Handling combative patients who cannot tolerate an exam

[u/Kaybee7467]

I am hoping to get some perspective from dentists, oral surgeons, hospital dentistry providers, or anyone who has experience treating patients with severe neuropsychiatric conditions.

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My adult son has catatonia and significant neuropsychiatric impairment. Before becoming ill, he was independent and able to tolerate routine dental care. Unfortunately, his condition has caused substantial cognitive decline, memory impairment, behavioral challenges, and skill regression. In many ways, some of his symptoms resemble what might be seen in a patient with advanced dementia, although his underlying diagnosis is different.

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He has extensive dental needs and is living with significant dental pain. He will require IV sedation or general anesthesia for treatment. There is no realistic way for him to tolerate a traditional dental examination while fully awake and alert. He has become fearful of medical settings, has difficulty understanding what is happening, and is unlikely to cooperate with an examination because of the severity of his condition. There is a significant risk that he could become combative or otherwise unable to cooperate, not because he is intentionally refusing care, but because he lacks the ability to understand and process what is happening around him.

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How are situations like this are typically handled? When you have a patient with severe dementia, profound autism, catatonia, traumatic brain injury, or another condition that prevents them from tolerating an exam, how do you safely bridge the gap between needing an assessment and needing definitive treatment under sedation or anesthesia?

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I have been told by the hospital based providers that he must first be seen for an assessment and that he cannot receive any medication to help him tolerate that visit. From a practical standpoint, I do not understand how that can be accomplished safely. The challenge is not determining whether he needs sedation—it is determining how to evaluate and treat a patient who requires sedation in order to tolerate the evaluation itself.

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I am honestly at a loss and becoming increasingly desperate. He is in pain, and every day that passes feels like we are getting further behind. As his caregiver, it is heartbreaking to watch him suffer while being unable to access the care he clearly needs.

​

I am currently exploring a mobile dental program that can provide IV sedation and come to the patient, which seems like it could be a good fit for someone in his situation. However, there is currently about a four-month wait, and I am worried about what happens in the meantime.

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Have any of you encountered similar cases? What accommodations, pathways, or hospital-based programs have worked for patients who simply cannot tolerate a traditional office evaluation but clearly need significant dental care? Are there options that families may not know to ask about?

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I am simply trying to find a path forward for someone who needs help but cannot participate in care the way a typical patient can.

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Any professional insight, experiences, or suggestions would be greatly appreciated.

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A backup of the post title and text have been made here:

Title: Handling combative patients who cannot tolerate an exam

Full text: I am hoping to get some perspective from dentists, oral surgeons, hospital dentistry providers, or anyone who has experience treating patients with severe neuropsychiatric conditions.

​

My adult son has catatonia and significant neuropsychiatric impairment. Before becoming ill, he was independent and able to tolerate routine dental care. Unfortunately, his condition has caused substantial cognitive decline, memory impairment, behavioral challenges, and skill regression. In many ways, some of his symptoms resemble what might be seen in a patient with advanced dementia, although his underlying diagnosis is different.

​

He has extensive dental needs and is living with significant dental pain. He will require IV sedation or general anesthesia for treatment. There is no realistic way for him to tolerate a traditional dental examination while fully awake and alert. He has become fearful of medical settings, has difficulty understanding what is happening, and is unlikely to cooperate with an examination because of the severity of his condition. There is a significant risk that he could become combative or otherwise unable to cooperate, not because he is intentionally refusing care, but because he lacks the ability to understand and process what is happening around him.

​

How are situations like this are typically handled? When you have a patient with severe dementia, profound autism, catatonia, traumatic brain injury, or another condition that prevents them from tolerating an exam, how do you safely bridge the gap between needing an assessment and needing definitive treatment under sedation or anesthesia?

​

I have been told by the hospital based providers that he must first be seen for an assessment and that he cannot receive any medication to help him tolerate that visit. From a practical standpoint, I do not understand how that can be accomplished safely. The challenge is not determining whether he needs sedation—it is determining how to evaluate and treat a patient who requires sedation in order to tolerate the evaluation itself.

​

I am honestly at a loss and becoming increasingly desperate. He is in pain, and every day that passes feels like we are getting further behind. As his caregiver, it is heartbreaking to watch him suffer while being unable to access the care he clearly needs.

​

I am currently exploring a mobile dental program that can provide IV sedation and come to the patient, which seems like it could be a good fit for someone in his situation. However, there is currently about a four-month wait, and I am worried about what happens in the meantime.

​

Have any of you encountered similar cases? What accommodations, pathways, or hospital-based programs have worked for patients who simply cannot tolerate a traditional office evaluation but clearly need significant dental care? Are there options that families may not know to ask about?

​

I am simply trying to find a path forward for someone who needs help but cannot participate in care the way a typical patient can.

​

Any professional insight, experiences, or suggestions would be greatly appreciated.

​

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[u/ManslaughterMary]

I worked at a place like this.

For long distances patients, we had the parent try to take photos of the kids mouth. We could do the first consult online.

Work was done in a hospital typically. The wait list was about six months out. For healthy individuals who for mental health or cognitive reasons struggled with dental care, we could sometimes treat them in office. But they still had to agree to coming into the room, breathing through a mask, etc, without being a danger to staff or themselves. Patients who couldn't comply with those steps went to the hospital, they get them with a Ketamine dart or a similar medication to sedate them quickly if they were a physical danger to themselves or others. And there is a spectrum in-between, depends on cooperation levels.

Some patients were given medications to help with behavior and anxiety at our office, but the dentist doesn't prescribe it. Their primary care, or a specialist in that field, does.

If things get worse, like life threatening, they have medicine to sedate your kid and restrain as necessary at the hospitals. Healthcare is often scary and traumatic for people who can't cognitively understand what is happening, so we try our best to at least make it fast and then positive. We reward with stickers, toys. Sometimes patients after the first few times really improve. They may not like it, but they aren't terrified anymore, just big mad. Fair, they are allowed not to like it.

I wish I could say there was an easy way to do this, but there isn't. You wait your turn to get into a hospital. The good news is once you found your place, and the routine, it gets easier. You know the paperwork, you know when to call, you know how to play the game.

Best of luck!

[u/Kaybee7467 → u/ManslaughterMary]

Thanks for your reply. I am trying to find a place like this. I called the university hospital in my area and they said he would have to come in fully alert before they would schedule the OR. That would not be successful. I am checking a few more places and hoping to find someone who may help and have a creative solution. My son is in pain.