available. In the absence of spe cial equipment, the wheelchair may be posi tioned behind a dental chair with a prosthetic-
Durnan—Thaler: DENTAL CARE FOR PATIENT WITH SPINAL CORD INJURY ■ 1319
Fig 2 ■ The wheelchair lift developed at West Roxbury Veterans Administration Hospital.
type headrest; the headrest then is reversed to support the patient’s head. Or, the dental chair may be moved, permitting the wheelchair to oc cupy a position adjacent to the dental unit (Fig 3). Both of these positions, although awkward and fatiguing for the dentist, permit the delivery o f all types of dental treatment to the patient.
Some special considerations The paraplegic or quadriplegic who comes to the dental office seeking treatment will be equip ped physically and psychologically to take his place in the mainstream of daily life. Thus, the dentist need not hesitate to ask the patient any questions concerning his limitations of move ment or position. The patient will probably feel more at east than the dentist who is unfamiliar with this type of injury. The dentist may notice that a patient in a wheelchair frequently shifts his weight in the chair. This is not a sign of pain or o f restlessness; the patient has trained him self to shift position frequently to avoid pres sure sores. Some practitioners who have encountered problems in treating patients with spinal cord injuries have ascribed them to apparent patient disinterest and extreme sensitivity to any manip ulation o f the oral tissues. Any sensitivity is probably a result of a tracheostomy performed during emergency phases of treatment, with subsequent shrinkage of air passages and loss o f function of some or all of the respiratory mus culature. Difficulty in controlling fluids in the mouth, coupled with impaired cough and gag 1320 ■ JADA, Vol. 86, June 1973
Fig 3 ■ Wheelchair next to dental unit. Headrest on reversed dental chair Is used.
reflexes, may add to the patient’s fear of asphyx iation. The thought of these hazards can greatly increase the patient’s anxiety and unwillingness to undergo dental procedures. However, the empathetic attitude of the concerned dentist will almost invariably allay the fears and anxi eties of his patient.
P r e v e n tio n
n e c e s s a ry
The patient with a spinal cord injury can bene fit from all types of dental treatment; his injury does not limit the care he receives. However, the degree of injury may limit the dental care that the patient provides for himself—his daily oral hygiene. It is extremely important that paraplegics and quadriplegics carry on a meticu lous daily oral hygiene program. Good personal preventive dentistry will obviate the need for repeated trips to the dental office for restora tive procedures. Maintenance of optimum oral health is of prime concern to the person with limited or no finger or arm movements, since the teeth are used to hold various objects. The teeth may be used to perform many operations, from opening wallets to holding page-turners, sculptor’s tools, and typing instruments (Fig 4). D iet and fluid intake are of the utmost impor tance to the paraplegic and quadriplegic to en sure general health and especially to maintain the healing ability of tissues and the optimum function of excretory mechanisms. The proper maintenance of the masticatory mechanism con tributes greatly to good health and is an integral part of the rehabilitation of the patient with a spinal cord injury. The dentist must educate the paralyzed pa tient in proper home care of the mouth and teeth; it is the responsibility of the hospital staff to do the same for patients under their care. Patients who cannot care for themselves will be encoun tered, especially in hospitals. In such instances, the dentist should see that the patient’s oral hy giene needs are met by paraprofessional staff members. Disinterest on the part o f the patient, ignorance of the importance of preventive oral hygiene on the part of the staff, and lack of per sonnel may impede the development o f an effec tive preventive dentistry program. Neverthe less, each injured patient must be given the op portunity of benefit from such a program. Spinal cord injuries have no predilection for persons of one age group, race, creed, color, or place of national origin. The individuals who re ceive such injuries have the same good and bad traits, the same strengths and weaknesses, and the same personal, family, social, and economic problems as the remainder of the population. In addition, these persons have the problems of paraplegia or quadriplegia. In our treatment of these patients, we should approach them as unique individuals, in the same manner that we deal with all our patients. The treatment of a
Fig 4 ■ Quadriplegic patient demonstrates mouth-held typing instrument (usually used with electric typewriter).
person with a spinal cord injury is often com plicated because of physical limitations, but it is gratifying to participate in the effort to help another person overcome those limitations. Additional information on various aspects of spinal cord injuries may be obtained from na tional and state organizations including the Para lyzed Veterans o f America, 3636 16th St, NW , Washington, DC 20010; and the National Para plegia Foundation, 333 N Michigan A ve, Chi cago, 60601.
Summ ary The dentist can contribute to the well-being of the individual suffering from a spinal cord in jury. A realistic approach to spinal cord injur ies, coupled with modern medical care, enables an increasing number of paraplegic and quadri plegic persons to participate in everyday life. We may assume that more persons with these injuries will seek care from the dentist in private or hospital practices. We have discussed fac tors that are pertinent to the treatment o f para plegics and quadriplegics and have emphasized the importance of the preventive philosophy of dental care.
The authors thank Dr. Peter C. Hofstra, director, spinal cord injury service, Veterans Administration Central Office, Washing ton, DC, for his assistance In preparing this article, and Dr. Eugene E. Fischer, Veterans Administration Regional Program Coordinator and former chief, dental service, Veterans Adminis tration Hospital, West Roxbury, Mass, for his encouragement and the permission to use the photograph (Fig 2). Dr. Durnan and Dr. Thaler were staff dentists, Bronx Veterans Administration Hospital, at the time of the preparation of this article. Dr. Durnan is a staff dentist, Veterans Administration Hospital, Northport, NY 11768. Dr. Thaler is a resident in peri odontics at the Manhattan Veterans Administration Hospital.
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