3rd year key points Flashcards
sensory impairment
when one or more of a person’s senses are no longer normal
macular degeneration (wet vs dry)
wet - severe, quick
dry - gradual loss of central vision
glaucoma
rise in intraocular pressure
lead to damage of optic nerve - loss of peripheral vision
causes of cataracts
senile
traumatic
disease associated
diabetic retinopathy symptoms
black spots and blurry
hemianopia main cause and symptom
blindness in one half of the visual field
stroke
causes of hearing impairment
build up of cerumen (earwax)
ototoxic drugs
otosclerosis
perforated eardrums
hearing loop
T setting
magnetic, wireless signal
cuts out unwanted background noise
impairment
something doesn’t work
any loss or abnormality in fx of psychological, physiological or anatomical structure
disability
- functional performance
- a restriction/lack (resulting from an impairment) of ability to perform an activity within the range considered normal for a human being
handicap
- disadvantage, resulting from impairment/disability that limits/prevents fulfilment of a role that is normal for that individual
- broader social and psychological consequences
activity limitation
difficulty encountered by an individual in executing a task/action
participation restriction
problem experienced by an individual in involvement in life situations
characteristics of service use of SCD
fewer visits, longer intervals limited access difficulty communicating pain financial emergency care rather than planned history of extractions tx with GA
important piece of legislation relating to incapacity
Adults with Incapacity (Scotland) Act 2000 part 5
In Scotland law, what age can you make legally binding decision for yourself?
what age is ADULT
16 yo
what should you always assume with capacity?
that someone has it
what is capacity?
ability to( AMCUR ):
- act
- make decision (reasoned)
- communicate
- understand
- retain memory
action/decision specific residual capacity may fluctuate
examples of communication aids
- British Sign Language
- spelling boards
- iPad
- pen and paper
- visual aids
5 principles of AWI Act
- benefit - cannot be achieved without the tx
- minimum necessary intervention
- take account of wishes of adult - present + past
- consultation with relevant others
- encourage adult to exercise residual capacity
2 types of proxy
- power of attorney
- guardianship orders
3 types of Power of Attourney
- continuing - cant consent dental tx
- welfare - can consent dental tx
- combined - can consent dental tx
Power of Attourney
- no expiry date
- remain dormant until adult incapacity
- granted while pt still has capacity
- done through lawyer (no court)
how are Power of Attorney made?
granted by adult while they still have capacity
registered w Public Guardian
ceases on day they die
continuing Power of Attorney
finances and property
welfare Power of Attorney
health and personal welfare
2 types of guardianship orders
- welfare guardian - can consent dental tx
- financial guardian - can’t consent dental tx
Welfare Guardian orders
- when adult can’t choose a Power of Attorney e.g. born with a severe learning disability
- need 2 medical reports
- continuous management of welfare and financial matters
- usually 3yrs
how long do Welfare Guardian orders usually last?
3yrs usually
certificate of incapacity
- only valid for your area of practice
- even if WG/WPofA still need CofI
- detailed - exact
- one for check ups for 3yrs where no capacity likely to be regained
- individual tx course
- photocopy it in notes
who can consent for dental tx
- pt with capacity
- welfare power of attorney
- welfare guardians
- medical/ dental practitioners under Section 47 of AWI Act (General Authority to Treat)
General Authority to treat conditions x3
- a valid certificate of incapacity is issued for the tx given
- principles of the Act are observed
- emergency
who can issue certificates of incapacity?
- GMP
- consultant incharge of the patient care
- dental practitioner / nurse/ optometrist who completed the training course
schizophrenia
disorders of thought (delusions) and perception (hallucinations)
schizophrenia aetiological factors
cannabis - tachycardia
neurotransmitter imbalance
genetic predisposition
triggers - stress
clozapine and schizophrenia
- atypical antipsychotic (not first line)
- neutropenia - monitor
- don’t do smoking cessation - can lead to severe toxicity - clozapine levels in plasma changed
why is dentist-led sedation contraindicated in pts with active uncontrolled psychiatric disease?
