Care for bedridden patients, in Primary Health Care dentistry, in the peripheral region of São Paulo, Brazil

O cuidado ao paciente acamado, na odontologia da Atenção Primária a Saúde, em região periférica de São Paulo, Brasil

ABSTRACT

Objective:

The objective is to describe the actions and activities carried out by the dentist during home visits.

Methods:

The experience took place during visits to users of the Basic Health Unit UBS Vila São Pedro in the Municipality of São Bernardo do Campo, a peripheral region with a lot of socioeconomic vulnerability, recording the periods from January to December 2022. The actions and activities described were cataloged as basic levels in health care: promotion, prevention, and diagnosis of soft tissue injuries and damage limitation. Dentists carried out 84 home visits with the purpose of offering oral health care to users restricted to bed, health promotion actions and activities were based on encouraging the practice of healthy habits, making caregivers of bedridden patients aware of the importance of oral hygiene, and how care should be carried out in the oral cavity of these patients where they no longer have the capacity for self-care.

Results:

The prevention actions were oral hygiene instruction mainly aimed at caring for patients who have restricted movements and who depend on a caregiver to perform oral hygiene, brushing or cleaning with gauze soaked with 0.12% chlorhexidine, and topical application of fluoride to the patients who still have dental elements. The other actions to limit pre-existing oral damage were tooth extractions with periodontal involvement.

Conclusion:

Therefore, dentist-in-home visits play a fundamental role in promoting quality of life and social life for patients who cannot go to a Basic Health Unit due to being temporarily restricted or permanently restricted to their home.

Indexing terms
Home visit; Visitors to patients; Community dentistry

RESUMO

Objetivo:

Onde o objetivo é descrever as ações e atividades desenvolvidas pelo cirurgião-dentista nas visitas domiciliares.

Métodos:

A experiência ocorreu em visitas aos usuários da Unidade Básica de Saúde UBS Vila São Pedro no Município de São Bernardo do Campo, região periférica e de muita vulnerabilidade socioeconômica, sendo registrado os períodos de janeiro a dezembro de 2022. As ações e atividades descritas foram catalogadas como níveis básicos na atenção à saúde: promoção, prevenção e diagnóstico de lesões de tecidos moles e limitação de dano. Os dentistas realizaram 84 visitas domiciliares no propósito de oferecer os cuidados em saúde bucal aos usuários restritos ao leito, as ações e atividade de promoção em saúde basearam-se no estímulo à prática de hábitos saudáveis, conscientizando os cuidadores dos pacientes acamados, a importância da higiene oral, e como deveria ser realizado os cuidados na cavidade bucal desses pacientes onde os mesmos não possuem mais a capacidade o autocuidado.

Resultados:

As ações de prevenção foram instrução de higiene oral principalmente orientado os cuidados do paciente restrito de movimentos e que depende de um cuidador para realizar a higiene bucal, escovação ou higienização com gaze embebida com clorexidina a 0,12%, e aplicação tópica de flúor aos pacientes que ainda apresentam elementos dentários. As demais ações de limitação de danos bucais já pré-existentes foram extrações de dentárias com envolvimento periodontal.

Conclusão:

Sendo assim, os dentistas nas visitas domiciliares assumem um fundamental papel de promoverem qualidade de vida, e social aos pacientes que não podem ir até a uma Unidade Básica de Saúde por estarem restritos de forma transitória os permanentemente restritos ao domicílio.

Termos de indexação
Visita domiciliar; Visitas a pacientes; Odontologia comunitária

INTRODUCTION

The home visit is characterized by a set of health promotion, protection, and disease treatment actions, provided at home, which consists of the Oral Health Team, going to the home of the patient who is restricted at home, being an extramural action, where it allows establishing links with users, getting to know the reality of the community and understanding the dynamics of family relationships, with a guarantee of continuity and comprehensiveness of care, provided for in the Family Health Strategy program [¹-⁴].

The Oral Health Team (ESB) is part of the Family Health Strategy (ESF), which is a form of reorganization of continuous primary care and constant programmatic activities [³-⁶]. The ESF signals that for effective changes in the quality of life of users, the focus of attention must be focused on the individual, assisted in their social space, taking into account their discoveries, through a multidisciplinary team, more resolute and integrative practical movements, with epidemiology as the structuring basis of collective actions [⁷,⁸].

The basic, ethical, and doctrinal principles of the Sistema Único de Saúde (SUS, Unified Health System) are followed during home visits, such as comprehensiveness, offering care to the user within the three levels of care; universality, including users restricted to bed and unable to travel to a health unit for dental care; and equity, meeting the needs of those most in need of health care, also highlighting the reception of bedridden patients, where humanization is presented, giving the user the right to be assisted, in a transmitted and unique way [⁹-¹²].

These principles strengthen the bond between patients and family members and Primary Health Care health services.

Just like the doctor and nurse, the ESF dentist needs to carry out periodic home visits, to offer health care to the bedridden individual, in addition to contributing to health promotion and prevention and providing a better quality of health. health. life to the patient, in the context of incurable diseases, to the terminal patient, the performance of curative procedures restoring or improving oral health for these patients [³,⁴].

