Bringing Dental Care Home with Gabrielle Mahler, DDS

I've had this happen as well, where I take off a denture or and I look and I'll see a huge sore and mouth and I say, oh my goodness, this poor thing, it must be so painful and you just adjust the denture. It's a very quick fix. You put it in, I had it happen with a patient a few weeks ago, actually. And I put it in and you could see right away, they're so much more comfortable. They don't even have to tell you. Oh, it feels better, because you could see that it feels better.

Hello, and welcome to dementia discussions, the podcast for and about caregivers. If you'd like to share your caregiving story with me, I'd love to hear it. Please call me at 310-362-8232 or email me at dementia discussions dotnet. Today on the show, I am thrilled to have Dr. Gabrielle Mahler. Dr. Mohler is a mobile dentist, along with her partner, comprehensive mobile dental care. She and Dr. Top run around LA. We are so fortunate to have them here seeing clients at home and they do have an office practice. Today, I really want to focus on your mobile practice, because that's most interesting to me. So Dr. Mahler, welcome to the show. It's great to have you here.

Thank Thank you. Thank you so much for having me. And I always tell everyone, please call me Gabby or Dr. Gabby. That's when pretty much everyone calls me in the field anyway.

Okay, well, we will do that. I find this so interesting. Mobile dentistry. I think it's probably a field that's been around a lot longer than I realize. You said you've been running around for long. Yeah.

So I've been doing it in some softball in a full time capacity, I would say for about 14 years. But I've been practicing for 18 years. I went to school on the East Coast. And so when I was in private practice in a regular office, I was also working for a company doing a little bit of nursing home dentistry in New York. And that was kind of my first exposure to it. And that's where I got my feet wet. And what we're doing now is a lot more involved than what I was doing over there. That was when I first kind of experienced interacting with patients who were stuck and couldn't get into an office. And when I moved out here, I always say As fate would have it, I was actually in touch with a mobile doctor, mobile physicians. His name was Matthew Leatherman. And he introduced me to a dentist who had retired already, his name is Dr. Cal Kurtzman. And he had kind of accidentally started up a mobile practice after he had retired, basically patients, ill patients of his would reach out to him and say, I have an app that's stuck at home. I have a mom who stuck at home, can you come and take a look. And so he was involved in this sort of little operation where he was going out to see patients who really had no other option. I was introduced to him. So I just went out with him one day to kind of see what he did and how he did it. I remember I went out the first day, and she was doing extractions on a woman. He couldn't convince her to allow him to get her numb to be able to do the extraction. So I kind of I was pretty bold, I guess, deceptive. And I said, Well, can I try and convince her? So he said, Yeah, so I leaned down, and I looked her in the eye. And I don't remember what her name was. I said, I'm here and I can hold your hands while Dr. Kurtzman gets you numb, if that will make you feel better. And she looks at him and she goes, fine, I'll let you get him. I'll let you get me numb if she stays here. And it was my first experience of being able to kind of convince the patient who was really adamant about not doing something, wanted to be able to do something. And he ended up doing the extractions and it was great. But when I got home that day, I my husband said to me, how was your day and I said, I think I just figured out what I'm going to do with the rest of my life. And it was really this aha moment. It was eye opening, where, you know, everybody goes into the health field to help people. But when I got exposed to this sort of dentistry, and this sort of care and a sort of help, it really pulled me in, I just love it. I feel like I'm really making a difference. I can help people who otherwise can't be helped. There are not so many mobile dentists, and most kinds of SWANA stay in their offices, which I totally understand. Not really very easy. But for the few of us that do do it. It's extremely rewarding in the sense that you really feel like you're making a difference and helping people out. So that was kind of how I got started. And I started working with Dr. Chrisman one day a week and one day in a week turns into two and then to three and then he turned around and said, I already retired. You want to do this. So we switched. switched roles. I bought them practices. Did you work with me for a few years. He was already a little older. He's still God bless him alive and well. He's 90 and retired. But I really consider him a mentor of sorts because he brought me in To a world that I didn't really know so much about, and took me under his wing and taught me a lot about how to treat these patients, which is just extremely different than when you're seeing a patient in a regular office,

extremely different. And I can attest to you helping people, you have certainly helped my clients. So let's talk a little bit about that. Because most of my practice, as I'm sure some of yours, or maybe even most of your clients, people with membrane impairment, and pretty far along in the disease, you know, some of my grants are pretty far along the disease and really can't get to a dentist office at this point. They're too agitated, confused, they might get there and not open their mouth. I mean, we know people struggle with transporting their loved one into an office and just getting in and out of the car like we right, all the difficulties that go along with getting into any sort of Office is so being able to bring a mobile dentist to the home is just eye opening. for so many reasons. A person can feel comfortable in their own home, a treat one of my clients in her assisted living facility, she's right there in her living room. It's it's wonderful, right, her cats right there, and then it couldn't be more comfortable for her. So talk a little bit about what you can do in a person. First of

all, what I usually tell her dentists is I don't want to see a patient that can be seen in an office, I'm not actually competition for a regular dentist. But there are way too many people stuck at home for a variety of reasons, I would say about 95% of my patients are dementia patients or patients with some sort of cognitive impairment, usually I'll get some sort of call, like, oh, we tried to take our loved one to the to the dentist and she, you know, got agitated, or she hit the dentist or fit the dentist, I had one person tell me, she threw her walker at the dentist. And the first thing they'll say to me is, I really don't know if you're gonna be able to get in. And I always tell them that the thing that's the hardest for a patient like this is being out of their environment. And once they're in their environment, and they're seeing a person who's not perceived as a threat, things can go extremely differently. That's, you know, the first thing that I usually that's first patient that I usually deal with, we do deal with other types of patients as well, that are stuck at home. But what I have found for these types of patients, first of all, another, another second of all, actually another thing that a lot of the times they're dealing with is, is most of the time, they're dealing with a lot of other health issues. And so I also always tell people is that oral care is usually the first thing to fall by the wayside. And we totally get that there's no judgement, when somebody calls us, I've gotten calls, like, my mother hasn't been seeing a dentist in 10 years, my mother has refused to see a dentist, I don't know what kind of care they've been getting. I just noticed that they have a bunch of broken teeth in their mouth, and so on and so forth. So I always say no judgment, we're used to everything. And I completely understand people are very overwhelmed. They have all these medical appointments that they have to get to they have to keep track of somebody else's health care, not to mention the fact that they're usually caregivers involved and other family members have always say we exist to make your life easier, we come into the home, because that makes it so much easier for the patient themselves. So they will be in an environment that they're used to. And we're just perceived a little bit as less threatening.

