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The Dentist's Perspective


Michael Wiseman
Toronto , Canada
Reprinted from Caring for Aging Holocaust Survivors, Baycrest Centre for Geriatric Care

Dentists may find themselves working with older Survivors in the community and the long-term care setting. The primary role of the dentist is the identification, prevention, and treatment of diseases affecting the head and neck region. This would involve a strong prevention program to prevent caries and periodontal disease.


An important element of dental care is the rehabilitation of the oral cavity. This could involve the restoration of carious teeth or the replacement of missing teeth by dentures or implants. Once the patient has received treatment, it is vitally important to maintain the oral cavity through a strong prevention program.


As Holocaust Survivors age, they are confronted by a variety of comorbidities that can affect their oral cavity. Many seniors are affected by arthritis that limits their dexterity to be able to maintain adequate oral hygiene. Furthermore, they may be taking many medications both by prescription or over-the-counter which cause a dry mouth or xerostomia. This condition will increase their vulnerability to caries and periodontal disease. Additionally, a dry mouth reduces denture retention in the edentulous (toothless) patient.


The dentist must be aware that many procedures are potential triggers of past experiences and can yield many painful memories. Many patients may not admit to having dental pain. It was known that those Holocaust concentration camp inmates that complained of pain were sent to the infirmary to never return.

 

Case Study 

Mrs. S. is an eighty-three year-old who survived two concentration camps. At her last camp, she was raped and beaten, and spent three days in the infirmary. As a result of the attack, she lost many teeth. Once she was liberated from the camps, she eventually emigrated to Montreal where she lived with an aunt who came to Canada before the war. She met her late husband in Montreal and they had four children.


Her children moved to Toronto fifteen years ago from Montreal and she had lived with her husband in their home until five years ago when he died a slow painful death of pancreatic cancer. She then lived with her eldest daughter until she began to develop moderate symptoms of Alzheimer's dementia. Subsequently, Mrs. S. was admitted to a nursing home and placed into a “ward” room with three other patients. Due to her many missing teeth, she was given a soft pureed diet. She began to yell out for her mother and father every night when the lights went out in the room. The nursing staff began to receive many complaints from the other patients and their families. The physician responded by prescribing antidepressants and anxiolytic medications to clam her. She soon developed cavities and mouth sores. These problems were noticed by her companion one day when she was cleaning her teeth. Mrs. S. never complained of any pain. She was referred to the dental department. Upon her being reclined into the dental chair with the dental light turned on, she began once again to cry out for her mother. She began to hit out at the dentist. Her hands were gently restrained by the assistant so that the dentist could conduct a cursory exam. Her mouth revealed many carious and broken teeth, a fungal infection and a large traumatic ulcer. She was rebooked for future treatments with sedation.

 

Dental Issues Raised in Case Study
Patient had dementia and was treated for her nightly outbursts with medications that have a side effect of inducing a dry mouth (xerostomia).
The xerostomia caused multiple caries, periodontal disease and ulcers.

The bright light from the dental chair and her recline in a supine position were triggers to remembering past experiences.

She refused to admit to having any discomfort. She became a silent sufferer.

Her poor dental status dictated the consistency of her food.


Impact of Chronic Illness
As Survivors age, comorbidities such as heart disease, dementia, and arthritis increase their exposure to health care professionals and possibly eventual admission to a long-term care facility. In the example above, Mrs. S. did not admit to having any pain as this would historically demonstrate a weakness that would require one-way trip to the infirmary and the crematorium. The dentist must be aware of this lack of self-reporting and must be vigilant in their examination. Additionally both the physician and dentist must be aware that many medications are xerogenic leading to dry mouths. This would affect the ability to speak, and chew, and would increase the rate of caries, periodontal disease, traumatic ulcers and fungal infections. Additionally, a dry mouth can affect the simple but important task of kissing a loved one.

 

Potential Triggers in the Dental Environment


The dental team must be sensitive to possible procedures, treatments and elements within the dental environment that may trigger difficulties for Holocaust Survivor patients. Smells of asepsis could yield thoughts of past medical clinics. Bright lights could be a trigger of past interrogations or guard towers. The wearing of a mask and gloves or simply having the patient recline in the dental chair could trigger the memory of past medical experimentations. If the dentist has to use any electrosurgery that yields the smell of burning tissues, this could be a trigger to the smell of the crematoria. The use of gas sedation (nitrous oxide) could be a trigger to images of gas chambers. Patients may also have an innate distrust of both dentists and physicians as they were often involved in the selection process to who would live or perish.


The rehabilitation of Mrs. S.s' dentition would enable her to enjoy many different foods. During the period of forced confinement, meals often consisted of diluted soups, potato scraps and occasional coffee. A functioning dentition would allow patients to eat varied food sources that would be more appealing and perceived as more edible. Additionally, patients with poor dentitions would often prefer to eat foods that are extremely moist and soft with high sugar content. This would increase the caries rate of these patients.


Impact on Family
Children of Survivors may be indulgent in their parent's dental treatment. They don't want their parents to “suffer” anymore by either the dental problem or its treatment. The dentist must involve the family in the treatment process and are an important aid in the explanation of the treatment options to the patient.


Tips for the Dentist:

  1. Tell, Show, and Do . Explain to both your patient and the Survivor's children if present, the treatment plans for the patient. Repeat the explanation using different words as the patient may pick up specific terms that would aid in the explanation. Use body language. Use a mirror so that the patient could visualize their dentition and point to a specific tooth when discussing a particular tooth. If available and appropriate, use dental models to explain the concepts of dentures and implants.
  2. Provide the patient with tinted glasses . The glasses will provide safety in case of a foreign object entering the eye, but will also decrease the potential of the bright light becoming a trigger.
  3. Verbalize that you are putting on a mask and gloves and they will be going backwards in the dental chair. This will involve them in what is about to happen and will decrease the element of surprise.
  4. Use a high speed suction to eliminate the odor generated during electrosurgery. Carefully selected room deodorizers will decrease the smells generated by the asepsis of the dental clinic.