14. Special Care Flashcards
What is the purpose of special care services?
To provide oral care to people who are unable to accept routine care due to an impairment.
What patients are seen by special care?
Disability
Older
Medically compromised
Mental health issues
Anxious/phobic
What is disability?
A physical or mental impairment that has severe and long term effects on a persons ability to perform normal activities.
List the 3 types of disability
Physcial
Learning
Sensory
What is dementia?
A collection of cognitive symptoms that gradually get worse over time
What are the 5 types of dementia?
Alzheimer’s
Vascular
Mixed
Lewy body
Frontotemporal
What are the principles of consent?
Informed
Given freely
Pt is capable
What is incapacity?
The inability of a person to act, make, communicate, understanding or retain a decision
How is capacity assessed?
AMCUR framework
Asking open questions
Chunk and check
Teach back
If someone lacks capacity what legal act applies?
AWI Act 2000
Is the AWI Act 2000 applies, what certificate is issued and according to what 5 principles?
Section 47 certificate according to 5 key principles of:
Benefit
Least restrictive of freedom
Persons wishes taken into account
Relevant others consulted
Residual capacity encouraged
What is a proxy?
A person who has been legally authorised to act on behalf of an adult with incapacity
List the 3 types of proxy:
Power of attorney
Guardian
Intervenors
What is power of attorney and what types are there?
granted while the person has capacity
Types:
Welfare
Continuing (property and finance)
Combined
What is a guardian and what are the 3 types?
Granted when an adult no longer has capacity or has never had capacity
Types:
Welfare
Financial/property
Both
What is an intervenor?
Appointed for a one off event by the court
What should you do if a person lacks capacity and there IS a proxy in place?
Follow AWI principles
Get consent from proxy
Have AWI section 47 issued
What should you do if person lacks capacity and there is NOT a proxy in place?
Follow principles of AWI
have section 47 certificate issued
What legislations are associated with adult protection?
Adult support and protection act 2007
Domestic abuse Scotland act 2018
Human trafficking and exploitation act 2015
Who can you report adult protection concerns to?
999 - immediate concerns
Local health and social care adult protection team
Social work
OPG
What 5 key medical conditions have effect on dentistry?
Cancer
Mronj
Cardiac
Bleeding disorders
Renal
What 3 key dental interventions should be carried out before someone goes through cancer Tx?
Screening
XLA of potential sources of infection
Duraphat toothpaste and varnish
What is MRONJ?
Medications related osteonecrosis of the jaw
- exposed bone that persists for 8 weeks + in patients taking antiresorptive or antiangiogenic drugs
List 2 antiresorptive mesications associated with MRONJ:
Bisphosphonates (e.g alendronic acid)
RANKL inhibitors (e.g denosumab)
List an anti-angiogenic medication:
Cancer medications
What are the symptoms of MRONJ:
Delayed healing
Pain
Soft tissue infection and swelling
Numbness
Exposed bone
What guidelines are available with relation to MRONJ?
SDCEP
How should you manage someone at risk of MRONJ?
- Assess risk
- Advise pt of risk
- Carry out XLA
- Review healing after 8 weeks
- refer to oral surgery or special care if Mronj suspected
What is a congenital cardiac condition?
Condition present from birth
What are the oral findings of congenial cardiac conditions?
Delayed eruption
Abnormalities
Enamel hyperplasia
Increased dental disease
What is an Ischemic cardiac condition?
Progressive restriction of blood supply to the heart
What are the oral findings in Ischemic cardiac conditions?
Serve dental disease
Lichenoid reactions
Gingival swelling
Angioedema
Ulcers
What is hypertension?
High blood pressure (over 140/90mmHg)
What are the oral findings of hypertension?
Xerostomia
Salivary gland pain/swelling
Lichnoid reactions
Angiooedema
Gingival hyperplasia
Sore mouth
Paraesthesia
What is cardiomyopathy?
Conditions that effect the structure of the heart
What are the implications for patients who have had transplants?
Medications
Higher infection risk
Impaired drug metabolism
What 3 drugs are associated with gingival enlargement?
Anticonvulsants
Calcium channel blockers
Immunosuppressants
What is the 4 step process of normal Haemostasis?
- Vasoconstriction
- Platelet formation
- Activation of coagulation
- Activation of fibrinolysis
What are the 2 types of bleeding disorders?
Platelet disorders
Clotting disorders
Give an example of a platelet disorder:
Thrombocytopenia
Give an example of a clotting disorder:
Vonwiliebrands or heamophillia
What 2 types of medications affect bleeding?
Antiplatelets
Anticoagulants
List 2 examples of an Antiplatelet medication:
Aspirin
Clopidagrel
List 2 examples of anticoagulants:
Warfarin
Heparin
What is a renal condition?
Condition that effects renal system: kidneys, ureters, bladder, urethra
What is the function of the renal system?