So to go back for one second, like he mentioned short and really interesting, which is this, this comes up so much in my support group. Oh, persons with dementia. At some point I forget how to brush their teeth don't want Yes their teeth. And so I would imagine there is a lot of shame on the care partners part that they can't bear their husband, their wife to brush their teeth. such a basic thing in life.

I've always say there's no judgement because I think people really feel like it's a reflection on them or how they're caring for their loved one. And that really is not just seen it so many times. I actually see a woman right now in her 90s. And I see her every two months, because she tells her family that she is brushing her teeth. But I know for a fact when I'm looking at her mouth and she is not brushing our teeth, or she might think she's brushing her teeth thoroughly. And she is not because a lot of times our senses are altered, or a patient's senses are altered. And so when they think they're brushing, I have watched patients, brush, brush, brush, brush brush for a couple of minutes. And then I look in their mouths and it's still full of food because they're either brushing not strongly enough or they're not brushing the right areas. And it's hard it's hard to get in and and brush someone else's. So yes, it is very difficult. And so that's actually why I usually stress preventive care for this type of patient because you know what I always tell everyone, I don't want to do dentistry for the sake of doing dentistry. I'm certainly not going to suggest it on a patient in this position. I really only try to do treatment when I feel like it's gonna make a difference in the patient's quality of life, or get them out of pain, get them free of infection, stabilize their teeth, allow them to eat more comfortably, things like that. So it's a little bit of a different philosophy than a regular dental office. But the one thing that I'm a little more aggressive on is how often they're cleaned. Because usually, a patient of mine is being seen every on average, every three months, there are patients that I see monthly, there are patients that I see every six months, but I would say on average, every three months, so that we can catch things when they're small, and take care of them if they need to be. There's also a lot of alternative methods of treatment that are not necessarily done in offices, because you're dealing with more able bodied patients. So you could treat them in a more ideal fashion. But there are modes of treatment for patients where you don't want to be really be invasive, but you don't want to do nothing at all

that can be really helpful to them. I was shocked at all the things you can do in a person's home. While you know they're in their recliner, and all sorts of things. So talk about that a little bit.

Sorry. So people, you know, when you walk into an office, there's a lot of machinery, there's a lot of equipment, there's a lot of space. So people automatically assume that because of that you can't really bring an office into home, you can most of the stuff that we're doing is with our instruments, I have a drill that I can plug into the wall, I can use a drill if I need it, I have a portable X ray machine, that is extremely useful in terms for diagnostic purposes, I really don't know how I would function without it, just on a more basic level, things like the cleaning. So a lot of times people will say, Oh, well do you use that thing that sports water out for the cleaning, because I don't think that my loved one will be able to tolerate that. And I always tell them, that's called a cavitron. I actually did not know what it was until I got to dental school because when I would see my hygienist growing up, she would always clean me by hands with scalars with instruments. And so I always say that's how I clean. That's how we clean our patients, our patients most of the time, our aspiration risks as well. And they can't tolerate a lot of water system using something like this machine, which is a cavitron, which actually makes the dentist life much easier because it's much easier to remove plaque with can't be used on this sort of patient. So we hand scale the patient, which is a perfectly acceptable method of cleaning someone's teeth. As I said, Actually, I got my teeth cleaned yesterday by my dentist and she didn't use cavitron at all, she just used scalars. And then what we have is a wireless polisher. That's I think that's one of the first things that people are kind of surprised by when they see. And it's basically the same polisher that they use to polish your teeth in the office we use at home, you know, it's the same thing, it's just a little more portable. It's not like attached to, you know, the wall in the office. And so we have that as a mode of treatment. And until we're ready, we have the X ray machine, we have the drill. Unfortunately, I hate to say this, but things like extractions, which we also do at home, they don't really require a lot of machinery, you're basically you're anesthetize the patient, usually locally, we don't really deal with any general anesthesia or any sedation. And I can go into why in a minute. But generally for taking out a patient's tooth, you're just using instruments. And those instruments, thank goodness are portable, so we just bring them into the home. Of course, one of the things that it always also stressed people is that because we work with such fragile population, we tend to defer a little more to the physicians that are working with the patients so will generally have some sort of medical clearance form filled out by the physician stating that nothing needs to be changed in order to do something invasive, like an extraction or we need to use some local anesthetic on a patient, we always touch bases with physician because we know that they're either on a lot of medications or can sometimes need changes to be made. Sometimes they need to be communicated with antibiotics, or we need to change the type of anesthetic that we use. So we're generally pretty careful with that. We say we're we're not into taking risks, because it's just a very fragile type of patient. But I always tell everyone is that we can do all sorts of dental treatment, we just tried to be as conservative as possible. So we can do fillings, and we can do extractions. And we can do crowns, and dentures and partial dentures, it can really be very helpful to these patients to be able to do that. But we also have to evaluate them based on their stage of cognitive impairment of whether it is something that they would be able to tolerate. So I think one of the biggest challenges for us is when we have to extract teeth on a patient and then they're missing teeth, and then we have to evaluate whether or not they're a candidate for something like denture or a partial denture. Sometimes they are and it can be extremely successful. And sometimes they're not. So I've actually two anecdotal stories about that. I had a patient years ago who I believe had a partial denture and we had to make him a new one and he was in memory care. necessity. And I made him a new one. This was back when I was starting out. So it was one of my first lessons in this. And I came to insert a denture, and I left it with him. And I told him that I would be coming back the following week to adjust anything that needed to be adjusted, things like that. And when I came back to the solid week to see him, I said to him, I think his name was Robert said, Where, Robert, where's your denture? And he said, I don't know. And I looked and looked, and I couldn't find it. And what I realized was, he probably threw it in the garbage or, you know, we'll put it on the side and one of the caregivers just maybe took it or he may have flushed down the toilet, we have zero clue. And so one of the first things that you need to evaluate with these patients is, can they be responsible enough? Or can someone be responsible enough for them to be able to have something like a partial or denture in their mouth, I had another case where the exact reverse happened, I kind of said to the patient's daughter, let's extract his tooth. But she and she said I would really like to replace her partial denture. And I said, I just don't think that you'll get used to one. And I said, I think it will be really hard, always say can make a denture that's not hard to getting the patient to wear it and get used to it. That's the part that's really challenging. And she said to me, Dr. Gavi, I owe it to my mom, I cannot leave her like this, I have to try. They said, Sure, no problem. So we made the partial. And I remember the day that of insertion, we put it in, and that was it. She just kept it in, and it seemed and she didn't complain about it. And I told the daughter, I said, You taught me an important lesson that sometimes it's worth trying things like this, because when you don't think that they'll work, sometimes they will. And it really is just very dependent on the patient themselves.

