Capt. Nicholas Makrides, DMD, MA, MPH, Chief Dentist at the Federal  Bureau of Prisons/ US Public Health Service answers questions correctional nurses have about dental issues.

What should nurses look for in a dental screening?

A screening examination is to be brief.  What you want to know is:  Is the patient in pain, does he or she have an active infection, and are there any lumps or bumps present or mouth sores that are not healing? Briefly review the patient’s health history (drug and alcohol substance abuse, HIV disease, and diabetes ). Next, conduct a hard tissue exam (look at the teeth). It is most helpful to get acquainted with what normal mucosa should look like.  Look for suspicious lesions on the tongue (dorsal, lateral borders, and under the tongue).  Often times we get in a hurry to counts holes in teeth but forget to conduct a soft tissue exam.  No one dies of periodontal disease and caries. However, missing an oral cancer is life threatening and if a patient survives he or she could be disfigured for life.

How do we tell the difference between mouths that look merely ugly and those with a condition that needs urgent attention?

If you encounter a patient with plaque laden teeth and rampant decay you know that that home care is not a high priority.  Refer the patient to dental services and take time to explain to the patient how to adequately brush and floss their teeth.  You don’t have to be a dentist or a hygienist to explain oral hygiene. Oral health literacy is a problem and we have to remember some of our patients are not from the US.

Flossing in controversial in corrections. What do you recommend?

Floss has been used and modified for nefarious purposes.  It has been dangled out high rise building to introduce contraband , tied into rope ladders, and has been used to strangle other inmates.   The list goes on.  However, precut floss, flossers, awesome floss are good alternatives to spool floss.  There are also many other dental aids out there that are a suitable replacement ( Gum Picks, Proxy Brushes, floss loops).  More than one alternative is needed as patients can present with special needs such as bridges, implants, braces, and misaligned teeth.

How can nurses determine if the mouth pain requires immediate dental attention or can be seen at the next available opening?

A toothache can be a fairly painful experience. Here is how a nurse should proceed to assess dental pain to determine treatment.

• Assess the pain using the pain scale (1 -10)
• Determine what incites the pain: thermal sensitivity (cold vs hot), biting pressure, constant pain, recent dental procedure.
• Have the patient describe the pain: continuous, intermittent, transient
• Have the patient  locate the pain by pointing to the tooth or area of the mouth. Sometimes the pain can be referred by an adjacent tooth or come from the opposite arch.
• Check the tissue for swelling. Check to see if the tooth is fractured. This helps to determine if the pain is from the soft tissue or from the tooth itself.
• Obviously a toothache that has kept a patient up all night due to unremitting pain needs to see the dentist immediately.
• Patient that are having  intermittent pain or occasionally occurring pain can usually be given pain meds and appointed to the dental office at the next available appointment.
• If there are cardinal signs of infection an antibiotic should be given.
• It is important that nurses have standing orders and afterhours access to a dentist to discuss those gray areas.

What medical conditions have oral manifestations that nurses should be aware of?

There a host of diseases and conditions that can cause oral manifestations.   This can range from poly pharmacy issues that may have created a xerostomia for the patient, metabolic disease, patients undergoing radiotherapy, auto immune diseases (Sjogrenes and Scleroderma), and immunocompromised  patients.  Diabetes can have a damaging effect on the peridontium  especially in patients with poor metabolic control.  In fact, periodontal disease is now considered the sixth complication of diabetes along with retinopathy, neuropathy, nephropathy, macrovascular disease and altered wound healing.  In one study, the relative risk for periodontal disease is 2.6 times greater for patients with type II diabetes.   Diabetics are at risk for soft tissue lesions, lichen planus, candidiasis, burning mouth syndrome and tooth loss due to periodontal disease. Nurse have a great opportunity to help diabetic patient with oral health through education during chronic care visits.

 

Have you been surprised by dental conditions in your correctional nursing practice? Share your experiences in the comments section of this post.