Oral Health: Adults with Traumatic Brain Injury: A Guide for Dental Professionals

Oral Health Fact Sheet for Dental Professionals Treating Adults with Traumatic Brain Injury

Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. (National Institute of Neurological Disorders and Stroke/NIH)

Prevalence

TBI is significantly more common among males

• 8–9% lifetime prevalence among individuals 30–59 years of age
• Average annual rate: Emergency Department Visits and Hospitalizations:
  • 20–24 years of age = 668.8:100,000
  •  >75 years of age = 572.6:100,000
  • Other ages intermediate
• 1.7 million individuals sustain a TBI each year in the United States:
  • 52,000 die
  • 275,000 are hospitalized
  • 1.4 million (nearly 80%) are treated and released from an emergency department
• TBI is a contributing factor to nearly a third of all injury-related deaths

Manifestations

General

• Wide range of functional changes affecting thinking, language, learning, emotions, behavior, and sensation.
• TBI can cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.

Clinical

• Cervical spine injury
• Spasticity, rigidity, and ataxia/tremors
• Feeding disorders including dysphagia
• Behavior change (impulsivity, changes in activity level, aggression, irritability, social withdrawal, and apathy)
• Cognitive impairments (learning disability, memory problems, and difficulty with visual spatial and visual motor tasks)
• Language disorders
• Vision and hearing impairments
• Sleep disturbances/sleep apnea

Oral

• Oral/dental trauma from TBI or self-injurious behaviors
• Bruxism
• GERD
• Inadequate oral hygiene due to cognitive impairments, spasticity and ataxia

Potential Other Disorders/Concerns

• Seizures
• Depression/Anxiety
• Post-traumatic stress disorder
• Personality disorders
• Substance abuse

Management

Medication

The list of medications below are intended to serve only as a guide to facilitate the dental professional’s understanding of medications that can be used for Traumatic Brain Injury or conditions associated with TBI. Medical protocols can vary for individuals with TBI, from few to multiple medications. Manifestations from TBI vary; therefore, a wide range of medications may be prescribed:

Behavioral

Depending on the presentation and severity of the brain injury, the patient may have difficulty cooperating in the dental chair and adhering to oral hygiene regimens.

• Plan a pre-appointment (in person/phone) to discuss the patient’s special needs prior to the first visit, if necessary.
• Determine the level of cognitive and functional abilities and explain each procedure at the appropriate of understanding. Use short, clear instructions. Use Tell-Show-Do approach when introducing new procedures if necessary. Give positive verbal reinforcement. As appropriate, provide verbal and/or tactile reassurances.
• Do not force limbs into unnatural positions or attempt to stop uncontrolled body movements. Exert a firm,
  gentle pressure to calm shaking limbs.

Dental Treatment and Prevention

• As tolerated, consider prescribing a mouth guard for patients with severe bruxism or self-injurious behavior.
• Dysphagia management during treatment: Place the patient in as upright position as possible to keep airway open, with head turned to one side. Use suction (high volume helps to minimize aspiration) frequently or as tolerated and consider lower utilization of water.
• Ask patient (or caregiver) for medication updates at each appointment. Medication changes can affect the appropriate care of the patient from a medical and/or appointment management standpoint.
• Powered toothbrushes may be too stimulating for some adults and should be recommended only after determining if the adult will tolerate one.
• Seizure management during treatment: Remove all dental instruments from the mouth. Clear the area around the dental chair.  Stay with the patient and turn patient to one side. Monitor airway to reduce risk of aspiration. Note time seizure begins: if seizure continues >3 min call EMS – Danger of Status Epilepticus
  (potentially life threatening)
• As needed for patients with xerostomia:
  • Educate on proper oral hygiene (brushing, flossing) and nutrition.
  • Recommend brushing teeth with a fluoride containing dentifrice before bedtime. After brushing, apply neutral 1.1% fluoride gel (e.g., Prevident 5000 gel) in trays or by brush for 2 minutes. Instruct patient to spit out excess gel and NOT to rinse with water, eat or drink before going to bed.
  • Recommend xylitol mints, lozenges, and/or gum to stimulate saliva production and caries resistance.

Some patients with Traumatic Brain Injury are fed by tube. Patients fed by tube typically have low caries, rapid accumulation of calculus, GERD (Gastro-esophageal Reflux Disease), oral hypersensitivity, and are at high risk for aspiration in the dental chair. Swallowing difficulties may occur with thin or thick liquids. No antibiotic premedication is needed for Gastric or Nasogastric tubes. Position the patient in as upright a position as possible and utilize low amounts of water and high volume suction to minimize aspiration

Look for signs of physical abuse during the examination. Note findings in chart and report any suspected abuse as required by law. Abuse is more common in people with developmental disabilities and often manifests in oral trauma.

References

• Corrigan, J.D., Whiteneck, G., Mellick, D. (2004) Perceived needs following traumatic brain injury. J Head Trauma Rehabi. (3):205–16.
• Centers for Disease Control – National Center for Injury Prevention and Control
• Andrews, K. (2005) Rehabilitation practice following profound brain damage. Neuropsychological Rehabilitation 12(3): 461–472
• Taylor, HG., Yeates, KO., Wade, SL., Drotar, D., Stancin, T., Minich, N. (2002) A prospective study of short- and long-term outcomes after traumatic brain injury in children: behaviour and achievement. Neuropsychology, 16: 15–27.
• McKinlay, A., Grace, R.C., Horwood, L.J., Fergusson, D.M., Ridder, E.M., MacFarlane, M. (2008) Prevalence of traumatic brain injury among children, adolescents and young adults: Prospective evidence from a birth cohort. Brain Injury, 22(2): 175-81.

Additional Resources

• NIH Institute for Traumatic Brain Injury
• Brain Injury Association of America
• ASTDD – Special Needs
• Block Oral Disease, MA
• Free of charge CDE courses: NIDCR CDE (2 CDE hours)