That's a good story. Yeah, lesson learned, you

never know. Right? That's, you know, half the battle with a patient like this is you're treading you know, uncertain ice and certain things. And you're you're trying and you don't want to put them through too much. And you have to decide whether you want to be aggressive, or whether you want to be conservative. And sometimes the decision is made for you. Sometimes their health is just at the point where they can't tolerate something like an extraction. I actually have another story about that. Years ago, I started seeing her she was fabulous. She was such an incredible woman, and I was seeing her in a in a facility. And when I started seeing her she was 99 years old, when she had broken lower front teeth, and her family. And she was a beautiful woman who was very dignified. And her family was very concerned with the fact that she would remain staying respectable. Every time I saw her, she was dressed in with makeup and everything. And so they said we really don't want her to have missing front teeth. What can we do about it? So I said, Well, ideally, you should extract these teeth. And they were like, We do not want to do an extraction on her. It's too invasive. That's, you know, what can we do without extracting so simple, you can make a little partial denture that goes on top of the broken teeth. And we can just leave them alone for as long as possible, which is not an ideal situation would never be done in a regular dental office, I always have to stress that. But with our patients, sometimes our hands are tied, because either family doesn't want to be very invasive, or a doctor won't allow us to extract teeth and you kind of have to think outside the box a little bit. So I made her a partial denture. And she wore it and she was fine. I was seeing her every three months for cleaning. And she was lovely. And when she was about mustard and Andre. And two, yes, I walked in and started cleaning her teeth. And I realized that the teeth, the broken teeth were affected, there was pus that was draining into her mouth. And I said to the family, you know, there's prostrating in her mouth, we should probably put her on antibiotics. Because these tips and they're effective, we should probably consider extracting them. And they said we really don't want to extract them just put her on antibiotics. So we put her on antibiotics. What happens is the infection levels go down but never goes fully away, because you're not getting rid of pardon the pun, the root of the problem, which is to so it happens I think another time. And then I said to the family, you're really doing her a disservice. You can't, you can't leave this teeth in her mouth anymore. And I kind of regretted not being a little more aggressive when she was 99. Because here I am working on 102 103 year olds to take his teeth out. So we ended up taking the teeth out. She did beautifully. She was lovely. She was already at the point in her in her life where she had cognitive impairment and don't think she had that as much when I began seeing her. But when I walked in after the extraction for the following visit where she had a cleaning, she looked at me and she says, I don't want you to take anything out of it. I said, don't worry, we're not gonna take anything out. You don't have to worry about it. But really the point of the story is that you really want to be as conservative as possible. You just can't always be as conservative as possible. And so in a case like that, it may have made more sense to conceive out earlier because you would have been working on a younger patient who may have had, you know, a healthier body at that point. Thankfully, it all worked out. She lived until the ripe old age I believe of 103 But yes, you live in you learn and so what I also always tell people is, I am not going to force anyone into treatment, I give treatment options. We always talk about the pros and the cons of things, leaving a tooth alone versus extracting a tooth, and you know, doing any sort of treatment really. And then I always say, it's, uh, you know, it's your prerogative. I'm not gonna force you because I know what it's like you're dealing with so much the family members and the caregivers are dealing with so much and I want to make their lives a little bit easier. And I don't want them to have to worry about much. It seems like unbroken TV or cavities, you're just going to provide fillings, mostly fillings and cleanings. For most people, yes, you can. Well, like I said, doing a filling is less invasive than an extraction. Sometimes you don't have a choice because the tooth is too broken down. But if I ever do have a choice, yes, I try to do that. Sometimes I also have to take into consideration the fact that the patient won't necessarily allow me to do something they have to learn to trust me over time. So I had a woman once who I walked in, and she said, I don't want to do anything except a cleaning. And I said, okay, and I did a cleaning. And then I presented a treatment plan to her daughter, and I said, Listen, she does need fillings. And I have to let you know that she needs the fillings. It's up to you whether you want to do them, and I probably went out for a second cleaning. And then the her mother got used to me. And she saw that I was pretty gentle. And she said, Okay, we'll try you know, I said, Why don't we do the bigger fillings, sometimes it's just triaging thing. So we did the bigger fillings, and then we did some of the smaller fillings. And we got to the point where I was just coming, she was very stable. I was just coming and we were cleaning her teeth. And that was it, because we had taken care of whatever was questionable in her mouth. So yeah, again, we try to be conservative, but sometimes we have no choice. And we do have the ability to do things that are invasive. As our patients, I have a patient who I've been treating him for many years, he's still alive, he's in his, I would say mid to late 90s. And I had to extract the tooth. I said, Let's make you a partial denture. And he said, I do not want anything removable in my mouth, I only want something permanent. And I said, okay, but that means we have to drill a lot, because we could do three or four unit range, whatever it was. But I said, I have to take off some of the crowns. And I have to drill everything. And we have to seek an impression. And he said, I don't care. That's what I want you to do. And so I said, fine. So I worked on him. But at this point, I think we've we've done three of his bridges. He's has all permit stuff in his mouth, no partials, he takes actually very good care of, for a 96 year old, and I see him every couple of months. I really try to do that a lot of times I'm speaking directly to the patient if they can, or speaking to the family member or the caregiver and saying what are our expectations for this case? What are we trying to achieve? And then you base your treatment plan on that. Because when you look at a patient like this, any patient really you can give a patient five or six different treatment options of what to do. And it really depends on what the goals are for the patient themselves. And

I would imagine the goals are pretty minimal, like you just want people to be able to eat right to be able to contra held back comfortable, right not to have actions in their mouth. as basic as possible, probably. Yeah, I

always say eating is one of the last pleasures that these patients have. A lot of times they can't hear so well and they can't see so well. And they can't read, you know, they can't read or watch television and they can't have conversations and you realize that they're eating capability is their joy. And because of that you really want to be able to have them keep that for as long as possible. So yes, that is the goal that kind of guides me through every patient that I see. It's so important. And I also tell people, you know, they'll say like, oh, they love eating ice cream, or they love, you know, there's just something that has further teeth that they love eating. And I always say eating is one of the last few pleasures that they have. You can let them eat whatever they want. They've gotten this far, but just you know, they're gonna eat ice cream, or they're gonna have a piece of cake, just do a little oral care, I'm there so that you can protect the teeth as long as possible. I certainly don't advise restricting anything, you know, unless of course, it's like, they're diabetic, and I really can't. But with respect to their mouths, I really don't want them to restrict themselves because, you know, joy in life is important. And they're not getting that much joy at this point. So eating is really very helpful. So a little ice cream is all good.