may have unpredictable reactions and increased tolerance
russell’s sign
calluses on knuckles due to repeated self-induced vomiting
signs of Sjogren’s Syndrome
- mirror sticks to mucosa
- food residues in oral cavity
- cracked tongue
- ocular symptoms
SS risks
oral infections
malignant change - lymphoma
altered taste
reasons for dry mouth
- Medication
- antimuscarinic (tricyclic antidepressants, antipsychotics )
- Antihistamine
- Diuretics
- Systematic disease
- Sjogren’s Syndrome
- Cancer treatment
- Radiotherapy in the head and neck region
- Treatment with radioactive iodine
- autonomic dysfct (endocrine)
- anxiety, stress
- dehydration
- starvation
cancer - pre-tx priorities
- OH
- reduce tx complications
- avoid chemo interruption
- avoid mucositis exacerbation
- remove potential sources of infection
- reduce post-tx complications
- prevention
- plan rehab
*
role of dentist for cancer pt
early detection
pre-tx assessment
- radiographs
- necessary tx
- pre-tx scaling
dentate pts
- imps for soft splints
- start F therapy
during cancer tx role of dentist
ulceration
infection
emergency tx
pain relief for mucositis
opioid analgesia - severe pain
pathogenesis/stages of mucositis
inflammatory/vascular - cytokines released
epithelial - atrophy
ulceration/bacterial - full thickness erosion
healing - epithelium renewal
grading of mucositis
0-4 WHO
management of mucositis
avoid smoking, alcohol, tea and coffee, v hot/spicy
Intensive OH
Remove sharp edges of teeth/ denture
topical lignocaine
Caphosol - Supersaturated CaPO4 MW
Difflam - Benzydamine Hydrochlorode
Analgesic - Morphine / Opioids (Doctor Prescription)
tea tree / Aleo Vera MW - check not allergy
ice during chemo
SEs of chemo
alopecia - hair loss nausea and vomiting anorexia bone marrow suppression mucositis transient dry mouth coagulation defects reduced WBCs
how does chemo work?
cytotoxic - interact with cancer cell DNA/RNA and affect a phase of life cycle
what % of chemo pts get mucositis?
around 75-80%
when does mucositis usually appear with chemo?
1-2 weeks after initiation of chemo
describe the general trajectory of chemo SEs
systemic but more transient
describe the general trajectory of radio SEs
chronic, progressive and localised
why is radio fractionated?
- only kills dividing cells ( more sensitive)
- reducing side effects
- allows time for normal cells to repair themselves between treatments
dental SEs of radio
hyposalivation hypogeuesia radiation caries fungal infections trismus ORN
why is trismus a SE of radio?
replacement fibrosis of MofM following progressive endarteritis of affected tissues with decrease in blood supply
irreversible
ORN as a SE of radio?
dead bone shards
avascular necrosis
endarteritis obliterans - progressive fibrosis in the endothelium
what dose is the risk of SEs greater from radio?
> 60Gy
cancer - IO reactivation of herpes simplex
so immunocompromised clinically atypical painful oral ulceration, sudden onset extensive, slow healing and aggressive ulceration on palate and tongue dorsum
xerostomia management
palliative
water
Sugar free gum
tooth mousse
cancer post-tx dentist roles
rehabilitation
prevention
monitoring
dentist pre-tx for cancer - getting pt dentally fit
if no time to restore - ext
can’t RCT - can’t guarantee
ask pt for GP and MDT team details at 1st appt
if pt refuses ext - explain risks, note it down, contact oncologist
MRONJ
exposed bone (not healed) at 8wks
incidence of MRONJ
overall risk small <1%
what is Parkinsons?
progressive neurodegenerative
basal ganglia - degeneration of dopamine receptors
aetiology of Parkinsons
approx 5% genetic most idiopathic toxins? cerebrovascular disease head trauma drug induced
how is Parkinsons diagnosed?
clinical diagnosis
Parkinsons S+S
rest tremor
- reduced by action
- increased by emotion/stress
which type of dementia is Parkinsons associated with?
Lewy body dementia
tx of Parkinsons
drug therapy when fct disability
Levidopa - non-ergot dopamine agonist
Carbidopa - prolongs action
late management - reduce motor fluctuation
outcome of Parkinsons
approx 10-15yrs death usually due to bronchopneumonia
Parkinsons dental risk
risk of postural hypotension
type of dementias
Alzheimers vascular dementia dementia with Lewy bodies frontotemporal dementia Korsakoff's syndrome early-onset dementia
Alzheimer’s
lose connections between neurones - protein plaques and tangles
less chemical messengers
vascular dementia
reduced blood supply to brain
dementia with Lewy bodies
protein deposits, links with Parkinsons
frontotemporal dementia
lose filter ability - sexual/inappropriate comments
Korsakoffs syndrome
alcohol
early onset dementia
U65s
signs of pain if pt not able to tell
behavioural changes
body language
mood changes
Huntington’s disease
Aetiology: Chromosome 4 mutation
Symptoms : relentless progressive chorea and dementia
often mid-life
Alzheimer’s Disease- 50% chance
cerebral atrophy
chorea
a movement disorder that causes involuntary, irregular, unpredictable muscle movements
S+S of Huntington’s
involuntary jerky movements
poor balance
personality changes - moody
dental aspects of Huntingtons
communication
movements
swallowing
stroke S+S
interruption of brain blood supply one side weakness/numb dizziness LOC altered speech
dental aspects of stroke
retain prosthesis?