Excretes waste
Maintains fluid balance
Secretes hormones
Excretes drugs
Give 3 examples of renal conditions that effect dentistry:
Chronic kidney disease
Renal failure
Renal transplants
Oral findings in chronic kidney disease:
Xerostomia
Metallic taste
Halitosis
Accelerated calculus production
Pale mucosa
Oral ulceration
Paraesthesia
Oral findings in renal failure:
More prone to bleeding
Infection
Dental management of renal failure:
Consult with renal physician
FBC and coagulation screen for Xla
Oral findings in renal transplant pts:
Gingival hyperplasia
Increases chance of tumours
Candidiasis
Herpes simplex
Immunosuppresion
Anxiety:
Physiological reaction to perceived threat/danger
Fear:
Physiological reaction to actual threat/danger
Phobia:
A persistent and excessive fear of something that is not dangerous
What are the 4 steps to managing anxious pts?
- Assess the pt
- Provide psycho education and identify causes of anxiety
- Provide coping strategies
- Expose pt to fears gradually
List 3 coping strategies for anxiety:
Deep breathing
Progressive muscle relaxation
Grounding
How can dental anxiety be measured?
MDAS
What is conscious sedation?
The use of drugs to produce a state of depression in the CNS but maintaining verbal communication.
What are the 6 effects of conscious sedation?
Anxiolytic
Anticonvulsant
Sedation
Reduced attention
Amnesia
Muscle relaxation
List the 3 main types of conscious sedation:
Inhalation
Intra venous
Oral
What 9 things are asssed at a sedation assessment?
MH, SH, Airway, height, weight, bmi, heart rate, bp, oxygen sats
What is inhalation sedation?
Nitrous oxide and oxygen
Delivered via a nose mask
Provides mild sedative effect
What are the 7 contraindications for inhalation sedation?
COPD
recent eye or ear surgery
Mask tolerance
Pregnancy
Vitamin B12 deficiency
Methotrexate
Chemotherapy
What are the 4 signs of overdose of inhalation sedation and how would you manage this?
Headache
Naesea
Vomiting
Diffusion hypoxia
- reduce dose and flush with pure oxygen
What is intravenous sedation?
Injection of sedative agent midazolam via an cannula that causes sedation and amnesia
What are the requirements to be allowed IV sedation?
Just have escort
What is the reversal drug for midazolam?
Flumazenil
What are the 5 contraindications for IV sedation?
Needle phobias
Medical conditions such as liver, kidney or cardiac disease
No escort
Pregnancy
Poor venous access
What are the signs of IV sedation overdose?
Loss of protective reflexes
Loss of consciousness
Decreased resp rate
Decreased heart rate
List 3 guidelines sources for sedation:
SDCEP
IACSP
IACSDS
What is oral sedation?
Sedation given via drink form
Midazolam used
Give examples of the 2 medications used as a pre-med for anxious patients:
What type of medication are they?
Diazepam
Temazepam
- both examples of benzodiazepines
What are contraindications of pre-meds?
Hepatic impairment
Renal impairment
Pregnancy
Breast feeding
What 3 things do pre medications interact with?
Antibacterials
Antivirals
Proton pump inhibitors
What is general anaesthesia?
A state of controlled consciousness that affects the whole body
Pt does not move or feel pain
All protective reflexes are lost
List the possible options for dental Tx:
- LA
- Inhalation sedation
- IV sedation
- GA
What are the 4 levels of sedation?
Minimal - anxiolysis
Moderate - conscious sedation
Deep - nearly unconscious
General anaesthesia - unconscious
What are benzodiazepines used for in dentistry?
IV SEDATION - midazolam
PRE-MED - diazepam
What are the precaution groups for benzodiazepines?
Elderly pts
Alcohol or drug dependent pts
Personality disorders
Resp disease
Cardiac disease
List the 5 contraindications for benzodiazepine use?
Pulmonary insufficiency
Respiratory weakness
Sleep apnoea
CNS depression
Compromised airways
List 4 types of mental health conditions:
Psychosis
Neurosis
Personality disorders
Eating disorders
Neurosis
Contact with reality maintained
Psychosis
Contact with reality lost
What is trauma?
An event or circumstance that is physically or emotionally harmful to a person.
List 3 signs of trauma:
Fight/flight/ freeze
Shame/guilt
Dissociation
How would you manage fight/flight/freeze?
Deep breathing
How would you manage shame/guilt?
Normalise
How would you manage disociation?
Grounding
List 3 drugs classed as stimulants:
Caffeine
Nicotine
Cocaine, amphetamines, ecstasy
List 3 examples of downer drugs:
Alcohol
Heroin
Morphine
Benzodiazepines
List 3 causes of poor oral health in drug users:
Dry mouth
Parafunctional habits
Sugar cravings
Oral findings in amphetamine users:
Xerostomia
Bruxism
Attrition/erosion
Oral findings in ecstasy users:
Bruxism
Xerostomia
Attrition/erosion
Mucosal burns
Oral findings in cocaine users:
Xerostomia
Caries on unusual surfaces
Oral findings in heroin users:
General oral neglect
Advanced dental disease
Oral findings in canabis users:
Decreased resp rate
Memory impairment
Soft tissue disease