It's amazing what you can do at home. It's just the range of services you can do at home. That's phenomenal. And it was eye opening for me. And I'm just wondering, how, how are your services covered? Like how do people pay for this?

Good question. I'll give you a little speech that I give to people But when they call me on the phone that I try and be as transparent as possible, I always tell everyone, the service is more expensive than a regular dental office, because the dental office is coming to you. So not only are we driving to wherever we need to go and bringing the equipment and but also these patients need a little bit more time, when you're treating them, we have to work according to what they're able to do. So we see them in bed, or we'll see them in an armchair or on a couch. So oftentimes, for us, it's a little more labor intensive, because we're on our knees, or we're careening, you know, to the side on their necks, I always tell people, if I could hang myself upside down, or make myself very small and jump into the patient's mouth, that would make things a lot easier. So I also always tell everyone, because of that the service is more expensive than a regular dental office. So the way our service is constructed is we have what's called a home visit fee. That's kind of what separates us from a regular office. And that's the covers us driving to wherever we're going to setting up the office cleaning up the office driving back all the extra time that it takes to do that, plus the extra time that it takes to treat the patients and the physicality of it, taking that into consideration. And then I say the rest of our fees are regular office fees. So if you walked into a regular office, wherever you were, and you would have an examination and cleaning and some X rays, which is usually what entails a first visit, those fees never change. You know, the only thing that changes is the home visit fee. And that just depends on where we're going. Now, with respect to insurance. I do not know any mobile dentist that accepts insurance. One of the things that we do is if a patient has a Dental PPO, I always tell families that we can file a claim on their behalf as a courtesy to them. So what that means is that we will take the information will file the claim after the patient is seen, but we're not considered in network dentists were considered an out of network dentist, which means that they don't cover as much as if they were if you were going to see an in network dentist, I also always tell everyone that we can't be responsible for what they reimburse, but every little bit helps. And we at least try and jump through the hoops of filing the claim for them. The one thing that I have learned over the years is that the home visit fee, which I include on every single claim that I file is never covered in any portion. That's just because an insurance company is not really equipped to cover a home visit fee. They're just usually working with patients that are being seen in offices. And I just try and be as transparent as possible about all of those things before we see somebody because I don't want them to misunderstand that. Sometimes they'll call the insurance company and the insurance company will say these are all things that I've learned along the way, by the way, insurance company will say oh, it's an out of network, dentists will in network dentists would cover 80%, but out of network dentistry cover 50%. And what they are leading you to believe is that they cover 50% of our fee, but what they are covering is 50% of their usual and customary fee, which is their fee schedule that they use for every dental office that is in their network. But that is not necessarily our fee. So there's sometimes misunderstandings along the way. For example, let's say I charged $150 for a cleaning, but their usual and customary fee is $75. So they're gonna pay 50% of the $75 fee, not $150 fee. And I really try very hard. As you can tell, I'm not talking it's very easy for me. I always have very, very specific with those things, because I don't like surprises any more than the next person. And I want to make sure that as transparent as possible. So we don't accept insurance, but we try as hard as we can to get you wherever we can get back. But we just can't be responsible for what that is. Got it. Okay, that's how most people most mobile dentists charge I would imagine. Yeah, like I said, I don't know anybody who is in network with an insurance company of one of the reasons is just that, because you're driving around seeing patients all day, you're not seeing as many patients as you can in a regular dental office. And so in an office, it just makes more sense to be able to accept insurance because you could see 20 patients in a day. For us seeing four patients in a day is a busy day, you kind of precludes us from being able to accept insurance. Absolutely.

That makes perfect sense. What would be the average amount of time you see a patient with would be like five years or, you know, you're putting people at the sort of the end of their

family. I mean, it's true, because but I always tell everyone is that we're encouraging patients to go into an office for as long as they possibly can. Now a patient can be at home and be bedridden or on hospice, as we've seen for many years. It's not like it used to be back in the day where when you were put on hospice, it was because you had you know, a couple of days or weeks to live. Now hospice is just a way that people are getting some extra care and they can be on it for quite a long time. I just actually lost the patient that I had been seeing. She just passed away I think a week or two ago. I've been seeing her for 11 years. I saw her in a facility and then in abort didn't care. And then in another boarding care, she was actually a young patient, she had early onset dementia. And so it was a very sad case, I can't tell you an average, because there are patients that always exceed my expectations. There are some patients where every time the three month mark comes, I'm bracing myself or reaching out to the family member and saying, hey, they're due for their cleaning, I'm waiting for them to respond to me and say, Oh, they passed away. And then they'll surprise me and say, Come on over. And so I've learned not to make predictions. But there are just, I don't think there's any rules. For this, I just spoke actually to a husband, of a patient of mine. And he, he said to me, they told me when this started that it would, wouldn't be more than 10 years. And he's like, we're already well past 10 years. And so that's good. But sometimes that's also bad, it's very hard to have to deal with it for that long for a caregiver for a family member. I think that's one of the things that I have been exposed to a lot over the years. And I you see, these family members are so devoted to their loved ones. And it's really amazing. And when you're devoted and the care, the quality of care is just that good. The patient is going to exceed expectations. A lot of times I'll ask about their health, I'll see besides the dementia, or the cognitive impairment, how's their general health? And they'll say, Oh, well, besides that they're actually extremely healthy. Or they used to have cholesterol, high blood pressure, you know, they were borderline diabetic. But now they don't have any of those things. So I have a theory that it's because their stress levels really lower. I really believe that higher stress levels can really contribute to a lot of things going haywire in our bodies. And so they ended up typically being sometimes pretty healthy besides the dementia, so they can live a long time. So hard, so hard for families. Yeah.