defer tx for 6m post Transient Ischaemic Attack/stroke
protective reflexes?
oropharyngeal dysphagia - swallow ability compromised. Risk of aspiration/pneumonia. Need good suction
SE of nicorandil (for angina)
large ulcers
VAP - Ventilator-associated pneumonia
most freq healthcare associated infection in intubated pts main risk factor - endotracheal tube - impairs natural defence mechanisms OH essential diagnosis - temp >38 - WCC >12000/mm3 - + tracheal cultures - resp distress - chest xrays
Berwick report
pt safety in NHS key principles - quality of pt care - engage patients and carers - growth and development of all staff - embrace transparency
barriers to change - OH in care homes
OH low priority assessed often by non-dentist carers limited knowledge of OH carers difficulty gaining access to teeth high turnover of care staff poorly paid
early stage dementia tx planning
oral assessment plan for future consider replica models identify and try to retain key teeth - 4 occluding pairs - L anteriors
mid stage dementia tx planning
maintenance and prevention
late stage dementia tx planning
comfort
free of pain and infection
non-invasive
txing pts with dementia
communication - approach from front
break it down
non-verbal
right env
causes of LD
preconception - parental genotype
pre-natal - maternal health, toxics
perinatal - injury
post-natal - infection, trauma, SSD
syndromes associated with LD
autism/Aspergers Down syndrome CP Fragile X syndrome Prader Willi PKU
CP
1 in 400 neurological - affect movement and coordination muscle stiffness/floppiness (hypotonia) random and uncontrolled body movements balance problems
Down syndrome
trisomy 21 CHDs increased risk of haematological malignancy reduced IQ risk Alzheimers PDD dental anomalies
Prader Willi syndrome
15 constantly hungry - obesity hypotonia learning difficulties behavioural problems
Autism prep before visit
my health passport social stories pre-visit timing specific language take straight to surgery
what can be used to aid keeping mouth open?
open wide mouth rests
LD RFs
poor motor control
pouching
mouth breathing
meds
LD toothbrushing advice
sit up
behind pt
encourage pt to do as much as possible
clinical holding
consent
no capacity and deemed of benefit - safety risk
unplanned emergencies
always record and justify
thickeners
dysphagia
prevent aspiration
self-injurious behaviour management
self-biting tx strategies - symptomatic relief - reassurance - distraction when SIB - pharmacological - behaviour psychology - positive reinforcement - extract specific anterior teeth - orthognathic surgery to create open bite
safeguarding
recognise respond record - non-urgent - contact SS within 24hrs - 999 immediate risk of harm
Removal (7days)
Assessment
Banning (up to 6m) - where adult at risk likely to be seriously harmed
dementia definition
syndrome - chronic/progressive
deterioration in cognitive fct beyond what might be expected from normal ageing
consciousness not affected
depression and anxiety often precursors
most common type of dementia
Alzheimers 60%
dementia risk factors
age gender genetics MH lifestyle
dementia early stage symptoms
often misattributed
STML
confusion
anxiety
dementia mid stage symptoms
need more support inc reminders distress, aggression wandering inappropriate behaviour hallucinations
dementia late stage symptoms
physical frailty - shuffle
can’t recognise people
incontinence
loss of speech
dementia testing
MMSE (not sensitive for frontal lobe) Blessed Dementia Scale MINICOG GPCOG dementia screen to eliminate treatable causes - diagnosis of exclusion
what drug may delay the progression of dementia?
anticholinesterases
risk of dementia in Down Syndrome
50%
severe haemophilia
<1% factor
non-selective B-blockers and LA
heightened sensitivity to effects of vasopressors in LA
hypertensive crisis
> 180/110
what is metformin?
antihyperglycaemic
what is the leading cause of renal failure?
diabetes
when do neutrophils drop to their lowest point in chemo?
10-14 days after chemo delivery
how long should you allow for healing after ext prior to oncology tx?
10-14 days
dose which gives risk of ORN
50 or more Gy
how many WGs do you need consent from?
1
UKELD
UK model end stage liver disease
biotene oralbalance
lactoperoxidase
saliva orthana
porcine mucin
tooth mousse
recaldent CPP-ACP
glandosane
carboxymethylcellulose
artificial saliva spray
caphosol
supersaturated Ca and PO4
where can chemo induced mucositis affect?
the whole GIT
why are bisphosphonates used in cancer?
to reduce the risk of metastatic spread
where do radiation caries typically appear?
cervical/smooth surface
what can cannabis do to the CV system?
cause tachycardia
for end stage liver disease, before operative dental tx what should you request?