Experience description

A 74-year-old female patient, following a stroke three months ago, has no history of cigarette or alcohol abuse, and her daughter denies that her mother has any comorbidities. During a home visit, as illustrated in figures 1, 2, and 3, it was evident that the patient required dental care. The dentist proceeded with an oral cavity cleaning and provided the daughter with oral hygiene guidelines, demonstrated through figures 4 and 5, to maintain her mother’s dental health. Continuous monitoring of the patient’s oral hygiene is being carried out by the Family Oral Health Team from the UBS São Pedro, while her daughter remains responsible for daily care.

Figure 1
Intraoral assessment being carried out by the dentist on a patient after stroke, with restriction to permanent bed.

Figure 2
Initial oral condition of the beed-bed patient.

Figure 3
Intraoral view of the patient’s oral condition without proper care.

Figure 4
The dentist providing oral hygiene guidance for the caregiver

Figure 5
The dentist demonstrating how the patient’s oral hygiene care should be carried out to the caregiver, and encouraging him to maintain oral hygiene habits.

Oral care for bedridden patients must not be overlooked, as diseases of the mouth persist even when mobility is compromised. In fact, poor oral hygiene, coupled with other underlying health conditions, may lead to further complications. Thus, regular dental care for bedridden individuals is crucial to prevent the worsening of oral and systemic health conditions.

In the homes of bedridden users, whether elderly or young adults suffering from the aftermath of urban violence or transport accidents, the dental team provided guidance on quality of life and oral hygiene. This included instructions on proper tooth brushing, the use of dental floss, and general oral care. For patients diagnosed with oral cancer, clinical dental examinations were conducted, and the dentist requested a team meeting with the Family Strategy Support Center (NASF) to arrange psychological support, aiding patients in coping with malignant diseases and treatments such as chemotherapy and radiotherapy. Moreover, the home visits allowed for clinical monitoring of stomatognathic lesions.

Health promotion and prevention activities were also carried out in the homes of dependent and semi-dependent elderly patients. These included education about systemic health, addressing conditions like hypertension, diabetes mellitus, and Alzheimer’s disease, along with encouraging healthy lifestyle changes, such as regular physical activity and medical check-ups. In terms of oral health, instructions were provided on tooth and prosthetic hygiene, changes in oral tissues, and the identification of potential lesions. Special care was taken for patients with disabilities, including those affected by a Cerebrovascular Accident (CVA), with oral health instructions tailored to the family’s level of understanding and care capabilities.

Family members and caregivers play a vital role in health education, as they are key to ensuring bedridden patients receive appropriate care. The importance of home visits for these individuals, who are unable to access Basic Health Units, cannot be overstated. The procedures and activities performed by dental surgeons during home visits are fundamental in maintaining the oral and overall health of bedridden patients, ensuring they receive the necessary care despite their physical limitations.

This study aims to report the experience of dental surgeons conducting home visits as an essential tool to ensure access to oral health care for patients who, due to various reasons, are unable to travel to a Basic Health Unit (BHU).

The focus is on describing in detail the actions and activities performed by these dental professionals during home visits, exploring how these interventions impact the patients’ oral health and quality of life.

The emphasis is on health promotion, disease prevention, and the treatment of lesions, particularly in patients facing socioeconomic vulnerabilities.

METHODS

This project approved by the Research Ethics Committee of the Universidade Municipal de São Caetano do Sul under number CAAE: 67390823.8.0000.5510.

The study was conducted through the experience gained during home visits carried out by the oral health team from the UBS Vila São Pedro, located in São Bernardo do Campo, São Paulo, a peripheral region marked by significant socioeconomic vulnerability.

The visits were conducted from January to December 2022, involving 84 bedridden patients who were unable to visit the health unit due to temporary or permanent physical limitations.

The actions performed by the dental surgeons were classified into three basic levels of oral health care: health promotion, prevention, and diagnosis and damage limitation. Each visit was carefully planned and documented, not only addressing immediate oral care but also providing continuous guidance to family caregivers.

To guide these actions, a literature review was conducted using databases such as MedLine, PubMed, and Google Scholar, alongside a consultation of ministerial ordinances and technical standards governing home dental care. These sources helped structure the best practices and protocols for treating bedridden patients.

Health promotion actions involved educating caregivers on the importance of maintaining oral hygiene for bedridden patients, who often lose the ability to care for themselves. Dentists provided instructions on proper tooth brushing, flossing, and maintaining prostheses when applicable. They also promoted healthy habits, including reducing the intake of cariogenic foods.

Prevention actions focused on instructing caregivers on oral hygiene practices for patients with reduced mobility. The use of gauze soaked in 0.12% chlorhexidine was demonstrated as an alternative to brushing in more severe cases. Additionally, fluoride was topically applied to patients who still had teeth, aiming to prevent the development of caries and other oral complications.