Oh, goodness. So we're so fortunate that you're in Los Angeles, I'm in Los Angeles, I get to use a person like you and your partner in Los Angeles, where would we find someone like you? I would go online, and just look for mobile dentists near me. Over the years, different people have reached out to me and, and said, Oh, can I talk to you about your practice, because I'm thinking about opening one up, you know where I live, I'll talk to people. I think the Alzheimer's Association, the local chapter is a great place to start. If you're dealing with any sort of home care, a homecare company would sometimes know any home visiting nurse, if you're in a facility, sometimes the nurses at the facility, if you know a social worker, or a Geriatric Care Manager like yourself, that, you know, is well versed Thank you can reach out to them, they can always help out this mission like a national association that you all belong to.

There, I don't belong to it. But I do know that there is a special care dentistry Association. It's for anyone that needs special care. So it's for children, I would imagine or anyone who has special needs and things like that. But that is also a good place to start. Sometimes there are if you can still take a patient into an office, but you want a different philosophy of care, to help themselves as a geriatric dentists. And so hopefully that means that their philosophy is a little bit different. They're looking at the patient with a different set of eyes than if it were a healthy 45 year olds with no health issues or cognitive impairment walking into an office, I always maintain that it is a very, you're looking at each patient with a different set of eyes. It's not. Yeah, it's not the ideal dentistry that you're taught in dental school.

A person's regular dentist that you've been going to for years might know.

Yes. And sometimes there's also mobile hygienist. So sometimes in areas where mobile, mobile dentists don't exist, they'll have a hygienist maybe that's has some sort of traveling practice that might at least be able to come out and do cleaning. They can't do any dental care, but better than nothing. But yeah, those are the types of places that I would tell people to reach out to. Okay. All right, great. Good ideas. Also ask the guests in your support groups, you know, if you're attending a support group, maybe other Yes, yes, yeah, good point. I've gotten referrals like that over the years where they'll say, I didn't know you existed, but then my friend told me and my support group that they used you or Dr. Top and that you were really helpful, will get referrals that way. So you have to do a little bit of searching, but always because people always will say, I didn't know this existed and I always say nobody knows we exist until you need us. And then we hope that you find us. Is there enough people if you're using a mobile physician, that's also a good resource because they'll sometimes be more in tune with who can go out to a patient who sometimes will have a mobile dentist as a resource? Absolutely, yes, mobile physicians are a great resource.

So can I ideas are good ideas.

And I think it'll over the years become a little bit more common to do my theory is that eventually it will be its own specialty in dental school, because it's so different. And you have to learn how to treat this sort of patient. You know, years ago, Pediatric Dentistry was not a specialty in dentistry, and then it became one because it's such a different mode of treatment, and you're treating kids that requires different training. And so I always tell people, when I retire, I want to create some sort of residency program for people who want to go into there's

just a yes do that. So many of us that need you. It's true. Yes, more and more of us will be dating you. So we talked a little bit about having dementia and it being harder and harder for people to brush their teeth to remember how to brush their teeth for caregivers to help their perhaps spouse brush their teeth. Do you have any ideas about how people can get their loved one to brush their teeth? Yes,

I have many ideas.

We want to hear, we want to hear them. This comes up in support group office. So yes, perfect.

So what I do actually, Barbara is for some facilities that I'm in, I will offer to give the caregivers and nurses or whoever really want to come to Alabama in service. And I come with a slideshow and I talk a little bit about oral care for the residents, particularly residents who are a little more obstinate and refused to oral care and what you can do to help them out. So the most obvious thing is to brush after eating to brush after any meal. But a lot of times the patient doesn't want to brush. And so what to do in that case, one of the things that I tell people is, after a meal, give the patient a glass of water and have them drink it. A lot of times these patients are pocketing food. And so it is a way for them to just naturally rinse their mouths and they're swallowing the water, which they should be doing. First of all, hydration is very important for this type of patient. Second of all, what happens is that when they're drinking a lot of the food that they're pocketing can be swallowed. And that's when it's supposed to be done with food anyway, so people don't realize it. But after a meal, it's super important, just give the patient a glass of water. If the patient has a little bit more of an ability to do things, you can give them a glass of water. And you can have them just rinse and spit on their own and mute and look at that glass when when they're done against fitting or the bowl that they're sitting into. And you will see how much food and particles are in there. And you will realize that just doing something like that is hugely helpful for these patients. So that's another suggestion that I make. And then if you're a little more bold, one of the things that I will tell people and actually have slides where I'll show the pictures of doing this to patients so they can actually see the difference. I will say to take a two by two of a gauze and you wet it. And you if you're afraid to go on the inside of the patient's mouth, because you're afraid that they're going to bite you, that's totally fine, you can leave that to the professionals. But what you do is you just wipe the gauze on the front of their teeth up by the guns wherever the food is just kind of sitting there. And again, you'd be surprised at how much you could wipe off the teeth. But I'll do one of these inservices I usually bring doughnuts, I have the caregivers eat the doughnuts. And then I give them gauze. And I say fill your teeth, and then wipe gauze on your teeth and then feel them again. And they can actually feel the difference of you know, they get rid of the doughnut particles or it feels a little bit smoother. And so just something like that is not necessarily brushing the teeth. So it's not the most ideal but it's better than not doing anything at all. The one of the things with respect to regular oral care and tooth brushing. As you know, a lot of times you can't floss these patients too hard, you don't want to stick your fingers in their mouth, I totally understand that. So something that I use, in addition to tooth brushing, which I recommend is something called a proxy brush. It looks like a little pipe cleaner on the end of the stick. I know Barbara, you've seen them when I use them on our patients together. And basically, it's an alternative to floss. I actually prefer it because it picks up a lot of food particles, you literally just stick it in between the patient's teeth. A lot of these patients have a lot more space in between their teeth than you and I do as a direct result of just being a little bit older. And so they can get a lot more food stuck in those areas. If you take a proxy brush and you clean them out after you brush their teeth. It can be extremely helpful. I have had patients where I probably told you the story. Barbara had a patient who was really bleeding like a stuck pig. Every time I saw her there was a pile of gauze full of blood every single time I saw her. She was a stroke patient and she was little she had a little bit of dementia but she was pretty much very cooperative. I kept saying to the caregiver, I really need you to brush your teeth. I really knew her she teeth and then one day I saw her teeth are really falling apart. And she was bleeding so much. And I looked at the caregiver and I said listen, I am not giving you a choice anymore. You need to use these proxy brushes at least once a day. She said she won't allow me to I said if she didn't allow you to change her. He would still change her because it's for her health. So you have to look at it from this perspective. And she will eventually she will allow you to you just have to, you know, kind of knew what I was dealing with with respect to the patient, I knew that she could be convinced. I mean, the next time I saw her, it was like seeing a completely different patient. I could not believe my eyes, there was barely any bleeding, her teeth were in such better shape. And I literally give a huge hug to the caregiver. And I cannot believe this, I'm so happy that you're doing this is going to make her her mouth so much more comfortable, because she's not bleeding as much and she doesn't have as much sensitivity. And from then on, it was wonderful. So what I always tell everyone is these proxy brushes if you're willing to commit to using them, which, again, is not easy, are a 180 degree turnaround for some of these patients. They're just extremely helpful. So that's one of my secret weapons. And then there are rinses, I would tell people, you can use a fluoride rinse that's over the counter from the drugstore. If the patient can't rinse and spit, because they don't understand how to anymore, you can take a swab and swab that onto their teeth, that's more for their teeth, not for their gums. If you're concerned about bleeding gums, there is a prescription rinse, it's called chlorhexidine. And that can also be used for a gum health. Again, if a patient can't rinse and spit, which we come up against a lot, what I will say is take huge swab and swab it onto their gums, it makes things a little bit better with respect to gum health. So there's a lot of different ways to treat these patients. And to help them out might not be the most conventional way of rinsing and spinning, let's say but you can still give them a lot of protection from things

