17th Annual AMMA Conference

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17th Annual AMMA Conference
Hobart- Tasmania THE SPECIAL NEEDS IN THE
DENTAL CARE OF VETERANS SUFFERING FROM
PTSD By GPCAPT (Retd) Norton. Duckmanton. OAM,
RFD, MDS, FRACDS, Adj. A/Professor,
Prosthodontist. Sydney South West Oral Health
Service Incorporating Sydney Dental Hospital 2
Chalmers Street, Surry Hills, NSW 2010 Tel 61 2
9293 3235 Fax [phone] Email
Norton.duckmanton_at_email.cs.nsw.gov.au The help
of Dr. John Pickering MB. BS, FRANZCP. in the
production of this presentation is gratefully
acknowledged
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• INTRODUCTION
• DVA beneficiaries treated at this center, who
  have served in the Vietnam Conflict and diagnosed
  as suffering from P.T.S.D., present daunting
  challenges in their Dental Treatment Strategies.
• It is now recognised that those who were P.O.W.
  of the Japanese in W.W.II, suffered P.T.S.D. in a
  more severe form, which was aggravated by the
  fact that it was ignored and thus they received
  no specific treatment for this syndrome at all.
• It is acknowledged that W.W. I veterans who
  experienced trench warfare were also similarly
  affected. It was termed Shell Shock then.
• Veterans from peace keeping and combat
  deployment can be expected to be similarly
  affected.
• It must also be recognised that their families
  also are adversely affected and their welfare is
  seriously at risk.

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• COMMON SYMPTOMS DISPLAYED BY PTSD PATIENTS
• DENTAL SYMPTOMS
• The main overt dental symptoms are-
• Bruxism - This causes pathological wear and
  damage to the natural teeth and appliances due to
  overload. This is seen as cusp fracture, broken
  restorations and dentures and implant failure.
• Muscle spasm and pain due to para functional jaw
  movements of masticatory and postural musculature
  is also seen.
• Xerostomia (dry mouth) as a result of anti
  depressant medication (indeed, if is not present,
  the dose is too low!).
• Uncontrollable caries of calcified dental
  structures will result because saliva has a
  diluent and buffering of PH effect, carries
  antibodies and mucins.
• Loss of retention of maxillary complete dentures
  due to lack of saliva which provides lubricating
  mucins and atmospheric seal.
• Frictional irritation of dry mucosal denture
  bearing structures to produce painful ulceration.
• Poor gingival health

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• GENERAL MEDICAL SYMPTOMS
• Sleep disturbances
• Apnea
• Nicotine, alcohol drug dependency and abuse
• Prescription drug side effects
• Prohibited drug abuse
• Diabetes
• Hypertension
• Obesity

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• PSYCHIATRIC AND LIFESTYLE SYMPTOMS
• Heightened response to stressful situations
• Depression
• PTSD
• Altered responses to work place, life style,
  interpersonal and family relationships.
• Family breakdown, divorce and a suicide of
  children incidences significantly greater than
  the national average

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• SHIFT IN EMPHASIS
• Traditionally, dental care is mainly focused upon
  TEETH and associated structures, independent of
  any in-depth appreciation of the patients
  emotional needs.
• PTDS patients require much more! Such as-
• Consideration of the psychiatric aspects of the
  general and emotional health.
• Their management needs to include input from
  Psychiatric and allied Mental Health specialists
  as well as Dentists.
• It is considered that only under these conditions
  may the most effective regimen be provided.

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• TREATMENT SUGGESTIONS AND GUIDELINES
• It is suggested that the Dental Management of
  patients with PTSD be divided into four phases.
• Phase I
• Diagnostic Phase
• Phase II
• Emergency and Provisional Phase
• Phase III
• Restorative and Definitive Phase
• Phase IV
• Maintenance Phase

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• DIAGNOSTIC PHASE I
• General history- openly discuss PTSD
• Be prepared for
• Anger at Dental, Medical and DVA entities
• Reluctance to relinquish control (e.g removal of
  teeth with poor prognosis) would be seen as a
  surrender
• Drug, alcohol and nicotine abuse.
• Family and relationship breakdown
• Unreliability in attendance
• Veterans with P.T.S.D. are more likely to trust
  Health Care Professionals who are veterans and
  have seen active service themselves.
• Establish rapport with patient and significant
  family member.
• Determine patients expectations.
• Obtain name of patients psychiatrist and
  establish communication with him/her.

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• DIAGNOSTIC PHASE I (CONT)
• Obtain relevant Dental History.
• Prescription drug regimen - particularly
  Antidepressant Medication which causes
  Xerostomia.
• Routine Records charting and evaluation of hard
  and soft Tissue, X-rays and mounted study casts.

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• PROVISIONAL TREATMENT PHASE II
• Guidelines-
• Dental condition likely to be in a chaotic state
• Attend to all causes of pain and discomfort as a
  result of Bruxism and Xerostomia. There may be
  wide spread caries activity and fractured teeth.
• Caries control.
• Discuss with Psychiatrist the choice of
  antidepressant medication to limit Xerostomia.
• Prescribe artificial saliva substitute.
• Develop oral hygiene programme.
• Provide occlusal splint to limit damage due to
  bruxism and alleviate parafunctional activity and
  muscle pain. These may be of the hard acrylic or
  soft vinyl resin types such as a mouth guard.

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• RESTORATIVE AND DEFINITIVE PHASE III
• Guidelines-
• Design simple and robust restorations to
  withstand stresses of at least double the normal
  values.
• Keep as simple and a - traumatic as possible.
• Delay loading of implants to allow a greater
  degree of osseointegration.
• Provide protective splints to protect tooth
  structure and reduce para functional activity,
  during treatment and upon completion of it.

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• MAINTENANCE PHASE IV
• Guidelines-
• Review at regular yearly intervals.
• Monitor and reinforce oral hygiene instruction,
  caries control and dentures.
• Monitor occlusal splint wear and keep functional
  by occlusal adjustment, or modifications.
• Review implant bone levels, screw integrity and
  soft tissue health.

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• CONCLUSION
• Veterans with PTSD have many seemingly unrelated
  symptoms which affect their dental health and
  these should be recognized and treated
  accordingly.
• A close relationship between the Dental and
  Medical Specialities, is essential and the role
  of the psychiatrist is of particular importance
  in the management of these cases.
• This paradigm shift in the dental needs of these
  patients should be recognized because Veterans
  from future peace keeping and combat deployments
  can be expected to suffer PTSD to a greater or
  less degree.
• It is imperative that this is recognized and
  treated appropriately, so that their
  rehabilitation will be successful.
• If this can be achieved, they and their families
  may be more able to enjoy a normal quality of
  life, relatively unaffected by their military
  service.