As for damage diagnosis and limitation actions, dental surgeons performed tooth extractions when periodontal disease had severely compromised the teeth. These procedures were crucial in improving patient comfort, especially in terminal cases or those with chronic diseases that significantly affected oral health.

RESULTS

The 84 home visits yielded concrete benefits for the oral health and quality of life of bedridden patients. In all cases, interventions focused on health promotion and disease prevention contributed to reducing complications related to poor oral hygiene, such as gingivitis and periodontitis.

Moreover, the caregivers’ awareness was critical. Most caregivers, usually family members without formal health training, showed significant improvement in their ability to maintain the oral health of the patients in their care. The use of chlorhexidine-soaked gauze, for instance, became a common practice, improving the oral condition of patients unable to perform conventional brushing.

The application of topical fluoride helped protect the remaining teeth, particularly in cases of xerostomia caused by medications or systemic conditions. In cases where tooth extraction was necessary due to severe periodontal disease, the procedures were safely performed in the home environment, relieving pain and preventing secondary infections.

The emotional and psychological impact of these visits was also significant. Bedridden patients, often isolated, felt valued by receiving care in their own homes, promoting a greater sense of dignity and well-being. The visits also strengthened the bond between health professionals and the community, bringing dentists closer to the daily realities faced by these families.

DISCUSSION

The Home Care Manual in Basic Health Care states that the caregiver, who is normally a member of the family, in turn, does not have specific technical training in the area of health, but can be qualified by health professionals to carry out basic tasks at home, assisting in the recovery of the person assisted [¹,²,¹³,¹⁴].

It is extremely important that the responsibilities are clearly defined between the health teams towards the family and the caregiver, within a continuous process of exchanging knowledge, powers, and responsibilities. He is willing to take on this care function in the best possible way, creating a supportive work bond, to achieve the objective of improving the health conditions and comfort of the bedridden patient [³-⁵].

In individuals in the aging phase, there is a prevalence of chronic diseases, psychosocial and physical dysfunctions, and extensive use of drugs. Due to these considerations, it is necessary for dental surgeons to evaluate the oral health conditions of their elderly patients from the perspective of their interrelationship with the individual’s general health conditions and quality of life [¹¹,¹²].

When the user depends on assistance to perform this task, guidance to the direct caregiver is necessary, individualized, and appropriate for each patient, taking into account all obstacles [⁴,⁸,¹²,¹⁵,¹⁶].

Care, such as adequate oral hygiene and dentures, when present, helps to improve the quality of life of the bedridden person. Attitude, understood as a predisposition to adopt self-care actions, can be taught and learned. Likewise, it is influenced by cognitive, motivational, and emotional components [⁹,¹⁰,¹⁷].

The necessary dental interventions begin with guidance on oral health, which includes instructions on oral hygiene and appropriate prosthetics; use of facilitating instruments; medication prescription, if necessary; diet guidance; removal of harmful habits; use of gels and artificial saliva for patients with xerostomia. Whenever necessary, contact the patient’s attending physician for further clarification, exchange of information, and adjustment of conduct (therapeutic or medication) for the benefit of the patient [¹⁵,¹⁶,¹⁸].

A referral must be made for care at an appropriate level of care (Basic Health Unit, Dental Specialty Center with a specialist in patients with special needs) if the demand for dental treatment is identified [⁹,¹⁰,¹⁸].

The Oral Health Team, at the time of the home visit, must let go of their prejudices, critically analyze their conceptions, values , and attitudes, always seeking to understand the other individual. Observing and embracing each family routine, and respecting their cultural and religious diversity, priorities and socioeconomic vulnerabilities, and their biological aspects that determine their daily lives, the dentist will know how to insert their primary objective in this context, which is the promotion of oral health [⁷,⁸,¹²].

CONCLUSION

Home visits by dental surgeons are essential for ensuring equitable access to oral health care, particularly for patients who, due to physical limitations, cannot travel to a health unit. These visits promote not only oral health but also overall quality of life, contributing to the physical, social, and emotional well-being of bedridden patients.

Home care enables the humanization of health services, ensuring that the needs of these patients are met in a dignified and individualized manner. Preventive and health promotion actions are crucial in avoiding more severe complications, and the curative procedures performed at home help relieve pain and prevent infections that could further compromise the patient’s general health.

This article highlights the importance of incorporating dental surgeons into Family Health Strategy (FHS) teams, emphasizing that home visits are essential for providing comprehensive, continuous, and humanized care tailored to the specific needs of a population often neglected by traditional health services.

How to cite this article

• Abrante BLA, Sanches CR, Munhoz L, Silva HAB, Silva JS, Freitas CF. Care for bedridden patients, in Primary Health Care dentistry, in the peripheral region of São Paulo, Brazil. RGO, Rev Gaúch Odontol. 2024;72:e20240028. http://dx.doi.org/10.1590/1981-86372024002820230079

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Edited by

Assistant editor: Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  07 Oct 2024
• Date of issue
  2024

History

• Received
  10 Sept 2023
• Accepted
  17 Oct 2023