like common things like Listerine or some of the Yeah,

so Listerine Listerine is great. I will say sometimes use the non alcohol version, because it's burns a little bit less that might be hard for patients to scholary one of the ones that I recommend, just actually this week closest has a fluoride rinse, c l o s ys is how you spell closest, I think they have a rinse X has a fluoride rinse that you can use. The paradox is prescription, one of the other things that I will recommend always on the first visit is if a patient has a hard time brushing the back of their teeth, first of all, to get an electric toothbrush, but you don't have to get fancy, you can actually get a children's electric toothbrush, the vibrations are less, so it's easier for them to tolerate it. And it's a smaller brush heads so you can get further back ends. And then also either the patient themselves can do it, or the caregiver will have an easier time doing it. Because it's smaller, and it can get back there as stress always brushing up near the guns. But that's for everyone, not just for my patients. And yeah, there's little like floss sticks. Little Yes, those are great. If a patient can use that, and they're willing to allow you to do it, or they can do it themselves. Those are wonderful. I'm typically seeing a patient that is already beyond being able to use that a lot of the time, certainly on their own. But yeah, it's definitely helpful. So all of those things. So a lot

of patients are, as we know, get agitated, and they you know, don't want to brush their teeth or maybe say they brush their teeth, but really don't. But at some point people stopped communicating with us, right? become so withdrawn towards the end of the disease or, you know, cannot really cannot communicate with us in any intelligible way. And so we How would we know if they're having kind of more serious pain or serious mental problems that maybe it's like we couldn't see. So that is

a great question. I think that that is one of our main challenges. I always tell people, one of the modes of diagnosis for a patient is self reporting. And if we cannot rely on the patient self reporting, we have to loose a little bit to figure out what's going on. But one of the things that I have found over the years is that a patient, even one that's non communicative, will figure out a way to let someone know when something is bothering them in their mouth, they will either refuse to eat completely, or they will wince when they're eating, you will notice swelling or redness. I recently had a patient where she was I think, refusing to eat or she was wincing a lot. And the care manager said I just want you to go out and and I just seen the patient a while back and she had a lot of broken teeth and a lot of things that were going on but the the family wanting to remain as conservative as possible. Could you just go out and take a look at her. So I said sure. You know, we'll see if they can see anything that's going on. Anyway, I was so happy that she sent me out. She relied on her intuition that something was going on. And when I got there, she had a broken front tooth that had I guess broken further and it was super sharp. And it was just causing a huge sore on the inside of her lip. And so that's why she was refusing to eat. It was hard hurting her every time she moved her mouth. In an ideal situation you're extracting this tooth, but this patient the family did not want any extractions. So I said we have to make her more comfortable. Let's at least smooth out the tooth and round out the area that's sharp, so that we can make her feel better. And that's what we did. And she went, you know, gums and sores like that in the mouth actually heal quite quickly, once you remove the offending agent, she went right back to eating a few days later, and the care manager was so relieved, because it was just something that she had an intuition about. And she was she knew it wasn't that she was slowing down or it was end of life. She's like, I'm telling you, it's not that there's something going on in her mouth. And this patient is completely 100% non communicative, not one word. So you, you learn over time to pay attention, and to know when something is going on. And I'm sure you've had those same experiences with patients, for example, who has let's say dentures, they'll start taking them out a lot. And so sometimes people say, Oh, it's just the disease. But they'll sometimes say, you know, what, just come and take a look to see what's going on. And what will happen is over time, Dentures settle, and they'll settle in. And sometimes they'll cause a sore spot after having been worn for many, many years, maybe the patient lost a little bit of weight, or the bone remodeled in the mouse a little bit. And so you go in, and you look and I've had this happen as well, where I'd take up a denture or, and I look and I'll see a huge sore in the mouth. And so my goodness, this course thing, it must be so painful, and you just adjust the denture, it's a very quick fix. And you put it in, I had it happen with a patient a few weeks ago, actually. And I put it in and you could see right away, they're so much more comfortable. They don't even have to tell you, Oh, it feels better, because you could see that it feels better. Really. Yeah, it's just a quick fix them again, it heals up extremely quickly, I do have one more story of a patient who was was basically screaming every time he would start eating. And they didn't know what's going on, they thought he had pain. And so I went to check him out. And when I looked in his mouth, he had a broken tooth that was so sharp and like a broken tooth can be extremely sharp teeth are very strong material, you know, is a tooth is very strong. And his tongue was rubbing on the tooth every time he would eat or drink or anything. And his tongue was lacerated because of it. And so how to just go in and just smooth out the area that was sharp, and then it went, you know, went away, not instantaneously, but almost sooner and could see right away that it was more comfortable. Those are things that you really need to be aware of that could happen because it's not always that there's a tooth that's infected, it could be that there's a tooth that's broken, it could be that there's a denture sore. Sometimes patients get fungal infections in their mouths, they have like a cottage cheesy appearance, you know, a little bit of redness, and it's something that can easily be taken care of. It just needs to be noticed. So those are all things to keep in mind in terms of things that could be bothering patients that, you know, can be taken care of quite easily. Okay,

