The care of the patient in a state mental institution offers a unique and challenging opportunity. With innumerable needs to be met, one is frequently faced with the almost insurmountable task of deciding priorities of patient needs. Often, with limited resources at one's disposal, the job of restoring psychologic function becomes a great challenge indeed.
The loss of autonomy that has resulted in the patient's hospitalization frequently also results in his need for adequate nourishment and a protective environment. When this is compounded by physical problems, effective coordination of available hospital resources will often cause a resident to be much better prepared to cope with the exigencies of life in the institution.
In many cases, the age of the exceptional patient is usually fairly well advanced, and his maladaptive patterns of behavior, which cut him off from society, are rather well established. Thus, added to physical and mental deficiencies are the psychologic characteristics that make him exceptional and represent another limitation in the program to minister to him.
In order to approach the care and treatment of such a patient, one must be aware of all the factors involved. The main effort must be to change his pattern of functioning by altering certain behavioral habits. The patient himself must have a need to change, and he must understand that he has a problem that may not be obvious. Upon being made aware of the problem, he must be apprised of the consequences of ignoring it.
If the patient is to be persuaded to cooperate, he must have a good relationship with his therapist. Once this is established, the patient's obligation in time, personal effort, and responsibility must pay off. His rewards are his comfort, improved appearance, and increased ability to function. AU these needs must be met before he can be motivated to react to the challenges for realization of his greatest potential in society.
One aspect of the multidimensional presentation of patient needs is dental care. The selfimage is his attitude towards appearance, selfesteem, and sexual appeal; any improvement has a profound effect on his life-style. To restore his self-esteem is one of the major components in resocialization - an important step toward regaining autonomy.
Ostensibly, a patient with decayed teeth and poor oral hygiene, often resulting in offensive mouth odor, will have little or no interest in making this step. There is no question that enhancement of self-image has a profound psychologic effect on the patient.
The facilities of the mental hospital permit accessibility of the patient for an extended period for evaluation of his physical and mental conditions. The physician-dentist consultation provides an unusual opportunity to review factors contributing to the patient's disorder.
Medications that are necessary to relieve an acute condition are administered during the patient's confinement. The ultimate referral to a clinic, private practice, home care, nursing home, or mental health center will be determined by the availability of the physician's armamentarium and professional consultation.
In screening our recipients for care, we find rather gross neglect of oral hygiene. Any plan to improve oral hygiene, however, is often overshadowed by the more pressing needs of personal custodial care, programs for patient improvement, and adequate personnel to attend the patient.
DENTAL TREATMENT AND CRITERIA
The role of the dentist, therefore, must be to determine the needs that are the most pressing and to suggest a practical plan of treatment that wiil provide the greatest amount of relief as expeditiously as possible. Inasmuch as total dental care is rarely a brief procedure, treatment programs may require much preparation, step by step, to attain oral health. Nonetheless, the opportunity to evaluate is indeed greater when the patient is confined in the hospital.
Perhaps the most distressing of conditions to observe is the disturbed patient debilitated as a result of the overall physical problem, compounded by mental incapacitation and the inability to express the physical pain that underlies an acute oral infection. The role of the psychiatric aide and ward nurse in becoming alert to the patient's need for oral care, usually expressed by his behavioral patterns, and the subjective observation of his physical condition are very important.
By means of preliminary screening, the physician-dentist may then gain insight into probable future oral complications. A practice in our facility has been to follow a routine wardby-ward examination with on-site examinations using portable examining equipment.
Each dental referral must be treated on an individual basis with an evaluation of the complete medical history and behavioral reactions, which can best be learned from the patient's attendants.
There is no substitute for communication between the dental team and those responsible for the daily care and welfare of the patient.
There is no single format or criterion to deal with the multitude of mental disorders with which a dental team will be confronted. For the most difficult patients to manage, schedules should be made in such a way as to minimize trauma to the patient from the procedures to be followed. The appropriate utilization of psychotropic drugs as adjuvant premedication to enhance cooperation will give significant aid to patient management.
For those who require even more special management, it is mandatory for the safety of the patient and attendant personnel that a specific treatment plan be designated and reviewed well in advance of the contemplated procedures. To design a course inappropriate to the difficult management of a patient may result in further psychic trauma and physical harm.
ALCOHOL TRAINING UNIT
During the treatment period for alcoholism, the patient becomes aware of his personal demeanor and requests dental care.
The pain threshold is usually low and healing is often delayed following indications for oral surgery procedures, and hematologic problems are often encountered.
The awareness of this is extremely important to the attending dentist, since postsurgical sequelae often ensue.
CRISIS INTERVENTION UNIT
In the crisis intervention unit, where patients stay on a short-term basis, we experience a variety of conditions. A high incidence of tooth loss due to advanced periodontal disease, as well as coronal fractures of the teeth, is common. In many instances, however, a pretext of oral pain is used in an effort to obtain analgesics and narcotics.
These patients present a particular problem during consideration of the rationale for treatment. In cases wherein clinical history has been particularly stormy, evaluation of the treatment plan should be made in consultation with a psychiatrist.
During treatment, the acute mental disorders may relate to such conditions as impacted third molars; malposed, impacted teeth in various quadrants of the mouth; acute periapical infections unheeded at the time of admission; and results of masochism while the patient is hospitalized. The etnologie factors for which the patient is selected for treatment should be carefully scrutinized.
The fact that a voluntary patient will request a given treatment whereas the involuntary patient is incapable of rendering a decision concerning his personal needs is also a circumstance that is met daily in hospital practice.
Many of the patients who are now confined will undoubtedly present for treatment in private practice, owing to the current mode of therapy with psychotropic drugs. One must be alert to a complete medical history when attending any patient, particularly with the extended-care facilities that are now being promulgated under the mental health system.
In this category, cases of indefinite confinement and routine examination are subjects for preventive dentistry as far as the capacity of the patient may warrant.
With the present trend of encouraging the patient to return to his usual life in society, and legislation enabling the handicapped to secure their fair share of employment, a total review and compliance with optimum health for such pursuits bring an added emphasis on dental function, appearance, and the total fulfillment of oral needs.
Even in the most idealistic environment, dental treatment, in itself, is not something to look forward to as a pleasant experience. It is therefore not uncommon to find extreme apprehension in a mental facility regarding acceptance of treatment. The examining team must be friendly in demeanor, promoting a nonthreatening attitude to the recipient.
Of great concern for these patients is the budgetary allowance for the extraordinary care that should be provided if funds are available for staff and the necessary equipment and supplies.
The dental department must be consistently updated with new techniques, and it cannot efficiently operate without modernization and adaptation as the need arises.
The woeful inadequacy of the tools of delivery of care should be the concern of the legislators. Adrninistrative attitudes toward finances mean very little to the patient who cannot have sufficient custodial care, cleanliness, and medical attention.
The expansion of services as recently encouraged under our system will unquestionably require an expansion of basic education of dentists who choose to serve in such a capacity.