FBC, coagulation screen, LFTs, U and Es
when should you tx a pt on haemodialysis?
day after haemodialysis
do you need an AWI certificate to tx a spreading dental infection?
no
max AWI
3yrs
WG
a person who is legally appointed by the courts to make the decision on behalf of a person who lacks capacity
PofA
person who is nominated whilst an individual still has capacity who is subsequently legally appt by a court to make decisions on behalf of that individual when they lose capacity
who should you contact to confirm welfare PofA?
Office of Public Guardian
purpose of AWI
provides a framework for safeguarding the welfare and managing the finances of adults who lack capacity due to mental disorder or inability to communicate
residual capacity
ensure everything possible is done to provide the individual with the opportunity to decide about the medical tx they receive
least restrictive option
any action/decision taken should be the min to achieve the purpose
should be the option that restricts freedom as little as possible
benefit
any action or decision must benefit the pt and only be taken when that benefit cannot reasonably be achieved without it
consultation with relevant others
take account of the views of others with an interest in the person’s welfare
Act lists who should be consulted whenever practicable and reasonable
which part of the AWI Act is relevant to dentistry?
part 5
if a pt needs ABP for invasive procedures, what does this cover?
“manipulation of mucosa and mucoperiosteum”
- not LA
Down Syndrome and immune system
neutrophil chemotaxis impaired
Dalteparin (fragmin)
low molecular weight heparin
where is thrombopoietin made?
liver
where are platelets made?
bone marrow
if platelets <100 what should you do before ext?
speak to someone
causes of inability to achieve haemostasis
inherited/congenital bleeding disorders medication induced other drugs e.g. chemo SE haematological disease infections liver disease
platelet level for a single uncomplicated tooth extraction
> 50 x10 ^9/L should be a safe level to achieve haemostasis
S+S of liver disease
jaundice palmar erythema, spider naevi bleeding and oesophageal varices ascites encephalopathy if alcohol related: tremors, cognitive impairment
causes of liver disease
infective - hepatitis virus autoimmune - primary biliary cirrhosis alcohol related non-alcoholic fatty liver disease hemochromatosis drug induced hepatocellular carcinoma
stages of liver disease
hepatitis: inflammation of liver, may/may not be reversible depending on the disease
liver cirrhosis: irreversible liver necrosis and fibrosis
liver failure: failure of normal liver fct
UKELD score
UK model for end stage liver disease
predicts a person’s prognosis in chronic liver disease, used as a guide to determine the need for a liver transplant
49 minimum for pt to be assessed for a liver transplant
- >9% mortality within 12m
liver disease and LAs
lignocaine fully metabolised in liver
only 5-10% of articaine processed in liver, most is metabolised in plasma
- decreases metabolic demand on liver
could use articaine infiltrations to avoid IAN blocks? - reduces risk of haematoma formation
liver disease and post-op analgesia
NSAIDs - bleeding risk - hepatorenal syndrome - inhibition of prostaglandins leads to reduction in renal perfusion, reduction in GFR and sodium retention paracetamol - risk of hepatotoxicity - safer than NSAIDs
liver disease and antibiotics
may need to alter dose
amoxicillin safe
may need to alter dose of metronidazole
erythromycin can affect liver
liver disease and IV sedation
dentist led IV sedation with midazolam not appropriate
if need sedation - anaesthetist led propofol sedation or GA
if pt needs medical transfusion product for tx
do as much tx as possible as transfusion comes with associated risks
is diazepam dialysable?
no
cannabis and dentistry
attend less regularly associated with schizophrenia increased caries rare - xerostomia - hunger - acts on hormone leptin - more PDD and gingival enlargement - oral leukoplakia and cancer acts on CV system - tachycardia with widespread vasodilation - can become acute medical issue if LA containing adrenaline given during tachycardia period
bulimia presentations
palatal NCTSL erosion
dry mouth
nutritional deficiency related - ulceration and infections
increased keratin in oral STs in response to trauma from purging/acidic vomit
sialadenosis
damage to nails or fingers if used to purge
post-vom methods of increasing pH
chew gum, rinse mouth with water/milk
rinse with antacid prep
avoid abrasive toothpastes
gentle brushing with desensitising toothpaste and a soft brush may be ok
cancer GDP pre-tx
radiographs and assessment any necessary tx pre-tx scaling imps for soft splints if dentate F therapy if dentate
cardinal features of Parkinsons
bradykinesia rigidity resting tremor postural instability gradual symptom progression sustained response to therapy with levodopa (precursor to dopamine)
features of Parkinsons
head forward micrographia mask like face drooling rigidity resting tremor akinesia
vascular dementia
reduced blood flow to brain
mod haemophilia
2-5% factor
mild haemophilia
6-40% factor