good to know. Wow, good to know, you're right. Were just at all concerned that someone is not eating the way they always have been missing while they're eating saying rarely. When they're eating Yes, there

are telltale signs, I always tell people, a patient doesn't have to see you, it's hurting me right here on my lower left side of my back to to be able to see I mean, that would be great if they could but with this type of patient, it's almost impossible. So we have to and most people are in tune with that, you know, especially as the caregiver of a patient who has dementia or cognitive impairment, or

we would notice that if someone every time they sit down with grimace, yeah, moaning Yeah, right, right. Yeah, absolutely. Good suggestions, good to know, you're talking about maybe taking out teeth that have been broken or decaying. If you're removing teeth and not creating some sort of denture for them or partial for them. So then they're living with less teeth? Does that affect what they can eat?

Definitely, you know, one of the things that we have to evaluate is just is it affecting the nutrition that they can get, you know, obviously, we want to take into consideration their quality of life and them enjoying food, but nutrition is of utmost importance at this point in life. So what I will tell people is, depending on the amount of seats that they have left, sometimes we will say you are totally fine, you can eat your regular diet, not a problem. There are different types of diets that these patients will have. So there's a regular diet, there's a mechanical soft diet, and there's a pureed diet, we try to really stay away from pureed foods just because it's not as enjoyable for a patient at that point. Sometimes you have no choice and you try and make it as palatable as possible. But sometimes what I'll say is for a mechanical soft diet, first of all, cut foods into very small pieces. Okay, soft foods like I use the example a lot of times that a baby will eat without teeth. If you think about it when they're young and you're giving them all sorts of foods. You just have to be careful to give them smaller pieces of food and soft foods. Baby babies can still eat things like chicken, pasta rice, that eggs, vegetables that are, you know, steamed and softer. So nutritionally, a patient can get what they need. Some of the challenges will be things like, I will tell people to stay away from nuts, or raw vegetables, because those are just harder to chew if you have less teeth, or if you have less surface area to chew with, one of the things that I'll tell people is it really is dependent on which teeth are missing. So you generally use your front teeth to bite a piece of food, and your back teeth, your molars are used to chew food. So if you're, if you're missing your front teeth, that is not so much fun with respect to aesthetics. But you can cut a person's food up into small pieces, and they can still use their back to the shoe if they're missing their back pay plan. So you can't necessarily bite into an apple, but you can run with an apple. Exactly, exactly. So most of the time, it's not that you're missing your friends, either your back teeth, it's usually a combination of the two. So you know, smaller pieces of food, just being aware that things need to be a little softer, you can still do a lot with nutrition. With respect to that sometimes one of the reasons for why we will say Okay, let's try a partial denture, because we just want the patient to be able to keep eating what they've eaten previous day before their teeth were extracted, what we'll do is I'll just say just give them the partial denture for what when they're eating and take it away, when it's when it's done. So you don't have to worry about losing the partial, because they're only using it when they're eating. It's not the conventional way that things are done. But you have to think outside the box. Absolutely.

So is that why mostly, I mean, the people mostly choose bridges that stay in the mouth.

So it's no I would say most people will will. This point and a patient's Yeah, most people are choosing what's less invasive. And so making a denture you need to make you need to take an impression, but there's nothing invasive, there's no drill in the mouth, the patient doesn't need to really be still a few minutes, you need to be still taking depression. But you know, they're willing to deal with the fact that it's something removable, in order for them not to have to deal with making a bridge, a very personal decision, one that we try and help walk the family members or the caregivers through so that they can make it with all the information that they need. But I would say in my experience, most people opt to have some sort of removable, partial or something. And that's all denture. Uh huh. Yeah, there's a couple of different kinds. There's one that's called a flipper, which is not very comfortable, but you know, more aesthetic. There's a valplast partial, which is like a little bit of a flexible, partial. The downside is you can't add to it. So if you're expecting to lose more teeth, it's not really a great choice. And then there's just a regular conventional partial, which is a metal framework with acrylic and teeth, and plastic seats that are in the partial that is just a more conventional type of fabrication. And a teak can usually be added to it. So it's a little easier to just keep it in the patient's mouth for longer without changing things. So you know, again, you have to take everyone's specific situation and circumstances into consideration when you're making the decision for what you're going to use partial. So I thought pressure will stay in the mouth, but they actually are movable. No, yeah, so they're the only thing that sees in an alpha is something called a fixed bridge, fixed branch God, and that's something that's cement or an implant, and those are cemented into the mouth, or screwed in. And those are great. But the process of actually getting something like that in your mouth is a little bit more invasive. And that's why our patients typically will not be choosing those options. I see. So a partial is removable and should be removed, probably to be cleaned. Just like yes, I had a patient I just told the story to somebody yesterday where I went to evaluate the patient and they said, Can you just evaluate their teeth? I said, Sure. When I got there, it looks in the patient's mouth. And I said, these are dentures are removable. We don't have the deep. We were horrified. It was like a board and they were horrified. They had no idea they were just brushing patient's teeth every night like regularly. They didn't realize I guess they looked so real. Yeah, the hardest thing, right? That's the hardest thing is that, I think probably years and years ago, most people just didn't have teeth and so you didn't have to worry about it. But now patients are living longer and they're keeping their teeth longer. And they are either you know missing some teeth, but then they'll have a personal or they'll have implants and there's so many different variables or variations of what could be in a patient's mouth. And so people aren't as in the know of what you're supposed to do in terms of taking care of a patient now and they're so overwhelmed with taking the patient taking care of the patient in general, changing and feeding and showering and doctor's appointments and medication So.

So then if they got a denture or partial, what do people do? Do they take them out every night and clean? It depends.

It depends on the patient. So I just saw a patient who is a little bit less cooperative. And it was even hard for me she has a partial denture. And it was hard for me to take it out of her mouth. So I can and I'm a professional, so I can't necessarily expect that a caregiver is going to be able to do it. The patient's husband actually said there are some caregivers that can on some caregivers that can't. And so he was a little bit worried about a better caregiver would either hurt the patient when she was taking the partial out or the denture out, or she really was worried that they wouldn't be able to get it back in. And then she wouldn't be able to eat until the caregiver that could put the denture in Congress, and that might be a few days. So the ideal is that they should take it out at night, allow their mouths to breathe and rest and then put it in the morning, you also get a chance to clean things you clean the partial or the denture. That's the ideal, the ideal to not always be done. So sometimes it's a combination. Sometimes it'll be kept in indefinitely. And just when the the caregiver that can take it out, arrives, they take it out, and they clean it and they put it back in. Sometimes, you know, it'll be a few days, yes, a few days. No, I always say I will take but I guess you just want everyone to be able to be comfortable and happy. And you don't want anyone to be overwhelmed. I think that's the point of what I'm trying to do is I just don't want anyone to be overwhelmed by what my suggestions are. So, you know, I say if you can great, and if you can't, then we will figure it out. And it is what it is. Just do your best. Yeah, do what you can and what you can't do. That's okay. Exactly, exactly. Actually, the husband said to me, I didn't even know she had a partial denture till we moved during here, because she probably never wanted her husband to know. Probably brushed it in the afternoon really quick and put it back in. And you know, how are you supposed to know unless you're really attuned to it? Yeah, you never know, it looks just like your regular teeth. So

how

I actually had a patient I've been seeing her for a while now. But she had not seen a dentist in about 10 years. And her daughter said that she wanted somebody to come in, I don't remember what the specific concern was. And I got there and I looked in the patient's mouth, and she had a partial on her lower and a partial on her upper. And I couldn't take them out because there was so much plaque buildup in the patient's mouth, that it was stuck. So I had to so that's a really good thought. So I'm sorry to interrupt. So it has to be adhered to other teeth that are there. Yes. So the difference, right, a partial denture is partially replacing teeth, because there are natural teeth, as opposed to a full denture which is replacing all the teeth because there are no remaining teeth. So a partial usually has some sort of something that hooks on to the natural teeth. And if you leave it in for long enough, as I learned, will sometimes build up around it and make it very hard to take out. So I have to see the patient, I would say three times and clean the plaque out a little bit more each time because it had to be able to do what she could tolerate it a visit. I couldn't overdo it on her, she would never let me back in her mouth. On the third time we took we were finally able to get the partial out. And it was I felt victorious. That we cleaned her up. And I talked to caregivers how to take it out and put it in and the patient actually is able to take it out and put it in and she just hadn't done it in such a long time that it got stuck. And so now I see her every two months, she still gets a lot of plaque buildup, but not enough for it. And they take it out at night. And yeah, and those are situations that you don't typically see in an office because when a patient's responsible enough to come into an office, it's usually because they can take care of their mouths appropriately. Hygiene. Yeah, absolutely. Yeah. Yeah,

sure you were worried about breaking that darn thing. Yeah.

I was also worried about breaking routine. I would like go in and kind of pull it out a little and see where it was getting hung up. And then you know, it was on one side more than the other. And so then I tried also, again, you're dealing with a patient who I am very blessed that she's even allowing me into her mouth. And I need to take that into consideration when I'm doing things that I have to maintain a good relationship with her at this visit so that she's not going to kick me out. Right and so that becomes a challenge in and of itself. I'm constantly apologizing. I'm so sorry, I know this hurts a little bit. I'm close to your gums, but I really need to clean you. There's no point in my being here unless I'm actually going to clean your teeth properly. So but a lot of times, it's just explaining and telling them that you're not trying to hurt them. And that you know that they're in charge, if they need a break and things like that, you give it to them. And they're very appreciative of that it feels like they have some autonomy, you're constantly talking to them, while you're talking to them while you're cleaning. Anything. Even with a patient that is non communicative or you feel doesn't understand what I always tell everyone is, I feel like they recognize the intonation of your voice. I really think that also what I'm doing, because they can't say out, is I'm watching their eyes while I'm working on them. So you'll see their eyes get real wide, and you're like, oh, that's hurting them. And so I will say, I know I'm so sorry, I know that's hurting you like just have to go in a little bit further or, or if they kick me out of their mouths, I'll say, Okay, we'll go there again, and they'll allow me back in and then I'll go to a different spot. And that's the patient management aspects of what we do. You know, every patient is different, you learn a little bit the techniques as you go. But what I do is try and really treat each patient with dignity and respect. And I do speak to patients even when they can't speak back. I've actually had, you know, every once in a while someone does answer back. And as a patient that literally doesn't ever speak. And even the caregivers will be like, Oh my gosh, they never say like, are you okay? And they'll nod or they'll say yes, or even something like that. And you feel amazing that you're able to have some sort of breakthrough like that. So even with something like this, I had a patient is one of my favorite stories and a patient, one facility and I saw him maybe two or three times, really nice guy very friendly, and I would clean his teeth. And I would only see him once every six months, because he took pretty good care of his teeth. And he ended up moving to a different facility. And I went to see him in his new facility. And his name was Willie, and the caregiver was taking Willie down the hall and I was following with my equipment because we were going to his room so we can plant his teeth. He says to the caregiver, I'm nervous. And so the caregiver said why? And I heard him and I said, I went over to him. I said, really? Why are you nervous? I'm just gonna clean your teeth. And he looks at me and he goes, Oh, you remember me, and for me, that's a huge victory. Because, you know, I don't know what's gonna get launched in someone's long term memory versus their short term memory. I'm constantly reintroducing myself every single time I see a patient, because I want them to feel comfortable, and they're not necessarily going to remember me. So I was just thrilled, but he was like, Oh, I I know who you are. And then nervous because he knew that I wasn't gonna hurt him. He was in his new, you know, facility and we didn't know, you know, I guess the ropes of this facility and who was going to be doing things and and so that made him feel more comfortable. So yes, it was always constant communication. Even if a patient doesn't communicate. That's super important.

Super important. Good to know. Well, Dr. Gaby, thank you for coming today and talking to me about this. My pleasure. I really appreciate you the work you do for my, my clients and for our community. So with all my heart, thank you.

Thank you. It was a pleasure to be here. I so enjoy what I do. I enjoy speaking about it with people to kind of disseminate information as well. So I'm more than happy to be here. At least

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